Communication Issues in the Emergency Unit - Research Paper Example

Communication Issues in the Emergency Unit Introduction Nurses face various challenges in the clinical practice and environment. These challenges often add to the responsibilities they have to deal with on a daily basis in the hospital. One of the most stressful and demanding work units in the hospital is the emergency room. Emergency room nurses are one of the busiest nurses in the hospital. They are pressured to think fast on their feet and to be constantly aware and conscious of their actions. And same as other units in the hospital, they also encounter a variety of issues which often affect the outcome of their work. This paper shall discuss communication issues that nurses encounter in the emergency unit of hospitals. This issue relates to the function of nursing leadership and on identifying strategies that leaders can apply to address this issue. This study shall set forth a clear strategy on how to deal with the issue and to identify the key stakeholders that have to be motivated and convinced into a favourable frame of mind. The best evidence shall be drawn to support the proposed strategy. Discussion: Nursing Communication Issues in the Emergency Department Effective communication patterns are essential in the healthcare service. Miscommunication or failure in communication can often lead to disastrous and dangerous consequences for the patient and for the healthcare team in general. Various studies have pointed out that miscommunication is one of the main causes of medical errors in the hospital. Incidents reported by physicians recorded 47 out of 75 errors attributed to issues in communication (Monegain, 2004). In some hospitals in the United States, they report that about 60% of the medical errors are actually preventable errors mainly credited to failure in communication. In 75% of these cases, patient death resulted (Tarrant & Varnell, n.d). These are very alarming figures. They imply that the breakdown in communication in the hospitals is a crucial matter that largely affects patient safety. And by simply overcoming barriers in communication, medication errors can actually be avoided. A study published in the Annals of Emergency Medicine evaluated and described the communication links and patterns between the emergency department (ED). The study established that 1655 communication events were seen in the total 39 hours of observation conducted by the researchers. Most of the communication gaps were seen between the ambulance providers and those who ended up taking care of the patients in the emergency room. There was a strong link in the communication between and among the different physicians in the emergency unit. And in the midst of the busy ED, the nurses served as important cogs in the wheels of communication. The charge nurse was especially important in the communication process because she “seemed to be the hub for communication, linking ED personnel with non-ED staff” (Fairbanks, 2006, p. 396). This study indicates that problems can often be seen in the linkages between the different areas of practice in the emergency room. These linkages are sometimes weak because of problems in coordination across various disciplines. Another study assessed the factors affecting effective communication among the different members of the emergency team. The study observed that communication overload and simultaneous tasks being performed by the nurse are just some of the challenges being faced by the charge nurse in the emergency department. And these factors and tasks in the ED ultimately affect the quality of the communication between the members of the team. The study emphasized that these findings “are an important measure of communication load, which can disrupt memory and lead to mistakes” (Woloshynowych, 2007, p. 386). The nurse is obliged to prevent communication overload even in the midst of the wealth of information she is obliged to process at any particular time. Issues in communication can be traced back to nurse-physician issues or nurse patient issues. First and foremost, communication problems and issues between the nurses and physicians were usually seen when the physician did not specify his orders to the ER nurses. In one such case, a physician did not specify his orders to ER nurses on an admitted patient. The patient’s condition was not properly monitored and his health consequently deteriorated; he died 5 days later (Anderson, 2005, p. 70). This case demonstrates how the physician often expects the nurse to interpret his orders as inclusive of other orders that he expects to be accomplished. The nurse, on the other hand, avers that her duty is to follow the doctor’s orders and she cannot be expected to perform other duties not specified by the doctor. This creates a dilemma which has disastrous consequences for the patient. In another case, the information given by the nurse to the physician was not sufficient for the latter to make a fair assessment of the patient’s condition (Anderson, 2005, p. 71). The problem in this case stemmed mostly from ambiguous communication between the physician and the nurse. Unfortunately this ambiguity resulted to the patient’s death yet again. The nurse was not thorough in her assessment, and the physician did not ask the nurse the right questions which would have triggered more appropriate action on his part. Moreover, the nurse did not also take on a more assertive quality as a leader in order to accurately determine the patient’s condition. The communication issues which stem from the nurse-physician relationship can be evaluated in terms of division of labour, delegation of authority and departmentalization. Nursing and physician roles which are not clearly defined or designated to each doctor or nurse will eventually result to incidents in the emergency department. The delegation of authority emphasizes the “conscious determination of what roles will have the right to make what decisions” (Arford, 2005, p. 73). The process of delegation would now help further define and create the scope and delimitations of the roles that the nurses and physicians play in the hospital. This process would help organize and structure the roles that the different members of the healthcare team play. Problems of breakdown in any of these aspects would cause incidents in the emergency department and even in other departments of the hospital. When the nurse’s or the physician’s role is not clearly defined and not properly designated, gaps in communication would allow for medical errors to be committed by either parties. Disorganization in the different departments of the hospital would also create problems in the delivery of healthcare services. These communication issues between the nurse and the physician eventually cause tension in the Emergency Department (Stefan, 2006, p. 16). Communication issues stemming from the nurse-patient relationship in the emergency department is mostly seen in instances when there is a language barrier between the nurse and the patient. The patient may speak a different language which the nurse does not speak or understand. In some instances, the patient may speak limited English and he may improperly utilize words in the English language which are different from the words and the message he actually wants to express. The patient may be hearing impaired or he may have a physiological impairment which prevents him from speaking. In emergency cases, any of the above conditions seen in the patient can create issues in his care. Even interpreters can misinterpret the patient’s words if they are not familiar with the colloquialisms of the language they are interpreting and the culture of the patients they are speaking for. Many emergency rooms do not have proper access to interpreters, nor do they have access to sign-language experts. And this can create problems in the care of the patient. Language barriers can have disastrous effects for the patients. “Patients who face such barriers are less likely than others to have a usual source of medical care; they receive preventive services at reduced rates; and they have an increased risk of nonadherence to medication” (Flores, 2006, p. 230). Because of these communication barriers, patients are exposed to risks and medical errors. Accounts from various hospitals demonstrate how language barriers have produced medical errors. Reports of wrong amputated limbs; children traumatized from informing their mother or father of their terminal illness; patients unable to reveal accurate information to doctors because of fear and shame of letting interpreters know about their condition; and interpreters not having a medical background and misinterpreting patient’s or doctor’s words are just some of the incidents that commonly occur as a result of miscommunication and misinterpretation in the emergency rooms (Abramson, 2006). The above issues related to communication require different strategies or solutions. Five of these are presented below. Strategies Various strategies can be used to address the communication issues raised by this paper. These strategies are enumerated as follows: active communication and listening between and among members of the emergency team; setting up an emergency protocol or network for easy access to interpreters and language experts within the hospital; developing a standard assessment tool; using simple language when communicating with patients; and reading back orders. Strategy 1: Active Communication Active communication refers to the “participatory form of communication that promotes change” (Cherry & Jacob, 2005, p. 392). It implies a two way process which entails parties communicating to be actively listening and exchanging ideas with each other. The open and active lines of communication between the nurse and the physician can create a trusting and comfortable environment where both parties can easily understand each other and can know what to expect from each other. In order to achieve active communication between the nurse and the physician, I recommend the SBAR (Situation, Background, Assessment, and Recommendations) model. These aspects in the patient’s care covers important areas which can help the physician make an accurate diagnosis and treatment of the patient. It is a comprehensive tool and technique for assessment, documentation, and reporting which also enables an easier and standardized communication about a patient’s condition (Callahan, 2008). Studies which assessed the application of the SBAR model, established that, through the SBAR, the communication between the physician and the nurse became quicker and the medical surgical teams developed a better appreciation for the value of communication (Callahan, 2008). Between the patient and the nurse, communication can be improved through active listening. The nurse must actively listen to the patient; observe and correctly interpret non-verbal cues; and empathize with the patient’s situation. “Further, the nurse should encourage dialogue that allows the client to hear himself or herself, since this engages individuals in active problem solving, leads them to a new understanding of what is truly important in life” (American Holistic Nurses’ Association, et.al., 2000, p. 71). These techniques in the communication process can help build rapport and trust with the patient. This trusting relationship can consequently give way to more open lines of communication between the patient and the nurse. Strategy 2: Emergency protocol for access to interpreters within the hospital The hospital must also set-up a protocol or standard operating procedure to follow in cases when patients who do not speak the English language or who speak little English are admitted into the ED. In cases where the patients come in without any family members who can speak English, the hospital must immediately call on members of their staff who do speak the language of the patient. These interpreters must be on-call 24 hours a day, and the emergency room must immediately contact them as soon as these patients are admitted. Failing such method of interpretation, the hospital, can connect with language assistance agencies in order to avail of emergency interpreters or phone-assisted translations. These practices are actually already being adapted by various hospitals. Their contact with international language experts have allowed for a more accurate interpretation of their patients’ conditions (Diversity Rx, 2003). Sign-language experts should also be available 24-7. Preferably, one should be in the employ of the hospital. His services should be immediately availed of before any procedure can be performed on the patient. In communicating with hearing impaired patients, it is important to maintain eye contact with the patient. This will help put across the message that the message is being directed to them and for them to understand the importance of the messages being translated to them (Choong-hee, et.al., 2007). Strategy 3: Developing a standard assessment tool Standard assessment tools to be used in the emergency rooms help ensure that all aspects pertaining to the condition of the patient are described and documented by the nurse. These standard assessment tools will subsequently help the physician diagnose and treat the patient. These tools also help focus and standardize the practice. They reduce distractions and serve as reminders to nurses (Pape, 2005). These standard assessment tools help ensure that no information is missed or overlooked by the nurse, and complete information is later endorsed to the physician who will subsequently make the necessary orders for the patient’s care. These standard assessment tools will provide “baseline information [which] will be used to evaluate the effects of therapeutic interventions” (Shergill, 2009). Through these tools, possible causes of the patient’s condition can be accurately determined. After such tool is used, an accurate transmission of information to the physician is now possible. The physician’s decision is based on accurate and holistic information about the patient. The chance of errors occurring due to miscommunication is reduced. There is also better clarity of content especially when telephone orders and referrals are involved (Marshall, 2009, p. 140). Strategy 4: Using the simplest possible language while communicating with the patient Using simple layman’s language in communicating with patients can help minimise misunderstandings between the nurse and the patient. It can also make the plan of care more patient-centred and evidence-based. The patient will easily understand what the doctors and nurses are saying and as a result, he can subsequently make well-informed decisions about his care (Reever, 2002, pp. 62-66). This is especially applicable in cases where the patient does not speak English, speaks limited English, or is hearing impaired. It will help simplify the translation process for the interpreter and help avoid misinterpretations on the part of the patient (Choong-Hee, et.al., 2007, pp. 541-544). It is sometimes very convenient for nurses and other healthcare practitioners to forget that patients do not share their understanding of medical terms. However, some of their patients may incidentally be members of the medical profession, and actually do understand medical terminologies. In these instances, the nurses should adjust accordingly. The important point is that nurses should come up with a patient-based communication approach in order to allow for an individualized plan of care for their patients (Parker, 2000, pp. 277-283). Nurses should remember that standardized methods are not applicable to every patient, and may even discriminate against others. Strategy 4: Reading back orders As much as possible, verbal orders should be avoided. However, in the emergency room, it is often an unavoidable practice because patients with different needs come in at anytime of the day (Parker, ed, 2009, p. 40). It cannot always be assured that physicians trained to handle their condition are in physically present in the emergency room at the time these patients are admitted. Hence, most of the time, the nurses would inform the physicians of the patient’s condition over the phone, and the physician would relay verbal orders for the nurse to carry out. To avoid medical errors resulting from misheard orders from the physician, ‘read-backs’ of these orders can be done by the nurse. This strategy will effectively prevent miscommunication and misinterpretation of orders. Read backs of these verbal or telephone orders “allow for clarification about whether the receiver correctly heard and understood the order” (Wakefield & Wakefield, 2009, pp. 165-168). This strategy is a simple solution to communication issues in the emergency room; they would not cost much time and effort on the part of the physician and the nurse to implement. Strategy and Key Stakeholders I would adapt the standard assessment tool and the read backs strategies previously mentioned above. The standard assessment tool shall be developed in cooperation with the physicians and the nurses in the emergency department of the hospital. The development of this tool shall be based on standards of medical and nursing practice, adapting a holistic and comprehensive assessment process. A series of meetings with the nurses and the physicians shall be conducted until the tool is completed. Such tool shall then be imposed as a compulsory part of the nursing process in the emergency room. Failure to comply with the standards set by the assessment tool shall be met with corresponding management action. I would also compel all nurses to read-back phone-in or verbal orders to doctors for verification. The remedy is a simple process to implement, and yet, it brings innumerable benefits to the patients and to the healthcare team in general. The key stakeholders that I would need to motivate and convince in order to bring them around to my way of thinking would be the physicians, hospital management, and all nurses in the emergency department. I would convince all the three parties to apply the above strategies by presenting statistics on percentage of errors credited to communication issues and problems. I would cite medical malpractice lawsuits involving medical errors committed by physicians and nurses caused mainly by communication issues and problems. After presenting the scenario to them, I would then propose the strategies I have chosen above. I would call attention to the fact that the strategies are very simple to adapt in the hospital. They would not be costly to apply and would not take away too much of their time. What time and effort the strategies would cost them would be sufficiently remunerated with fewer medical errors and more satisfied patients. I would also point out how the hospital would benefit from lesser funds diverted to malpractice lawsuits. I would also convince these stakeholders of the general benefits that these strategies would bring to the patients and to healthcare professionals. Communication is an important aspect of the healthcare process in the emergency department. Communication issues usually involve the patient, the nurse, and the physician; and they are mostly caused by ambiguities in the communication process. And yet these problems can be addressed through standard assessment tools, active listening, and read-backs. The nurse should look into these strategies as important and effective tools in reducing and ultimately eliminating issues in the nursing clinical practice. 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