Advanced practice registered nurses and physician assistants have been taking on an increased role in nursing homes and assisted living facilities.
The importance of proper communication is often understated. The Joint Commission reported that failure in communication causes two-thirds of sentinel events in healthcare. With numbers this high, there has to be a better way to improve communication.
Coordination of care requires collaboration and communication between the attending physician and the other providers working to care for these residents.
By establishing the preferred method of communication there will be less confusion and misunderstandings.
When reporting to the doctor, have the basic facts available such as vitals, associated diagnosis, appropriate medications, and explanation in a clear brief manner. You should also have the medical chart available in case any data is needed. Then allow for the doctor to ask questions.
What form of communication do you use in your facility?
If there are APRNs in the facility seeing patients, what type of communication style do they use to relay their findings regarding the diagnosis and treatment of the residents? Is there any communication with the attending doctors?
It is best to develop some guidelines regarding communication in the nursing home. Instructions should be conveyed by the doctor, letting the APRN or PA know which method of communication they prefer.
- HIPPA compliant texting
- Smoke signals
Not only do you need to know how to express your thoughts, but you also need to know what information they require. Some medical providers like to know everything going on with their patients. Others want to identify significant changes in conditions.
Either way, when discussing the patient, the plan of care and followup plan should determine the best possible outcome available.
Most providers usually call or text for urgent issues only, while some will call at the end of the day to give a brief report to the doctor so they are in the know.
Problems with poor communication between providers
- Decreased quality of care
- Increased risk of rehospitalization of patients in the facility
- Decreased patient safety
- Shortened lengths of stay
- Decreased transfer delays (Disch, 2012)
Doctor frustration with lack of communication
Ever receive calls from the nurses in the facility about a sick resident, and the nurse doesn’t have any information regarding the patient other than the chief complaint?
You ask about the vital signs, allergies, how long have the symptoms have been going on and they don’t know the answer? Maybe the nurse takes a long time getting the answers to your questions because they don’t have the chart or EHR open?
If you have had these frustrations as an APRN or PA, imagine the same frustration if you don’t have the necessary information before calling the attending physician. By being prepared before calling the attending, you will help decrease the issues.
Having the necessary information to present to the attending doctor will make the report more smooth and mutually appreciated. It can also lead to better collaboration between providers.
These small modifications will help look at you as an asset and member of the team.
Data suggests that when healthcare professionals communicate effectively—conveying critical information in a timely or easily understandable manner, clearly spelling out orders or instructions, and answering questions thoroughly and thoughtfully—they deliver safer and higher-quality care. Research indicates that care is also more cost-efficient and cost-effective—essential considerations in the value-based healthcare equation. (Morr., 2018)
Unclear communication contributes to significant work dissatisfaction among physicians, APRNs, and PA’s. It is up to us as a team to improve communication from both parties.
Barriers to communication between providers
There are many barriers to good communication between providers. It could be a lack of knowledge of what APRNs and physician assistants are capable of doing.
It could also be that many doctors are accustomed to taking care of patients themselves without the assistance of the NP or PA.
Other times it comes down to cultural differences, where the doctor feels they are the top of the hierarchy and are not willing to work with the other providers in the care of the patients.
The barriers to improved communication between the doctors and other medical providers aren’t that difficult to overcome when all parties keep an open mind to change.
Develop a plan on what patient situations require a phone call, text, or a faxed update. Some providers who use electronic health records can send a copy of their completed notes to the doctor once the visit is complete.
The main barrier will be developing a level of trust between providers. If the attending believes that the patient will receive quality and timely care, the doctor will most likely require fewer updates and communication.
In the beginning, the nursing home leadership may need to get involved to let all parties know what is expected of their medical team.
Does the facility wish to develop a model using the nurse practitioners and physician assistants as the front line medical staff with an attending doctor for collaboration? Do they want the APRN and PA to provide acute care visits and leave chronic care visits to the physicians?
Interventions for communications
There are suggestions to improve communication between nurse-physician that could have a positive effect on APRN-Physician communication.
According to an article in the International Journal of Nursing Sciences, these interventions categorized into:
- Communication tools/checklists.
- Team training.
- Electronic situation–background–assessment–recommendation (SBAR) documentation template.
- Doctors need to be respectful when speaking with nurse practitioners and physicians assistants. If the providers are fearful of calling, they will be less likely to communicate when needed.
Developing a communication tool or checklist helps to provide clear guidelines for when the attending should be updated and consulted regarding the plan of care. The list is usually straightforward bullet points that each in house attending may develop.
Team training is done by the leadership of the facilities or the management of the medical staff. The Director of Nursing or administrator should educate the doctors, APRN, or PA regarding their expectations for communication and collaboration.
SBAR is an abbreviation for a situation–background–assessment–recommendation.
- Situation refers to the current condition of the patient and working diagnosis.
- Background refers to the history of presenting illness, past medical history, and patient medication.
- Assessment refers to the examiner’s evaluation and assessment of the disease or condition.
- Recommendation refers to the plan of care and anticipated changes in health or treatment. (Panesar et al., 2014.)
Visit components that may require communication included
- Hospital discharge summary review
- Medication reconciliation
- Follow-up care
- Advance care planning
- Patient and family education.
An article in clinicaladvisor.com stated, “A successful model of nurse-practitioner (NP) and physician co-management in primary care includes effective communication, mutual respect and trust, and clinical alignment, also known as a shared philosophy of care, according to a study published in the Annals of Family Medicine.” (M. Morr, 2018)
Finding someone that you know and trust can significantly reduce your work burden as a medical doctor in the nursing home. It decreases the excessive workload of checking all orders and repeating evaluations.
Strong communication among healthcare team members has been shown to influence the quality of working relationships and job satisfaction (AHRQ, 2017).
If you have an APRN or physician assistant that works well with you, try to foster that relationship, not only to help you but your patients as well.
A.H. Rosenstein. Original research: nurse-physician relationships: impact on nurse satisfaction and retention. Am J Nurs, 102 (6) (2002), pp. 26-34
A.H. Rosenstein, M. O’Daniel. Disruptive behavior and clinical outcomes: perceptions of nurses and physicians. Am J Nurs, 105 (1) (2005), pp. 54-64
International Journal of Nursing Sciences, Volume 5, Issue 1, 10 January 2018, Pages 81-88 Interventions to improve communication between nurses and physicians in the intensive care unit: An integrative literature review. https://www.sciencedirect.com/science/article/pii/S235201321730087X
J. Merlino, MD. Communication: A Critical Healthcare Competency. (2017). PQHS, Patient Safety, and Quality Healthcare. https://www.psqh.com/analysis/communication-critical-healthcare-competency/ Retrieved September 15, 2019
K.M. Sutcliffe, E. Lewton, M.M. Rosenthal. Communication failures: an insidious contributor to medical mishaps. Acad Med, 79 (2) (2004), pp. 186-194
M. Morr. A Model for Nurse Practitioner-Physician Comanagement. Clinical Advisor. https://www.clinicaladvisor.com/home/topics/practice-management-information-center/a-model-for-nurse-practitioner-physician-comanagement/ (2018) Retrieved September 15, 2019
R.S. Panesar, B. Albert, C. Messina, M. Parker. The effect of an electronic SBAR communication tool on documentation of acute events in the pediatric intensive care unit. Am J Med Qual, 31 (1) (2014), pp. 64-68
T.V. Caprio, MD. Physician Practice in the Nursing Home: Collaboration with Nurse Practitioners and Physician Assistants. Volume 14 – Issue 3 – March 2006 – ALTC. https://www.managedhealthcareconnect.com/article/5474 Retrieved September 14, 2019