Communication Techniques for Healthcare Teams

"The greatest problem with communication is the illusion that it has been accomplished." George Bernard Shaw

1. Communication in Healthcare

Communication is a structured process by which information is clearly and accurately exchanged among team members. Clear communication is a key skill of an effective team; however, it remains a challenge for healthcare teams. A meta-analysis of 72 independent studies across a range of industries identified that information-sharing positively predicted the performance of the team.

Multiple interfaces between members require the transmission of information for safe and effective care. These are particular areas where information sharing has been shown to be inadequate:

• transfers between departments or facilities
• high-acuity settings such as emergency rooms or surgery
• handoffs at shift change
• transfers across professional boundaries, such as between doctors and nurses

In a study of hospital unit handovers, less than half of the residents felt confident in their patient handovers. In an observational study, Lingard classified over a quarter of communication events as failures, and 36% of these had visible adverse effects, including inefficiency, waste, delay, tension, and procedural error. Mazaoco et al found that teams who shared information about the patient less frequently at the start of a surgical case and upon transfer post-surgery had double the risk of surgical complications than teams that shared such information frequently. There is also evidence that specific techniques to improve information-sharing can improve clinical management, such as sharing of mental models.

The following strategies can assist team members in clearly and accurately sharing information attentively.

big idea

Always "close the loop" to validate that something was heard and understood. In the military they use the HUA (Heard, Understood, Acknowledged) system.

hint

The following description of tools and case examples have been taken from Team STEPPS™ program and can be found at https://www.ahrq.gov/teamstepps/index.html.

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2. Structured Communication Tools

2a. SBAR

SBAR is a technique for communicating critical information about a patient’s concern that requires immediate attention and action. The technique is intended to ensure the correct information and level of concern is communicated in an exchange between health professionals.

Step	Questions	Example
Situation	What is going on with the patient?	"I am calling about Mrs. Joseph in room 251. Chief complaint is shortness of breath of new onset."
Background	What is the clinical background or context?	"Patient is a 62-year-old female post-op day one from abdominal surgery. No prior history of cardiac or lung disease."
Assessment	What do I think the problem is?	"Breath sounds are decreased on the right side with acknowledgment of pain. Would like to rule out pneumothorax."
Recommendation	What would I do to correct it?	"I feel strongly the patient should be assessed now. Are you available to come in?"

2b. Call-Out

Call-out is a strategy to communicate important or critical information that

• informs all team members simultaneously during emergent situations
• helps team members anticipate the next steps
• directs responsibility to a specific individual responsible for carrying out the task

EXAMPLE

A call-out exchange between a team leader and a resident would be as follows:
Leader: Airway status?
Resident: Airway clear.
Leader: Breath sounds?
Resident: Breath sounds decreased on right.
Leader: Blood pressure?
Resident: BP is 96/92.

2c. Check-Back

This is a simple technique for ensuring information conveyed by the sender is understood by the receiver, as intended, using exchanges like these:

• sender initiates message
• receiver accepts message and provides feedback
• sender double-checks to ensure the message is understood

EXAMPLE

A check-back exchange between a doctor and a nurse would be like this:
Doctor: Give 25 mg. Benadryl IV push.
Nurse: 25 mg. Benadryl IV push.
Doctor: That’s correct.

2d. Handover or Handoff

Handover or handoff is a crucial time where errors in communication can result in adverse outcomes. "I pass the baton" is a strategy to assist timely and accurate handoff.

First letter	Strategy	Description
I	Introduction	Introduce yourself, your role and job, and the name of the patient.
P	Patient	Gather name, identifiers, age, sex, location.
A	Assessment	Present chief complaint, vital signs, symptoms, and diagnosis.
S	Situation	Record current status or circumstances, including code status, level of (un)certainty, recent changes, and response to treatment.
S	Safety concerns	Know about critical lab values or reports, socioeconomic factors, allergies, and alerts (falls, isolation, and so on).
The
B	Background	Learn about co-morbidities, previous episodes, current medications, and family history.
A	Actions	Share what actions were taken or are required. Provide brief rationale.
T	Timing	Determine level of urgency and explicit timing and prioritization of actions.
O	Ownership	Determine who is responsible (person or team), including patient or family.
N	Next	Ask What will happen next? Anticipated changes? What is the plan? Are there contingency plans?

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3. Resolving Disagreement and Conflict

It is important for all members of the team to feel they can speak up when they see something they feel will impact the safety of the patient. The following protocols have been developed to help members of a team express their concerns in a graded manner.

3a. Two-Challenge Rule

The two-challenge rule is designed to empower all team members to “stop” an activity if they sense or discover an essential safety breach. Sometimes someone will make an approach to a team member but be ignored or dismissed without consideration. This will require a person to voice his or her concerns by stating their concerns at least twice if the initial assertion is ignored (thus the name “two-challenge rule”). These two attempts may come from the same person or two different team members.

With the two-challenge rule, it is important to note the following:

• The first challenge should be in the form of a question.
• The second challenge should provide some support for the team members’ concern.
• Remember this is about advocating for the patient—the “two-challenge” tactic ensures that an expressed concern has been heard, understood, and acknowledged.
• The team member being challenged must acknowledge the concerns.
• If this does not result in a change or is still unacceptable, then the person with the concern should take stronger action by talking to a supervisor or the next person up the chain of command.

3b. CUS

CUS is shorthand for a three-step process in assisting people in stopping an activity.

Step	Description
1	I am Concerned.
2	I am Uncomfortable.
3	This is a Safety issue.

3c. DESC Script

DESC describes a constructive process for resolving conflicts.

• Describe the specific situation or behavior and provide concrete evidence or data.
  
• Express how the situation makes you feel and what your concerns are.
  
• Suggest alternative actions and seek agreement.
  
• Consequences should be stated in terms of impact on established team goals or patient safety. The goal is to reach consensus.

Authored by Cindy Ebner, MSN, RN, CPHRM, FASHRM

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Support

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