Communication should be clearly stated and directed to the appropriate, responsible individual.
After completing this chapter, you should be able to:
• Analyze effective communication as it relates to patient safety.
• Analyze TeamSTEPPS Tools as an evidence-based teamwork system to optimize patient outcomes.
• Identify current methods of transcribing physicians’ orders.
• Use a standardized hand-off communication tool (SBAR or I-SBAR-R) for receiving and giving change-of-shift report.
• Discuss strategies to manage and prioritize your time in the clinical setting.
• Identify criteria for supervising and delegating care provided by others.
The entry-level nurse is expected to demonstrate competence as a manager of patient care. The process of building nursing management skills encompasses effective communication, management of prioritization in the clinical setting, and management of other members of the health care team to maintain patient safety and prevent harm. The topics in this chapter will be helpful in your development of management skills that keep patients safe while you are a student, as well as during your transition period as a new graduate.
Communication and Patient Safety
We have all learned different ways of communicating. Our tone, inflections, and decibel level are all learned. Roles with perceived authority differences have a significant impact on how we communicate and how much information we communicate. This is called an authority gradient, that is, the balance of decision-making power or the steepness of command hierarchy in a given situation (AHRQ, 2015). Even gender plays a large part in how we communicate information. Consider asking a female colleague how her day was yesterday (or about a particular movie). Then ask a male colleague the same question. Chances are, the information you receive will vary greatly in the amount of detail and the number of words it takes to tell the story.
The same is typically true in the medical field where perceived authority gradients exist between physician and nurse, supervisor and direct report, expert and novice. How and to what degree information is shared will vary. This is why team building and simulation are so important: to break down perceived barriers to communicate effectively. Consider how you might share information regarding a patient’s condition with a colleague with whom you’ve worked and trusted; then consider how you might communicate this same information to the chief of staff who happens to be the primary physician on this case. Do you think the volume and detail of information might differ? Additionally, nurses and physicians are trained to communicate quite differently. Nurses are taught to be broad in their narrative. They give a descriptive picture of the clinical situation. Physicians, on the other hand, learn to be very concise—they want the facts and the important points. Whether under stress or relaxed, nurses must find effective ways to communicate critical information in very short periods of time.
A 2010 study by The Joint Commission (TJC) reported that communication failure was a primary contributing factor in almost 80% of more than 6000 adverse events. Another TJC study into fundamental reasons for failure or inefficiency of processes that led to patient harm validated that communication continued to be in the top three root causes in sentinel events from 2013 to 2015. Integrating teamwork and effective communication into day-to-day practice can help to eliminate errors. Through exercises in teamwork, cultural sensitivity, and self-awareness/situational awareness techniques, health care providers learn skill sets that promote expeditious and appropriate care. The Department of Defense (DoD) Patient Safety Program in collaboration with the Agency for Healthcare Research and Quality developed an evidence-based teamwork system in 2007 that focused on improving communication and teamwork skills in the health care industry to improve patient outcomes (AHRQ, 2013). The result was TeamSTEPPS—Team Strategies and Tools to Enhance Performance and Patient Safety (Box 11.1).
Communication challenges in practice were identified early by The Joint Commission. The National Patient Safety Goals were developed for implementation beginning in 2003 with the expectation of full implementation and compliance as a condition of accreditation. Failures in communication involved incomplete communication among caregivers. The Joint Commission issued National Patient Safety Goal #2: Improve the effectiveness of communication among caregivers. Specifically, “Get important test results to the right staff person on time” (The Joint Commission, 2015). It is now an expectation that facilities have embedded a standardized approach to hand-off communication, including passing information regarding orders and test results.
How Can I Improve My Verbal Communication for Patient Safety?
Let us focus on a couple of communication techniques that can improve the accuracy of the care we provide. First, The Joint Commission notes that there is a big difference between verbal orders and telephone orders. Orders received verbally (with the physician present) should never be accepted except in an emergency or during a procedure where the physician is in a sterile procedural environment and read-back verification techniques are utilized to assure accuracy. There is too much opportunity for transmitting and transcribing the order incorrectly. Telephone orders are acceptable, because the physician is simply not present to input the orders himself or herself. To make this even safer, practice a “read-back.” In other words, handwrite or input into the electronic health record the order or test results given to you, and read them back to verify accuracy of the orders and to confirm that they were understood correctly. As many as 50% of all medication errors have been directly attributed to the failure to communicate information at the point of transition (Institute for Healthcare Improvement, 2008). Specifically, any hand-off of communication is a point of vulnerability, whether it is a telephone communication, a written communication, communication of a critical test result, or a shift-change report. All have been shown to be critical points in the patient’s journey. Points of transition in communication encompass all disciplines.
Consider how often we miscommunicate with each other casually and think of the implications for the clinical setting. Your friend asked you to stop by the store and pick up bread, eggs, and milk, but you forgot to pick up the milk because you didn’t write it down, you thought you had committed it to memory. You had other things on your mind and you haven’t been able to get much sleep lately, which you already know impairs your memory. What other areas of your life might be impacted from your lack of sleep and stress?
These variables are called “human factors,” and they often influence the communication transition between different parties. These are the very same factors that can and do affect your ability to recall information you just received.
How much more effective would it have been had you actually written down what you were told to bring home and then read that list back to the person who gave it to you? Fatigued, distracted, worried, or sleepy—had you repeated the written list back to the other person, chances are the milk would have made it home, too! This is precisely how to manage the verbal and telephone transmission of information from caregiver to caregiver (Box 11.2).
It’s that simple! This process minimizes errors of omission and commission, and it eliminates the need to rely on memory to recall an order accurately. Your patients’ lives depend on it!
How Can I Improve My Written Communication for Patient Safety?
The next communication concern is how we write and document in the electronic health record (EHR) to communicate essential information. Legibility and clarity are nonnegotiable essentials. Remember, the written or typed word is another point of transmission that has proven to be a root cause of many catastrophic errors. How often has a medication ordered at 5.0 mg been mistaken for 50 mg, because the decimal point was too light to be noticed? Consider instead .5 mcg being mistaken for 5 mcg. The resultant overdose could have devastating consequences. When documenting numbers, the trailing “0” must be eliminated to avoid the confusion between 5.0 mg and 50 mg. Likewise, the insertion of the “0” before the decimal is crucial to differentiate 0.5 mcg from 5 mcg. In 2003, TJC released a Sentinel Event Alert that is still being addressed today regarding these very documentation issues that have led to grave miscommunications and includes strategies to eliminate harm. Although the EHR has helped to mitigate many of these issues, the risk is ever present.
Furthermore, many written abbreviations used to designate dosage frequency must be eliminated. Abbreviations such as Q.D. for “daily” have become targets for clarification, because they can be easily misunderstood (Q.D. has been mistaken for Q.I.D. meaning “four times a day”). Many facilities have disallowed the use of these “unsafe” or “unapproved” abbreviations because of their potential for causing errors leading to harm for a patient.
Organizations within the health care delivery system will have their own abbreviations, acronyms, and symbols that should not be used. These abbreviations and symbols may be in addition to the recommendations from The Joint Commission. It is imperative that you become familiar with the approved abbreviations, symbols, and acronyms that you can use. The Joint Commission has mandated that these dangerous abbreviations be eliminated from any documentation, printed or written, when communicating patient-care issues (Critical Thinking Box 11.1, Table 11.1).
CRITICAL THINKING BOX 11.1What happens when an unsafe abbreviation is found in a patient order?
• Step 1: Notify the prescriber of the order containing the unsafe abbreviation.
• Step 2: Ask for a clarifying order to clear any misinterpretation of the order.
• Step 3: Document the clarification.
Once again, it’s that simple! However, one more word of caution must be added for written communication when dealing with patients. Cultural variances of the written word must be acknowledged and minimized. Consider a prescription for a primarily Spanish-speaking patient that reads, “Take once daily for 5 days.” The word once in Spanish means eleven! Interpretive services must be accessed if the language spoken and written is not the patient’s primary language. Direct and succinct written and verbal communication in a language that is clearly understood by the patient is essential to appropriate and safe care. Remember that just because the patient can speak English, it does not mean that the patient can read English, or any language at all. It’s important to use a TeamSTEPPS strategy “check-back.” A check-back is a closed-loop communication strategy used to verify and validate information exchanged (AHRQ, 2013). Simply put, ask the patients to repeat back to you what they understood— for example, discharge instructions, how to take their medication, how to do their dressing change, and so forth. The Centers for Medicare & Medicaid Services (CMS) requires organizations to provide language services for all patients who need them (Critical Thinking Box 11.2).
TABLE 11.1
The Joint Commission Official “Do Not Use” List of Abbreviations∗
| Do Not Use | Potential Problem | Use Instead |
| U, u (unit) | Mistaken for “0” (zero), the number “4” (four) or “cc” | Write “unit” |
| IU (International Unit) | Mistaken for IV (intravenous) or the number 10 (ten) | Write “International Unit” |
| Q.D., QD, q.d., qd (daily) | Mistaken for each other | Write “daily” |
| Q.O.D., QOD, q.o.d., qod (every other day) | Period after the Q mistaken for “I” and the “O” mistaken for “I” | Write “every other day” |
| Trailing zero (X.0 mg)† | Decimal point is missed | Write X mg |
| Lack of leading zero (.X mg) | Write 0.X mg | |
| MS | Can mean morphine sulfate or magnesium sulfate | Write “morphine sulfate” |
| MSO4 and MgSO4 | Confused for one another | Write “magnesium sulfate” |
CRITICAL THINKING BOX 11.2Role-play with a partner the transcription of verbal physician orders and the reading back of those orders for clarity and accuracy. Can you identify any potential miscommunications?
Health care literacy has become a focal point across the nation. It is staggering how many patients, who are seemingly literate, simply do not understand their discharge instructions or medication administration directions. The National Library of Medicine (2012) reported that reading abilities of adults are typically three to four grade levels behind the last year of school completed. A high-school graduate typically has a seventh- or eighth-grade reading level. Therefore, it is essential for the health care provider to ask patients to repeat back what they understand about their condition, medications, education, and discharge instructions (a check-back). As a health care professional, you now speak a language that is unfamiliar to the public. Consider that you and the patient’s physician may refer to the patient’s high blood pressure condition as hypertension. Does the patient realize that hypertension and high blood pressure are the same things, or does he or she think that hypertension is a “hyper” condition in which the person cannot sit still? You might be surprised when you hear what the patient understands about his or her own condition!
Transcribing Written Orders
In the process of providing safe patient care, it is essential that physician or health care provider orders be communicated clearly and correctly to the health care team. The physician order must clearly indicate what is to be done, when it should be done, and how often it should be done. All orders must include the patient’s identifying information and the current date and time. Table 11.2 provides a summary of the various types of orders. The process for transcribing orders may involve other health team members, such as the unit secretary, but it is the nurse’s responsibility to verify that the orders are implemented correctly. This involves making sure that the order is clearly understood and documented accurately. If any component of the order is not clear, the physician should be contacted for clarification (Box 11.3).
The computer prescriber order entry (CPOE) is an electronic means for entering a physician order. This system has the benefit of reducing errors by minimizing the ambiguity of handwritten orders, as well as intercepting errors when they most commonly occur—at the time the order is written. The system also has the added benefit of allowing a new order to be entered from multiple locations. This in turn decreases the need for telephone orders, as the person writing the order can use any computer terminal within the system to do so (and sometimes smartphone technology is utilized to facilitate remote order entry). The CPOE system is integrated with other patient information, including laboratory information, diagnostic results, and medication records. Even with all the advantages of the electronic health record, in the event the systems shut down, the best practices related to transcription of orders, accuracy of orders, and legibility of orders cannot be forgotten.
TABLE 11.2
| Type | Description |
| One-time-only order | An order for a medication or procedure to be carried out only one time. |
| PRN order | An order to be carried out when the patient needs it, not on a scheduled basis. For example, a PRN pain medication order. |
| Standing order | A physician’s routine set of orders for a specific procedure or condition. For example, a surgeon may have standing preoperative and/or postoperative orders for an abdominal surgery patient. |
| STAT order | An order that is to be implemented immediately. Usually, it is a one-time order. The term is derived from the Latin word statim, which means “immediately.” |
Communicating When it is Critical—What Do You Need To Do?
Critical Patient Tests
Communication of critical test results is yet another vulnerable time when errors can occur. Critical test results warrant expeditious communication to the responsible licensed caregiver without delay. This includes not only laboratory panic values but also other diagnostic test results specifically defined by the institution. The primary goal is to transmit the critical information to the person who can most quickly fix the problem. Documentation of how this was accomplished is essential to promoting and providing validation that the critical test result was communicated and, if needed, acted on.
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