The potential for adverse events is high in the complex ICU environment. Ineffective communication between nurses and physicians could adversely affect a number of outcomes, including resulting in longer lengths of stay or hospital readmissions. Currently we know little about communication between nurses and physicians in the ICU setting or how characteristics of the work culture might promote or inhibit effective communication. The ICU Nurse-Physician Questionnaire, the most widely used measure of nurse/physician communication in ICU settings, was developed almost 20 years ago. Although this instrument was tested extensively for reliability and validity it may not represent the state of communication between professions today nor capture important context specific issues that influence communication. In addition, since nurses and physicians have significantly different perceptions about collaborating with each other, their perceptions regarding issues of communication may also differ. Qualitative methods, including engaging in observations of nurses and physicians followed by interviews, may be the best approach to help characterize and understand this vital process.
This project had two objectives:
1. To develop qualitative procedures for obtaining information about how and what information gets communicated between nurses and physicians.
2. To test and further validate a quantitative instrument designed to identify behaviors that support a culture of safety and may prevent adverse outcomes in the ICU.
We used a convenience sample of 3 ICUs in the same VA facility: a Medical ICU (MICU), a Surgical ICU (SICU), and a Thoracic ICU (TICU). Subjects of the research were nurses and the physicians with whom they communicated.
First we identified potential tools for observing communication patterns in the ICU through a literature review and conducted "pre-observation" observations in the MICU and SICU to ascertain the feasibility of observing actual patient care rounds and to work out logistics and mechanics of conducting observations and interviews. Next, we developed and refined both a preliminary observation data collection tool and observation protocol through actual observation in the Medical, Surgical and Thoracic ICUs using an iterative process. A pair of observers, one nurse and one non-nurse, conducted observations starting with the preliminary observation data collection tool and protocol. These materials were iteratively refined by the study team throughout the study period. In addition to the observations, observed nurses and at least one of the physicians they communicated with were asked to participate in retrospective, semi-structured interviews after rounds were observed in each unit. All interviews were tape recorded and transcribed. Interviews focused on general communication issues as well as on communication that was observed during the observation period. Using an iterative process, we developed and refined an interview protocol, including separate protocols for each healthcare discipline and for interviewing nurse managers and physician directors.
Data analysis consisted of content analysis and categorization of all observation and interview data, during which time we developed a code book. Codes were derived from literature suggesting that all healthcare errors involving communication stem from one of four categories (audience-who; content-what; context-where/when; and purpose-why) as well as from the study data.
Before observations and interviews began, we also administered the Safety Organizing Scale (SOS), a 9 item instrument using a Likert-type scale, to measure nurses' self-reported behaviors that enable a safety culture. Surveys were distributed to unit mailboxes of all nurses in all 3 ICUs. Data were aggregated to the unit level because the instrument measures the collective and shared attitudes and behaviors of nurses on a unit that inform a safety culture. Descriptive statistics and ANOVA were the main statistical tests. We conducted confirmatory factor analysis to test the content validity of the SOS.
We conducted a total of four observations, 2 in MICU, and 1 each in the SICU and TICU. We interviewed 4 nurses and 4 physicians. Of the physicians, 2 were attendings, 1 was a 3rd year resident, and 1 was a new physician. We developed and tested an observation data collection tool, an observational protocol, and interview guides for both nurses and physicians. During data analysis we also developed and refined a code book, beginning with the four categories described above, and adding a fifth category of "how" (i.e., looking for evidence of how communication was sent between nurses and physicians, and vice versa).
A total of 40 nurses completed and returned the SOS, including at least 60% of nurses in each ICU. Scores on the SOS range from 1-7, with higher scores reflecting attitudes and behaviors more congruent with a safety culture. Scores ranged from 1.56 - 6.78 (X = 4.79, SD = 1.19), and ANOVA revealed significant differences between the 3 units (f = 4.57, p = .02). There were also significant differences on 4 of the 9 items. The SOS was tested for reliability ( = .93) and principal component factor analysis revealed a single component solution, suggesting that the SOS is both a reliable and valid tool in VA ICU settings.
Effective communication between nurses and physicians is important in promoting the best possible care for our veteran patients and particularly for those who are critically ill.
We developed and tested the qualitative methods (including tools, protocols, and guides) and analysis template (code book) for measuring nurse/physician communication. In addition we demonstrated that the SOS is a reliable and valid tool that can be used to identify key attitudes and behaviors that inform a safety culture on a unit. The observation data collection tool, observational protocol and semi-structured interview guide, as well as the code book developed in this pilot study will be used in a future project to characterize and better understand both the phenomenon and the context of nurse/physician communication in the ICU.
Better understanding the dynamics of communication and the context in which it occurs provides an opportunity for developing strategies to promote more effective communication between nurses and physicians in the ICU with the ultimate goal of improving care outcomes for hospitalized veteran patients.
None at this time.
Acute and Combat-Related Injury