Open Posted By: ahmad8858 Date: 23/04/2021 Graduate Report Writing

 This assessment requires you address the following topics:

  • Define the seven principles of patient- clinician communication
  • Explain how you apply three of the seven principles to your interactions with your own patients
  • Describe the three methods being used to improve interdisciplinary communication
  • Choose the one that you think applies best to your own area of practice, or the one that your area of practice currently uses, and clearly describe how you use it.
  • Explain the ethical principles that can be applied to issues in patient-clinician communication
  • Explain the importance of ethics in communication and how patient safety is influenced by good or bad team communication
Category: Accounting & Finance Subjects: Finance Deadline: 12 Hours Budget: $120 - $180 Pages: 2-3 Pages (Short Assignment)

Attachment 1


Last updated: 06/07/2017 © 2017 School of Nursing - Ohio University Page 1 of 2


Levels of Achievement

Accomplished Needs Improvement Not Acceptable


(5 Points)

5 to 5 Points

 Clearly states the purpose of the paper.

 Provides a comprehensive overview of topic or questions.

 Engages the reader.

 Organized and has easy follow.

2 to 4 Points

 Overview is provided, but key points/ideas are missing.

 Purpose statement is not clear.

 Does not engage the reader.

 Somewhat disorganized but still comprehensible

0 to 1 Points

 Does not provide an overview of the paper or is


 No purpose statement.




Key Requirement 1 - Principles of


8 to 8 Points

 Clear definition of each of the seven principles with examples of how

three of the seven are applied to the

student's own interactions with


 Evidence of critical thinking.

4 to 7 Points

 Defines each of the seven principles, examples given are not

specific ones from practice but are

general to nursing

 Lacking organization or critical thinking

0 to 3 Points

 Does not provide definitions of each


 no examples given,

 no evidence of critical thinking.

Key Requirement 2 -

Methods of


8 to 8 Points

 Clearly defines and describes each of the three methods of

interdisciplinary communication;

 Chooses one that best applies to own practice, gives a clear

discussion of how the student uses that method.

4 to 7 Points

 Lists the three methods of interdisciplinary communication

but does not describe each in


 Does choose the one that applies

best, but discussion is disorganized.

 More detail is needed.

0 to 3 Points

 Discussion of methods of interdisciplinary

communication is weak

and disorganized;

 Example given is weak

and disorganized.

 No evidence of critical thinking.

Key Requirement 3 -

Ethical Principles and


8 to 8 Points

 Student clear defines at least four ethical principles that can be

applied to patient clinician

communication and gives clear

examples of each;

 Explains the impact of ethical communication and how patient

safety is impacted by team


 Thoughts are well organized, each topic is thoroughly addressed.

4 to 7 Points

 Student defines two to three ethical principles that can be applied to

patient clinician communication

and gives examples, but may be

missing depth;

 Touches on patient safety and impact of ethics in communication.

 Thoughts are somewhat disorganized, scattered

0 to 3 Points

 Student's writing is difficult to follow;

 Difficult to determine if all subjects have been


 No evidence of critical thinking.


(5 Points)

5 to 5 Points

 Summarizes paper and reflects on what the reader has learned from

the paper.

 Demonstrates persuasive thought and is well organized.

2 to 4 Points

 Merely summarizes the introduction or contains new ideas

not present in the paper contents.

 Somewhat disorganized but still comprehensible

0 to 1 Points

 Simply restates the introduction or is absent.

 Disorganized to the point of distraction.


Last updated: 06/07/2017 © 2017 School of Nursing - Ohio University Page 2 of 2


Levels of Achievement

Accomplished Needs Improvement Not Acceptable


(6 Points)

6 to 6 Points

 APA Citations are appropriate.

 Formatted correctly.

 Reference page is complete and correctly formatted.

 At least 4 references provided: Two (2) references from required course

materials and two (2) peer-reviewed

references. *References not older than five years.

 More than 600 words excluding title and reference pages.

3 to 5 Points

 APA Citations are appropriate and formatted correctly.

 Reference page is formatted correctly.

 References are not professional or is not formatted correctly.

 Missing 1 professional reference.

 At least 600 words or more excluding title and reference pages.

0 to 2 Points

 No citations are used or citations are made but

not formatted correctly

 Reference page is missing.

 Less than 600 words excluding title and reference pages.

Peer-reviewed references include professional journals (i.e. Nursing Education Perspectives, Journal of Professional Nursing, etc. –), professional organizations (NLN, CDC, AACN, ADA, etc.) applicable to population and practice area, along with clinical practice guidelines (CPGs - National Guideline Clearinghouse). References not acceptable (not inclusive) are UpToDate, Epocrates, Medscape, WebMD, hospital organizations, insurance recommendations, & secondary clinical databases. *All references must be no older than five years (unless making a specific point using a seminal piece of information) Note: You will have three (3) attempts to submit a written assignment, only the final attempt will be graded. For each attempt you will receive a SafeAssign

originality report. This will give you a chance to correct the assignment based on the SafeAssign score. Click here to view instructions on how to interpret SafeAssign originality report.

Attachment 2


50 august 5 :: vol 29 no 49 :: 2015 NURSING STANDARD

Abstract Teamwork requires co-operation, co-ordination and communication between members of a team to achieve desired outcomes. In industries with a high degree of risk, such as health care, effective teamwork has been shown to achieve team goals successfully and efficiently, with fewer errors. This article introduces behaviours that support communication, co-operation and co-ordination in teams. The central role of communication in enabling co-operation and co-ordination is explored. A human factors perspective is used to examine tools to improve communication and identify barriers to effective team communication in health care.

Author Heather Gluyas Associate professor, School of Health Professions, Murdoch University, Mandurah, Western Australia. Correspondence to: [email protected]

Keywords Communication, co-operation, human factors, patient safety, revalidation, structured communication tools, team briefing, teamwork

Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.

Revalidation Prepare for revalidation: read this CPD article, answer the questionnaire and write a reflective account. Go to www.rcni.com/revalidation

Online For related articles visit the archive and search using the keywords above.

To write a CPD article: please email [email protected] Guidelines on writing for publication are available at: journals.rcni.com/r/author-guidelines

E�ective communication and teamwork promotes patient safety NS805 Gluyas H (2015) Effective communication and teamwork promotes patient safety. Nursing Standard. 29, 49, 50-57. Date of submission: March 15 2015; date of acceptance: May 14 2015.

Aims and intended learning outcomes This article aims to inform the reader about effective teamwork and communication. The behaviours required for effective teamwork, the key elements of effective communication and common tools that support successful communication within a team are discussed. After reading this article and completing the time out activities you should be able to:  Explain the pivotal role of effective

teamwork in promoting patient safety and quality care.  Describe the behaviours that are required for

effective teamwork.  List the barriers to effective communication

in health care.  Describe common tools that can be used to

improve team communication.  Relate effective communication to your own

practice.  Develop your communication skills in your

team environment.

Introduction Teamwork involves a group of people working together to achieve a common purpose (St Pierre et al 2011). Teamwork requires co-operation, co-ordination and communication between members of a team to achieve desired outcomes. In industries where there is high risk, such as health care, effective teamwork has been shown to achieve team goals successfully and efficiently, with fewer errors. Conversely, poor teamwork has been shown to result in errors and suboptimal outcomes (Walker 2008, Donohue and Endacott 2010, Lee et al 2012, Lyons and Popejoy 2014).

This article introduces behaviours that support communication, co-operation and co-ordination in teams, and explores the central role of communication in enabling

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NURSING STANDARD august 5 :: vol 29 no 49 :: 2015 51

co-operation and co-ordination. A human factors perspective is used to identify barriers to effective team communication in health care and to examine tools that improve communication. Complete time out activity 1

In health care, teamwork is integral to providing safe and effective care to patients. The importance of effective teamwork in response to the growing complexity of care involving chronic conditions and associated comorbidities is increasingly recognised (St Pierre et al 2011). Most patient encounters involve more than one healthcare professional and may involve many people, depending on the type of healthcare problem. These individuals may include doctors, nurses, allied health professionals and other specialist professionals. Teams from different healthcare sectors, such as primary care, acute care, mental health or chronic care, may also be involved. Effective communication – both verbal and written – between team members and between different teams is essential to ensure co-operation and co-ordination of care.

Ineffective communication, which leads to poor co-operation and co-ordination of care, is a major cause of errors and adverse events in patient care (World Health Organization 2009). Communication errors occurring at handover, either between team members or between different teams, may lead to inaccurate diagnosis, incorrect treatment and/or medication errors (Wong et al 2008). Poor communication in teams leads to team members having different perceptions of situations and of what is required to manage them (Brady and Goldenhar 2014). Such differing perceptions of a situation among team members may be viewed as the lack of a shared mental model, and this has been shown to contribute to serious safety events (Gluyas and Morrison 2013, Brady and Goldenhar 2014). Moreover, a lack of effective team communication has been shown to contribute to delayed response to deteriorating patients (Endacott et al 2007). Patient safety in surgical interventions may be compromised if there is poor team communication (Lyons and Popejoy 2014). This may result in serious adverse events such as wrong patient, procedure and/or site; retained instruments; infections; and unanticipated blood loss (Treadwell et al 2014).

Thomas et al (2013) examined data from 459 patient safety incidents relating to clinical handover in acute care settings. They found

that 28.8% of incidents (n=132) involved transfer of patients without adequate handover, 19.2% of incidents (n=88) involved omissions of critical information about the patients’ condition and 14.2% of incidents (n=65) involved omission of critical information in patients’ care plans.

Poor communication is not limited to incidents in the acute sector. It may also be a factor in poor outcomes when transferring care between sectors, such as from primary care to the acute sector and back again (Russell et al 2013). There is a convincing case for investing time and resources in improving communication and teamwork in health care to improve patient safety. Complete time out activity 2

Teamwork behaviours Teams are composed of individuals with different knowledge, skills and attributes, who all contribute particular characteristics to team performance. However, for a team to perform successfully, individuals must share an understanding of what is required to achieve the desired goal (Endsley 2012). This means team members must work individually to carry out their duties while maintaining an awareness of the need for the collective contribution of team members (Gluyas and Morrison 2013). The skills that contribute to successful teamwork include team leadership, mutual support, situation monitoring and effective communication (Baker et al 2012). Table 1 indicates the knowledge and behaviours that are required to demonstrate these skills.

Communication Communication is necessary in each of the skills team members require to contribute to an effective team (Table 1) and may be considered as the basis for effective teamwork. It may involve spoken communication, non-verbal (gestures, facial expression) and/or written language. It involves one person initiating a message, along with receipt of this message by another person or persons (St Pierre et al 2011). However, the powerful effect of cognitive processes on the communication process should be understood and recognised, since this is central to promoting effective communication. A human factors perspective provides a framework for understanding these effects and considers the

2 Read the case study in Box 1. Draw a diagram indicating the different teams that may have been involved in Mary’s care in the community and in hospital. Identify specific points where effective teamwork and communication were required between team members and teams.

1 Before completing this article, recall a time when you were part of a team that did not work well together. Write down the factors and behaviours that may have contributed to this. Once you have completed the article and reviewed Table 1, add any factors you may have omitted from this list.

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52 august 5 :: vol 29 no 49 :: 2015 NURSING STANDARD

CPD communication

effect of systems, environments, equipment and processes on human cognitive abilities and limitations (Catchpole 2013).

Human cognition is a dynamic process that allows people to perceive, interpret and make decisions about required actions (Gluyas and Morrison 2013). The cognitive load is relatively low when undertaking well-known tasks in familiar situations. In such instances, humans are able to carry out tasks in a somewhat automatic manner with little conscious thought. However, in unfamiliar or complex situations, humans must use increased conscious attention to process what is going

on around them and what actions are required. Cognitive overload may occur if the situation is complex, for example where constantly changing circumstances require intense cognitive attention to process what is happening (Endsley 2012). Several cognitive processing failures may then arise, including attentional tunnelling, confirmation bias, memory failures (slips and lapses) and inaccurate mental models (Endsley 2012) (Table 2). These limitations in cognitive processing may be precipitated or exacerbated by workload pressures, time pressures, stress, anxiety, fatigue, poor team relationships, constant interruptions and changing situational requirements (St Pierre et al 2011).

The cognitive load of the individuals involved in the communication may affect their processing of the information. Communication failures may occur if an individual is in a situation where there is cognitive overload, for example because of the volume of data they are trying to process. Transmission failures may arise from incomplete, incorrect, ambiguous or unclear messages, while reception failures may arise because the message is misinterpreted, disregarded or not processed and retained in memory (Endsley 2012). Therefore, it is important to recognise the context of communication and the individual stresses that might affect the communication process. The communication process itself is only one aspect of effective communication; there are additional barriers that may lead to communication failures.

Barriers to e�ective communication General factors that can increase the likelihood of communication failures in any setting include differences in gender, culture, ethnicity, education and styles of communication. Also, there are contextual and cultural issues specific to healthcare settings that may affect communication in healthcare teams.

One major difference between health care and many other environments is the existence of a hierarchical system, both among different health professional groups and among senior and junior staff in the same professional group (Nugus et al 2010). This hierarchy results in an authority gradient; those further down the hierarchy may be hesitant to challenge those further up the hierarchy, raise concerns or ask questions. In a situation where one member of the team feels there may be a patient safety issue, or has concerns of some kind, they may not feel comfortable raising this or discussing their concerns with the team (Makary et al 2006, Reid and Bromiley 2012).

Teamwork skills and required behaviours TABLE 1

Skill Required behaviours

Leadership  Communicate awareness and understanding of the desired outcome.

 Communicate understanding of purpose, team roles, responsibilities, task requirements and plan.

 Plan and allocate tasks.

Mutual support  Provide feedback to other team members when required.

 Provide and request assistance when required.  Trust in other team members and have confidence

in their actions and intentions.

Situation monitoring  Review ongoing team performance.  Adjust, adapt and reallocate tasks and

responsibilities as required.

Communication  Share information with other team members.  Communicate clearly using objective language,

correct terminology and structured processes or tools, where available.

 Acknowledge communication and check for correct interpretation (closed loop communication).

(Miller et al 2009, Baker et al 2012, Gluyas and Morrison 2013)

Case study 1: Mary BOX 1

Mary presented to the GP feeling unwell, with pain in her right leg of several days’ duration. On examination the GP identified that Mary had tenderness and swelling in her right calf; she denied any falls or other incidents that may have caused this. Since Mary had recently taken a flight overseas, the GP suspected a deep vein thrombosis (DVT). The GP ordered an ultrasound scan and blood test, which were positive for DVT, and Mary was commenced on oral anticoagulation therapy. Later that day, she presented to the emergency department with acute shortness of breath and was admitted with a diagnosis of pulmonary embolus. She was commenced on parenteral anticoagulation and respiratory support. After several days, Mary improved and was discharged into the care of the GP for monitoring of ongoing anticoagulation therapy, and the community nursing service, which would provide home visits and support during the recovery phase.

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NURSING STANDARD august 5 :: vol 29 no 49 :: 2015 53

An example that illustrates this authority gradient is provided in Reynard et al (2009). A child experienced facial burns from a dry swab that caught fire from the diathermy machine during maxillofacial surgery. The surgeon immediately changed his practice to using wet swabs, but ascertained from colleagues that they previously changed to this practice because the risk of using dry swabs had already been identified. When the surgeon asked nursing staff why they did not inform him of this practice, they indicated that he had discouraged suggestions in the past, so they did not feel comfortable raising issues about his surgical practice (Reynard et al 2009).

Other studies confirm that reluctance to speak up about possible patient risk is an important factor in communication errors (Leonard et al 2004, Makary et al 2006, Mackintosh and Sandall 2010, Carayon 2012, Lyndon et al 2012, Okuyama et al 2014). Lyndon et al (2012) reported that 12% of staff were unlikely to speak up even when there was high risk; this reluctance was related to previous rudeness or intimidation from other staff. Other factors that contribute to this hesitancy include poor leadership and relationships in the healthcare team, fear of the responses of others, and concerns about appearing incompetent in ambiguous or complex clinical situations (Okuyama et al 2014).

Differing communication styles between doctors and nurses may exacerbate authority gradients that exist in health care. Doctors are educated on a scientific basis that emphasises cure and treatment in the management of patient care. This results in a communication style that tends to be succinct, with a focus on scientific facts. Nurse education is informed by science but has a holistic focus on caring linked to treatment and management. Nurses’ communication style differs from that of doctors in that it tends to be more narrative, rather than concisely factual (Wachter 2012). Communication between different professional groups can lead to misunderstanding and misinterpretation of the message being communicated, because different professional staff have expectations of others that are not explicitly communicated (Donohue and Endacott 2010).

Implicit expectations, or those not explicitly communicated, may also be described as a ‘hint and hope’ dialogue. This can result in the sender and receiver failing to communicate, with the sender

hinting at what is required and the receiver completely missing their message. One example of this is the case of Elaine Bromiley, a patient who died following a failed intubation for a surgical procedure (Reid and Bromiley 2012, Bromiley 2014). During the emergency situation, the medical staff involved were focused on continuing to try to intubate; the patient became severely hypoxic, resulting in her death 13 days later (Walker 2008). The authority gradient discouraged any direct assertion by the nurses that the situation was an emergency. When a nurse brought in the tracheostomy tray (without being asked) and stated that it was ready, the implicit message was: ‘I have brought in the tracheostomy tray because you need to look at alternative airway access for oxygenation.’ This was not the message received by the medical staff, who remained focused on the task of intubating the patient and ignored the interruption (an example of attentional tunnelling, Table 2). A second nurse was also ignored when she stated that she had contacted the intensive care unit (ICU) for a bed. The implied message was: ‘I have contacted ICU because this is an emergency and I am worried about the patient’s deteriorating observations.’ However, the nurse’s comments were not interpreted in this way. The communication failures were a result of differing communication styles, as well as the authority gradient and the cognitive overload of the medical staff attempting to manage the situation.

Cognitive processes to manage challenging situations

Cognitive process Description

Attentional tunnelling Focusing cognitive attention on one aspect of a situation that is proving challenging in terms of understanding or task completion, while ignoring other information from the environment or context.

Confirmation bias A tendency to consider only confirming evidence and to disregard evidence that does not confirm.

Memory failures (slips and lapses)

Memory failures are associated with automatic behaviour, where we intend to do something but our attention is focused elsewhere. We either forget to carry out an action (lapse), or undertake steps of an action in the wrong order or leave out a step entirely (slip).

Inaccurate mental models

Erroneous mental models of events and what decisions or actions are required, resulting from flawed perception or comprehension of a situation.

(Adapted from Endsley 2012)


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54 august 5 :: vol 29 no 49 :: 2015 NURSING STANDARD

CPD communication

In health care, teams are often not fixed or established, but have come together for a specific purpose. They have not had time to establish roles and responsibilities or to articulate clearly the apparent objectives of the team (Wachter 2012). This can lead to different perceptions or mental models of the situation and the required outcomes. Shift work, long hours leading to fatigue, and other common factors in health care, such as distractions, interruptions, workload and time pressures, add to these different perceptions. Therefore, it is not surprising that poor communication within teams contributes to errors and poor patient outcomes. It is imperative to develop strategies that decrease the likelihood of communication failures arising from authority gradients, from differing professional communication styles and from cognitive failures such as those listed in Table 2.

Strategies to improve team communication in health care Many strategies to improve communication rely on organisational structures and processes. These strategies include education and training programmes that focus on improving communication in teams and developing an understanding of barriers to effective communication, such as authority gradients and different communication styles. Such programmes have been shown to improve teamwork and communication (Stead et al 2009, Gorman et al 2010, Baker et al 2012, Bunnell et al 2013). Other organisational strategies to improve communication include implementing practices such as checklists and read-back protocols for different clinical situations, instigating structured communication tools and introducing briefing and debriefing procedures in teams (Lepman and Hewett 2008, Gorman et al 2010, Knox and Simpson 2013, Brady et al 2013, Goldenhar et al 2013, Lyons and Popejoy 2014). These steps require commitment from the organisation’s leadership team and provision of resources. However, healthcare professionals can still use many of these strategies, even in the absence of formal organisational support, as is discussed in this article.

Team brie�ng and debrie�ng The purpose of team briefing, huddles and debriefing is to diminish authority gradients and enable common agreement on the team’s objectives and intended outcomes (Wachter 2012, Goldenhar et al 2013). Briefings may take the

form of a pre-procedure or pre-shift pause, during which team members articulate their roles and responsibilities and discuss the intended outcomes. This may identify agreed protocols that are intended to alert team members to changing conditions or other important information (Brady and Goldenhar 2014).

Huddles are ongoing team briefings that occur throughout the period the team is working together. They involve team members coming together frequently for short periods to review and make plans for ongoing care. If used effectively, this strategy addresses problems with overload or limited short-term memory capacity, establishes safeguards in the process and improves the effectiveness of communication in the team. The essential elements of a huddle are that it is short, it has a team facilitator, discussion is encouraged based on data and the focus is on problem solving and solutions planning (Goldenhar et al 2013).

Debriefings involve the team coming together at the end of a shift or procedure to discuss what went wrong and what went well (St Pierre et al 2011). Team performance is improved through the lessons learned. Debriefings enable team members to recognise opportunities to speak up in critical situations, or instances of communication failure, for example, attentional tunnelling, confirmation bias, memory failures and inaccurate mental models. Facilitation and leadership are essential to ensure a safe, blame-free environment for debriefing, in which all team members feel comfortable to discuss aspects of the team performance explicitly (Wachter 2012).

Structured communication tools Structured communication tools address problems that may arise as a result of authority gradients, different professional communication styles and cognitive limitations. These tools establish safeguards in processes, reduce the steps and variability in processes and increase the likelihood of effective communication (Lee et al 2012). Many different tools have been developed to provide an objective framework for structured communication between clinicians in response to concerns about a patient’s condition (Gluyas and Morrison 2013). For example, the SBAR tool, where the mnemonic (Gluyas and Morrison 2013) indicates:  Situation: what is going on with the patient?  Background: what is the clinical background

or context?  Assessment: what do I think the problem is?

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NURSING STANDARD august 5 :: vol 29 no 49 :: 2015 55

 Recommendation or response: what do I think should be done in what time frame?

Practice is required to use this form of communication, to implement it and to overcome any hesitancy that may occur because of authority gradients. However, objective communication focused on data decreases the likelihood of misunderstanding and minimises problems with implicit communication styles (Lee et al 2012). Variants of the SBAR structured communication tool have been developed for use in handover of patient care to other clinicians (Porteous et al 2009). Complete time out activity 3

Managing the authority gradient can be difficult, and the CUS structured tool may be particularly useful in this situation. The tool provides a communication process for escalation, to focus attention when there are safety concerns that are not being acknowledged or addressed by other members of the team (Mackintosh and Sandall 2010). The CUS tool involves individuals using the following prompts to communicate:  I am Concerned.  I am Uncomfortable.  This is a Safety issue. For example, in a situation where a patient is deteriorating and the nurse has been unable to get a response for urgent review from a clinician, the nurse might contact that clinician again, or a more senior member of staff, and express their concern using the phrase ‘I am concerned’, stating the reasons for this. If there is still no timely response, the nurse could contact the team leader or a senior clinician and repeat their concern, using the phrase ‘I am uncomfortable’. If there is still no response, the nurse could contact the senior clinician or management and use the phrase ‘This is a safety issue’, again expressing their concerns about the patient’s condition and the lack of timely response.

The escalation in the CUS tool should be used only for serious and urgent issues, where the concern is significant. If the concerns raised are not addressed adequately, then it may be necessary to escalate them, bypassing the person with whom the concerns were initially raised. By using the objective language of the CUS tool, the focus remains on patient safety.

It is important to note that organisations have policies or procedures for escalation when urgent clinical concerns are not being addressed. The nurse should comply with

these protocols. The CUS tool is an ideal tool to guide the communications. Complete time out activity 4

There are several other structured communication tools that may be used to hand over the care of patients to other clinicians. These include the SHARED communication tool, where the mnemonic indicates Situation, History, Assessment, Risks, Expected outcomes and Documentation (Hatten-Masteron and Griffiths 2009), and I PASS THE BATON, where the mnemonic indicates ‘Introduction, Patient, Assessment, Situation, Safety concerns, THE Background, Actions, Timing, Ownership and Next’ (Youngberg 2013).

With the exception of CUS, all these communication tools can be used for both verbal and written communication (CUS is usually used in time-critical situations that require immediate response). The tools provide an objective framework for communication for both the sender and receiver of the message, decreasing the cognitive load that may lead to communication failures.

Checklists and read-back protocols Checklists and read-back protocols can be useful tools in assisting to prevent communication breakdowns, since they provide a visual format for standardised communication (Lyons and Popejoy 2014, Treadwell et al 2014). They act as ‘memory joggers’ to decrease the likelihood of cognitive slips and lapses associated with automatic tasks. They also provide a prompt

4 Review the case study in Box 2. Assume that the SBAR communication with the doctor has not elicited an appropriate response. Samuel’s respiratory rate is decreasing further and he can be roused only with difficulty. Using the CUS headings (‘I am concerned’, ‘I am uncomfortable’, ‘This is a safety issue’), write down how the nurse could objectively convey concern about the patient’s deteriorating condition.

3 Read the case study in Box 2. Identify the barriers to effective communication demonstrated in this situation. Using the SBAR communication tool – with the headings ‘situation’, ‘background’, ‘assessment’ and ‘recommendation’ or ‘response’ – write down how the nurse could communicate in an objective way the clinical information underlying concern about the …

Attachment 3

Patient-Clinician Communication: Basic Principles and Expectations

Lyn Paget, Paul Han, Susan Nedza, Patricia Kurtz, Eric Racine, Sue Russell, John Santa, Mary Jean Schumann, Joy Simha, and Isabelle Von Kohorn*

June 2011

Discussion Paper

*Working Group participants drawn from the Best Practices Innovation Collaborative and the Evidence Communication Innovation Collaborative

of the IOM Roundtable on Value & Science-Driven Health Care

Advising the nation • Improving health

The views expressed in this discussion paper are those of the authors and not necessarily of the authors’ organizations or of the Institute of Medicine. The paper is intended to help inform and stimulate discussion. It has not been subjected to the review procedures of the Institute of Medicine and is not a report of the Institute of Medicine or of the National Research Council.

Patient-Clinician Communication: Basic Principles and Expectations

Lyn Paget, Paul Han, Susan Nedza, Patricia Kurtz, Eric Racine, Sue Russell,

John Santa, Mary Jean Schuman, Joy Simha, and Isabelle Von Kohorn 1


Marketing experts, decision scientists, patient advocates, and clinicians have developed a

set of guiding principles and basic expectations underpinning patient-clinician communication.

The work was stewarded under the auspices of the Best Practices and Evidence

Communication Innovation Collaboratives of the Institute of Medicine (IOM) Roundtable

on Value & Science-Driven Health Care. Collaborative participants intend these principles and

expectations to serve as common touchstone reference points for both patients and clinicians, as

they and their related organizations seek to foster the partnership and patient engagement

necessary to improve health outcomes and value from care delivered.


Health care aims to maintain and improve patients’ conditions with respect to disease,

injury, functional status, and sense of well-being. Accomplishment of these aims is predicated

upon a strong patient-clinician partnership, in which the insights of both parties are drawn upon

to guide delivery of the best care, tailored to individual circumstances. An important component

of this partnership is effective patient-clinician communication.

In the 2001 IOM report Crossing the Quality Chasm, patient-centeredness was defined

as one of the six key characteristics of quality care and has continued to be emphasized

throughout the IOM’s Learning Health System series of publications. Dimensions of patient-

centeredness include respect for patient values, preferences, and expressed needs along with a

focus on information, communication, and education of patients in clear terms. Consistent and

effective communication between patient and clinician has been associated in studies not only

with improved patient satisfaction and safety, but also ultimately with better health outcomes,

and often with lower costs. Breakdowns of communication, or disregard for patient

understanding, context, and preferences, have been cited as contributors to health care disparities

and other counterproductive variations in health care utilization rates. Moreover, professional

ethics in health care stress the intrinsic importance of respectful and effective

communication as a core aspect of informed consent and a trusting relationship. In an era of increasingly personalized medicine and escalating clinical complexity, the

importance of effective communication between the patient and the clinician is greater than ever.

As the ultimate stakeholders, patients should expect an active role in, and often shared

responsibility for, making care decisions that are best for them. Clinicians, in turn, should respect

and support patients in this role, valuing their input and prioritizing their preferences in shaping

care choices.

1 Working Group participants drawn from the Best Practices Innovation Collaborative and the Evidence

Communication Innovation Collaborative of the IOM Roundtable on Value & Science-Driven Health Care.

Copyright 2012 by the National Academy of Sciences. All rights reserved.


Whether considering risks and benefits or personal values and preferences, patients and

clinicians each have unique and important information to contribute to understanding and

deciding on prevention, diagnosis, or treatment options. Obtaining the highest-value care for

each individual requires establishing common goals and expectations for care through shared

deliberation that marshals the best information. Effective communication therefore requires

clarity about patient and clinician roles, responsibilities, and expectations for health care;

principles to guide the spirit and nature of patient-clinician communication; and approaches to

tailor communication appropriately to circumstances (e.g., routine care, chronic disease

management, life-threatening disease) and individual patient needs (e.g., health literacy and

numeracy, living circumstances, language barriers, decision-making capacity).

Passage of the Patient Protection and Affordable Care Act of 2010 offers both

opportunity and mandate to reorient strategies, incentives, and practices in support of health care

that reliably delivers Americans the best care at the highest value—care that is effective, efficient,

and most appropriate for the circumstances. As an element of best practice, the effectiveness of

patient-clinician communication can be as important as that of a diagnostic or treatment tool and

should be the product of similarly systematic assessment and evaluation. The principles and

expectations identified in this document offer a framework to evaluate and improve patient-

clinician communication, and to sharpen and focus patient discussion tools, patient safety

assessment (e.g., the Agency for Healthcare Research and Quality [AHRQ], the National Quality

Forum [NQF], organizational and individual performance assessment and quality improvement

efforts (e.g., Consumer Assessment of Healthcare Providers and Systems [CAHPS], and

clinician certification processes (e.g., the American Board of Internal Medicine [ABIM]).



Many factors affect the quality and clarity of communications between patients and

clinicians. However, at the core of the matter, certain basic principles pertain and serve as the

starting point for the expectations of patients and clinicians: mutual respect, harmonized goals,

a supportive environment, appropriate decision partners, the right information, full

disclosure, and continuous learning.

Patient-Clinician Communication Basic Principles

1. Mutual respect 2. Harmonized goals 3. A supportive environment 4. Appropriate decision partners 5. The right information 6. Transparency and full disclosure 7. Continuous learning


Drawing from these principles, the basic individual and mutual expectations of both

patients and their clinicians can be identified. These expectations are discussed below and

summarized in the accompanying box.

1. Mutual respect

Each patient (or agent) and clinician engaged as full decision-making partners.

Communication should seek to enhance health care decision making through the exchange

of information and by supporting the development of a partnership relationship—

whenever possible—based on trust and focused on the whole patient. This includes

considering psychosocial needs, identifying and playing to the patient’s strengths, and

building on past experience to meet immediate needs and anticipate future concerns.

Respect for the special insights that each brings to solving the problem at hand.

Information exchange should be characterized by listening, inquiry, and facilitation that is

both active and respectful on the part of both the patient and the clinician. Information

needs include patients’ ideas, preferences, and values; living and economic contexts that

may affect patients’ health or decision making; the basis and evidence for alternative

choices and recommendations; and uncertainties related to the proposed course of action.

2. Harmonized goals

Common understanding of and agreement on the care plan. Full understanding—to the

extent practicable—of care options and the associated risks, benefits, and costs, as well as

patient preferences and expectations, should lead to an explicit determination of the shared

agenda and goals. Factors should include health, lifestyle, and economic preferences and

should accommodate language or cultural differences and low health literacy.

3. A supportive environment

A nurturing and secure services environment. The success of the care plan depends on the

attention paid in the service setting to patient culture, skills, convenience, information,

costs, and implementation of the care decision.

A nurturing and secure decision climate. The comfort and ability of the patient and

clinician to speak openly is paramount to discussion of potentially sensitive issues inherent

to many health decisions.

4. Appropriate decision partners

Clinicians, or clinician teams, with skills appropriate to patient circumstances. With

increasingly complex problems, and time often a factor for any individual clinician, it is

important to ensure that the patient has access to clinicians with skills appropriate to a

particular encounter; that, as indicated, alternative clinician opinions are embraced; and

that provisions are made for the communication needed among all relevant clinicians.


Assurance of competence and understanding by patient or agent of the patient.

Understanding by both patient and clinician is crucial to arriving at the most appropriate

decision. Understanding of patient options is important: how specific they are to

circumstances; the associated risks, benefits, and costs; and the needed follow-up. If

indicated, an appropriate family member or similar designee should be identified to act as

the patient’s agent in the care process.

5. The right information

Best available information at hand, choices and trade-offs thoroughly discussed. The

starting point for shared decision making should be the sharing of all necessary

information. When working collaboratively to craft an appropriate care plan, clinicians

should provide evidence concerning risks, benefits, values, and costs of alternative

options. All options should be discussed to bring out patient preferences, goals, and

concerns and to explicitly consider the impact of various options on these issues.

Presentation by patient of relevant perceptions, symptoms, personal practices. The

clinician’s appreciation and understanding of patient circumstances depends on accurate

sharing by the patient of perceptions, symptoms, life events, and personal practices that

may have a bearing on the condition and its management.

6. Transparency and full disclosure

Candid and explicit acknowledgment to patient of limits in science and system. A basic

element of the care process is comprehensiveness and candor with respect to the limits of

the evidence, delivery system constraints, and costs to the patient that may affect the range

of options or the effectiveness of their delivery.

Patient openness to clinician on all relevant circumstances, preferences, medical history.

Only by understanding the patient’s situation can the most appropriate care be identified.

Patient and family or agent openness in sharing all relevant health and economic

circumstances, preferences, and medical history ensures that decisions are made with

complete understanding of the situation at hand.

7. Continuous learning

Effective approach established for regular feedback on progress. Identification and

implementation of a system of feedback between patients and clinicians on status,

progress, and challenges is integral to the development of a learning relationship that is

flexible and can adapt to changing needs and situations.

Established periodicity for course assessment and alteration as necessary. Early

specification of treatment strategy, expectations, and course correction points is important

for ongoing assessment of care efficacy and to alert both clinician and patient to possible

need for care strategy changes.



These principles and expectations offer general guidance for successful patient-clinician

communication. Moderating factors or constraints present in individual circumstances require

certain tailored approaches and expectations for a particular visit—still with the aim of

maximizing faithfulness to these principles to the fullest practical extent. Examples of such

considerations include:

Expectations 1. Mutual respect

Each patient (or agent) and clinician engaged as full decision-making partners. Respect for the special insights that each brings to solving the problem at hand.

2. Harmonized goals

Common understanding of and agreement on the care plan. 3. A supportive environment

A nurturing and secure services environment. A nurturing and secure decision climate.

4. Appropriate decision partners

Clinicians, or clinician teams, with skills appropriate to patient circumstances. Assurances of competence and understanding by patient or agent of the patient

5. The right information

Best available evidence at hand, choices and trade-offs thoroughly discussed. Presentation by patient of relevant perceptions, symptoms, personal practices.

6. Transparency and full disclosure

Candid and explicit acknowledgement to patient of limits in science and system. Patient openness to clinician on all relevant circumstances, preferences, medical history.

7. Continuous learning

Effective approach established for regular feedback on progress. Established periodicity for course assessment and alteration as necessary.


Visit reason


Chronic condition management

Acute or urgent episode

Decision characteristics

Number of decisions to be made during the visit

Certainty, uncertainty, and relevance to the available evidence

Decisions related to a preference-sensitive arena or choice

Access to and use of the Internet

Patient characteristics

Functional capacity (level of physical or mental impairment)

Communication capacity (language, literacy/numeracy, speech disorder)

Receptivity (motivation, incentives, activation, learning style, trust level)

Support (skilled family or other caregiver, financial capacity)

Living situation (housing, community, grocery, pharmacy, recreation, safety)

Clinician and practice characteristics

Patient volume and complexity

Patient support systems (language aids, interpreters, physical space, digital capacity)

Decision support systems (digital platform, information access, decision guidance)

Professional team profile and culture

Condition-specific skill network and referral follow-up systems

Reimbursement and other economic barriers



As touchstone reference points for patients and clinicians, the principles and expectations

presented here are vital to achieving the full measure of potential health outcomes and value

from care delivered. But achieving that potential requires intent, commitment, and creativity in

developing the tools and processes for adaptive targeting in the myriad conditions and

circumstances found in different health care settings. Noted below are questions that may

stimulate thought, conversation, and innovative approaches to their successful implementation in

various settings and circumstances.

For clinicians and health care organizations

How are we doing now with respect to the principles and expectations?

For which of them is our current culture and practice pattern most challenging?

What initial steps might be good starting points for systems changes necessary?


How can we enlist patients and staff working together to help develop and lead?

How can we take advantage of initiative and help from professional societies?

What community tools or resources might be adaptable for us?

How can we measure the impact for feedback to patients and staff on the results?

For patients, consumers, and advocates

What makes a clinician a good listener?

What should we expect in conversations about health care with clinicians?

How can available care and condition-specific materials be more easily understandable?

Are there helpful ways to judge a care setting’s support of effective communication?

What should we expect from clinicians to help interpret medical evidence?

How can we best help clinicians in their efforts to improve information sharing?

How will “continuous learning” from my care lead to better health care?

For professional societies, policy makers, health plans, insurers, and employers

How do current practices compare with the principles and expectations?

What ought to be our expectations for clinicians we support?

What metrics will be most useful for quality improvement and feedback?

What tools are most needed to assist in application and site-specific tailoring?

Can we develop case material to illustrate approaches and feasibility?

What information can help demonstrate material returns in outcomes and value?

Which reimbursement incentive structures are most important to consider?


Godolphin, W. 2009. Shared decision-making. Healthcare Quarterly. 12:e186-190.

IOM (Institute of Medicine). 2001. Crossing the Quality Chasm: A New Health System for the

21st Century. Washington, DC: The National Academies Press.

______ . 2003. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.

Washington, DC: The National Academies Press.

Stewart, M., J. B. Brown, H. Boon, J. Galajda, L. Meredith, and M. Sangster. 1999. Evidence on

patient-doctor communication. Cancer Prevention and Control. 3(1):25-30.

Stewart, M. A. 1995. Effective physician-patient communication and health outcomes: A review.

CMAJ 152(9)1423-1433.

Wennberg, J. E., A. M. O’Connor, E. D. Collins, and J. N. Weinstein. 2007. Extending the P4P

agenda, part 1: How Medicare can improve patient decision making and reduce

unnecessary care. Health Affairs 26(6):1564-1574.

Attachment 4

Clinical Simulation in Nursing (2020) 43, 44-50

Financial Di

cific grant from

profit sectors.

* Correspondi

1876-1399/$ - se



Featured Article

Relationship between Interprofessional Communication and Team Task Performance

Kyeong Ryong Lee, PhD, MDa, Eun Jung Kim, PhD, RN, ACNP-BCb,* aDepartment of Emergency Medicine, School of Medicine, Konkuk University, Konkuk University Medical Center, Seoul 05029, Republic of Korea bSchool of Nursing, Research Institute of Nursing Science, Hallym University, Chuncheon, Gangwon-do 24252, Republic of Korea

KEYWORDS simulation training; nursing education; communication; performance; healthcare; crew resource management;

team communication; interprofessional communication

sclosure Statement: This

funding agencies in th

ng author: [email protected]

e front matter � 2020 Int 0.1016/j.ecns.2020.02.00

Abstract Background: Communication among health care professionals is essential for ensuring quality patient care and safety. Although communication appears to be crucial during critical events, this assumption has not been widely evaluated. This study aimed to determine whether Situation, Background, Assess- ment, Recommendation, and Read-Back (SBAR-R) communications are related to team task perfor- mance in a simulated emergency. Methods: A convenience sample of 49 teams with 194 nursing students participated. Trained ob- servers rated team task performance and SBAR-R communication with a mock doctor in a team- based simulated emergency. Results: SBAR-R communication scores differed significantly according to overall team task perfor- mance. The initial team performance, including patient assessment, correlated positively with SBAR with the physician. The team task performance without error correlated positively with read-back communication. Conclusions: These findings suggested that the SBAR-R communications are important to consistent team performance in an emergency.

Cite this article: Lee, K. R., & Kim, E. J. (2020, June). Relationship between interprofessional communication and team task performance. Clinical Simulation in Nursing, 43(C), 44-50. https://doi.org/10.1016/ j.ecns.2020.02.002.

� 2020 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.

Poor teamwork and communication among health care staff correlates with patient safety incidents and worse outcomes for patients (De Meester, Verspuy, Monsieurs, &

research did not receive any spe-

e public, commercial, or not-for-

ym.ac.kr (E. J. Kim).

ernational Nursing Association for Clinic


Van Bogaert, 2013). The Joint Commission identified failure in communication as one of the root causes for over 60% of reported sentinel events in 2013 (The Joint Commission, 2014). Common barriers to effective communication include inconsistency in team membership, varying communication styles, distractions, fatigue, lack of confidence, and misinter- pretation of cues (Foronda, MacWilliams, & McArthur, 2016). Team training and standardization of verbal

al Simulation and Learning. Published by Elsevier Inc. All rights reserved.

Communication and Team Task Performance 45

communication have been suggested as methods for improving communication among health caregivers and, thereby, patient safety (Rabøl et al., 2011).

Situation, Background, Assessment, Recommendation and Read-back (SBAR-R) communication form the most

Key Points � Team performance correlated with SBAR and read-back commu- nication in a simulated emergency.

� Initial team taskperfor- mance was positively associated with SBAR communication.

� Team task performance using verbal instruction correlated with read- back communication.

frequently implemented framework in the health care setting (Kostiuk, 2015). This framework is one standardized method of communication that is sim- ple, concise, and fully rele- vant to the information medical teams need. By us- ing SBAR, the person starts to communicate by noting what is currently happening and then moves on to the context, provides a problem assessment, and suggests a solution (Rodgers, 2007). The SBAR technique helps staff members anticipate the

information needed by colleagues and encourages assess- ment skills. It allows one to promptly formulate the informa- tion with the right level of detail. The technique of read-back, the fundamental mechanism of closed-loop communication, involves a person receiving information and then repeating it back verbally to the sender (Boyd et al., 2014). Grbach, Vincent, and Struth (2008) adapted SBAR to I-SBAR-R format, adding an identification of the person calling and read back the orders to promote safe practice. Especially dur- ing a critical event, nurses and physicians often communicate over the telephone, which makes these communications error prone (Rabøl et al., 2011). Read-back lets the sender know the message has been received and provides an opportunity to correct any mistakes (Boyd et al., 2014). In health care, the potential risks of not using closed-loop communication are increasingly acknowledged, and read-back is considered to be an essential feature for error prevention and quality of care. The Joint Commission’s National Patient Safety Goal that addresses communication requires write-down and read-back of the critical value information on a timely basis (Singh & Vij, 2010).

Communication among health care professionals is known to be particularly crucial in the context of critical events, but this assumption has not yet been widely evaluated and there is a lack of clear relationship between team performance and communication. Previous studies of health care professionals or students mainly have focused on improvement in commu- nication skills, perceived interprofessional competence, and critical thinking skills as a result of SBAR training (Foronda et al., 2016; Kesten, 2011; Kostoff, Burkhardt, Winter, & Shrader, 2016), and few studies have investigated how SBAR-R communication contributes to patient-important outcomes (Shahid & Thomas, 2018).

Nurses are at the forefront of ensuring patient safety, but there is little reliable evidence on nurses’ performance in interprofessional teams (IOM, 2003). This study attempted to identify whether verbal critical incident report focused on SBAR-R communication tool is related to team task per- formance and can affect patient outcomes in a simulated emergency. We hypothesized that the association between team task performance and interprofessional communication would be more apparent in nursing students who lack clinical experience than in those already familiar with clinical practice. Similarly, we hypothesized that read- back communication would be important for students unfa- miliar with the situation and environment when acting on verbal instructions without introducing errors or missing important aspects. The results of this study may help iden- tify specific nursing behaviors that are essential to ensuring patient safety. We conducted this study in nursing students.


Study Design

This study used a prospective observational study design to examine the relationships between nursing students’ team task performance and SBAR-R communication.

Setting and Participants

This study was approved by the university’s institutional review board. The study was conducted at a university. From 2015 to 2016, senior-level nursing students enrolled in the integrated nursing practicum, a required nursing laboratory course before graduation, were eligible for inclusion, and all students agreed to participate (N ¼ 194). All of the students had no previous simulation experience and had the same experience completing all the clinical exercises required for graduation. The students were grouped into 49 teams by name in an alphabetical order for convenience to partici- pate in the simulation training; 47 teams included four mem- bers with the other two teams having three members. The analysis unit was the observed behavior of the team.


The fundamental measures of this study were team task performance and SBAR-R communication using checklists developed by researchers.

Team task performance was categorized into two phases: the initial team performance before a call to a mock doctor and the team task performance after receiving verbal instructions from a doctor via phone. These were measured using a checklist of observable key actions based on practice guidelines derived from the literature.

The initial team performance phase refers to the stage in which team members work together at the beginning of an

pp 44-50 � Clinical Simulation in Nursing � Volume 43

Communication and Team Task Performance 46

encountered emergency. The expected behaviors by the team were as follows: obtaining a brief, targeted history; checking vital signs; performing a targeted physical exam- ination; cardiac monitoring; checking oxygen saturation and administering oxygen, if needed; and elevating the head of the bed. The phase related to the team task performance after the call to doctor assessed the key clinical actions in response to the mock doctor’s verbal order and was as follows: administering and maintaining oxygen through a nasal prong; establishing an intravenous line; administering aspirin, nitroglycerin, morphine, and heparin; obtaining venous blood for laboratory tests; and arranging 12-lead electrocardiography (ECG). A dichoto- mous scoring scale of 0 ¼ not done and 1 ¼ done was used to assess each item. The possible scores for this checklist ranged from 0 to 12 for the initial team performance and 0 to 8 for the actions after the call to the mock doctor.

SBAR-R communication behaviors were assessed using a checklist. We assessed the participants’ ability to apply the SBAR-R technique when reporting to the mock doctor and receiving telephone instructions in the simulated emergency scenario. These communication behaviors were categorized into two phases: SBAR reporting to a mock doctor after the initial assessment and read-back after receiving the order from the mock doctor. The checklist included 29 key communication behaviors. The scenario included four items: patient’s name, sex, age, and reason for the phone call (major problem). The background included three items to obtain a previous diagnosis or past history of the patient. The assessment used nine items to be reported, including vital signs. The recommendation comprised two items including one general suggestion about problem solving and one concrete suggestion. The verbal read-back comprised 11 items to be evaluated as closed communication while clearly the identifying the doctor’s instructions. A dichotomous scoring scale of 0 ¼ not done and 1 ¼ done was used. The possible scores ranged from 0 to 18 points for SBAR and 0 to 11 points for read-back communication.

We also recorded the time of the first call and the number of calls to the physician. The contents of the tools had been validated bythree expertswithsimulationtrainingexperience.


Medical emergencies can have devastating consequences. Chest pain can be a sign of an impending catastrophic medical condition if a patient collapses, and its effective management requires the medical team to perform several tasks simultaneously. These tasks include information gathering and immediate life support including administra- tion of oxygen, morphine, aspirin, and nitroglycerin, applying 12-lead ECG, establishing an intravenous line, and sampling of venous blood.

Before the simulated emergency scenario, students received a mini-lecture about SBAR-R communication and

determined the team leader. Each of the 49 teams was presented with a scenario involving an acute myocardial infarction using a high-fidelity patient stimulator. According to the expected sequence of clinical actions, the team should take a series of four phase actions. In the scenario, the patient presented to the emergency department because of chest pain. The expectation for the first phase was immediate assessment and initial management of the patient by the team. Each team’s initial task performance before the call to the mock doctor was assessed. In the second phase, the team leader then reported the patient’s condition to the mock doctor over the telephone, and communication behaviors were assessed using the SBAR checklist. In the third phase, the team leader received a verbal order about the key actions from the doctor over the telephone. The read-back checklist was used to evaluate the leader’s closed-loop communication behaviors. A doctor was immediately available by telephone, if requested. A faculty member played the role of the doctor receiving the SBAR report and provided orders based on a premade order set. In the fourth phase, the team’s perfor- mance of the expected actions in accordance with the physician’s order was assessed using the checklist.

All simulation exercises were videotaped for assessment. Two trained assessors independently reviewed five of 49 videotaped simulation scenarios. Cohen’s kappa, a measure of interrater reliability, ranged from 0.78 to 0.87 for team task performance and from 0.67 to 0.91 for SBAR-R communi- cation, and these values were judged to be acceptable. The remaining cases were measured by one assessor.

Data Analysis

We used descriptive statistics to assess team task perfor- mance and SBAR-R communication. The mean team task performance score was 13.80 (SD 2.59) and the median was 14. We categorized the individual teams into better or worse teams with respect to their team task performance. Scores �14 of 19 were categorized as better (n ¼ 26) and those <14 were categorized as worse (n ¼ 23). The Mann-Whitney nonparametric U test was used to compare the SBAR-R communication between the better and worse teams. Because of the ordinal nature of the scores, the nonparametric Kendall rank correlation was used to examine the correlations between team task performance and SBAR-R communication. The data were analyzed us- ing IBM SPSS Statistics (IBM Corp., Armonk, NY, USA).


Team Task Performance

Eleven key actions were assessed to examine the initial team performance. Most teams performed brief and targeted history taking (94%), and about half of the teams

pp 44-50 � Clinical Simulation in Nursing � Volume 43

Table 1 Descriptive Measures of Team Task Performance and SBAR-R Communication (n ¼ 49) Category Behavior Markers % of Frequency

Initial performance Obtaining present history 94 Obtaining past history or family history 55 Checking vital signs: blood pressure 100 Checking vital signs: pulse 47 Checking vital signs: respiration 37 Checking vital signs: body temperature 78 Performing targeted physical examination 41 Applying the cardiac monitor 88 Checking oxygen saturation 90 Administering oxygen 18 Elevating head of bed 57

Key action after call to a physician Administering and maintaining oxygen 92 Establishing the intravenous line 78 Administering aspirin by chewing 88 Administering NTG by sublingual 92 Administering morphine by IV 90 Administering heparin by IV 29 Obtaining venous blood for laboratory test 49 Arranging (requesting) the 12-lead ECG 47

SBAR-R communication (% of scores) SBAR-R communication 62 Situation 72 Background 56 Assessment 63 Recommendation 30 Read-back 66

Note. SBAR-R ¼ situation, background, assessment, recommendation and read-back; NTG ¼ nitroglycerin; IV ¼ intravenous; ECG ¼ electrocardiogram.

Communication and Team Task Performance 47

performed past or family history taking (55%). For vital signs, the teams checked the patient’s blood pressure (100%), pulse (47%), respiratory rate (37%), body tem- perature (78%), and oxygen saturation (90%). Most teams applied the cardiac monitor (88%) and half elevated the head of the bed (57%). However, only 18% of the teams initially administered oxygen to the patients.

Eight key actions were assessed to examine team performance after receiving verbal instruction from the mock doctor. Most teams administered oxygen (92%), aspirin (88%), sublingual nitroglycerin (92%), and morphine (90%), and established an intravenous line (78%). Less than one-third (29%) of the teams administered

Table 2 Comparison of SBAR-R Communication Between Better (�14 (n ¼ 49)

Variables Better Teams Median (IQR) (n ¼ 26)

W (

SBAR-R 20 (16-22) Elapsed time to first call in seconds 179 (156.5-179) 1 Frequency of call 2 (2-3)

Note. SBAR-R ¼ situation, background, assessment, recommendation and read

heparin to the patient. About half of the teams obtained a blood sample for laboratory tests (49%) and arranged for the use of a 12-lead ECG (47%). Table 1 shows the relative distribution of scores.

SBAR-R Communication Behaviors

The communication behaviors when reporting to and receiving instructions from the physician are shown in Table 1. SBAR-R communication behaviors were on average 62% of possible frequencies. The SBAR-R were 72%, 56%, 62%, 30%, 66% of possible frequencies, respectively.

of 19) and Worse (<14 of 19) Teams in Team Task Performance

orse Teams Median IQR) (n ¼ 23)

Mann-Whitney U test Z p

17 (14-19) 167.50 -2.645 .008 25 (103-174) 133.00 -3.327 .001 2 (2-3) 240.50 -1.277 .202


pp 44-50 � Clinical Simulation in Nursing � Volume 43

Table 3 Correlation Coefficients Among Team Task Performance and SBAR-R Communication (n ¼ 49)


Initial Performance SBAR Read-Back

taub (p) taub (p) taub (p)

SBAR 0.313 (0.004) d Read-back 0.153 (0.164) 0.076 (0.486) d Performance after receiving verbal instruction 0.175 (0.129) 0.072 (0.529) 0.285 (0.014)

Note. SBAR-R ¼ situation, background, assessment, recommendation and read-back.

Communication and Team Task Performance 48

Comparison of SBAR-R Communication Between Better and Worse Teams According to the Task Performance Scores

Table 2 shows the difference in SBAR-R communication between better and worse teams according to the task per- formance scores. The SBAR-R scores differed significantly between better and worse teams (U ¼ 167.5, p ¼ .008). There was a significant difference in elapsed time to first call (U ¼ 133.0, p ¼ .001), but no difference in the numbers of calls (U ¼ 240.5, p ¼ .202) between better and worse teams.

Correlations Between Team Task Performance and SBAR-R Communication

Table 3 shows the correlations between team task perfor- mance and SBAR-R communication. The initial team perfor- mance score correlated positively with SBAR scores (taub ¼ 0.313, p ¼ .004). The score for team performance af- ter the call to the physician was correlated positively with the read-back score (taub ¼ 0.285, p ¼ .014). No significant cor- relations were observed between the initial and postcall team performances (taub ¼ 0.175, p ¼ .129) or between the SBAR and read-back communication (taub ¼ 0.076, p ¼ .486).


The strength of our study is the use of observable assessment tools, which contributed to the reliability of the results. Observation of behaviors or events is considered to be more accurate and reliable than self-assessment, particularly for human factor skills and behaviors (Siassakos et al., 2011).

The main finding of our study was that SBAR-R communication was associated with the overall team task performance of nursing students with limited clinical experience. SBAR-R is an important technique for infor- mation delivery (Chapelain, Morineau, & Gautier, 2015) and preventing or reducing the risk of errors (Andreoli et al., 2010; De Meester et al., 2013; Randmaa, M�artensson, Swenne, & Engstr€om, 2014). In addition to the aforementioned findings, this study showed that the

better teams had a higher interprofessional communication score than the worse team, which suggests that successful team performance is related to interprofessional communi- cation during a critical event. This result is consistent with a study by Reising et al. (2017) who reported a positive cor- relation between interprofessional team communication and procedure accuracy in the simulation. Also, Chapelain et al. (2015) showed that the number of sponta- neous information exchanges between pairs of participants correlated positively with overall performance and with ac- tions performed at the right moment.

Before the call to the mock doctor, SBAR communica- tion correlated significantly with initial team task perfor- mance. This finding suggests that the teams that were successful in the first phase of recognizing the situation and gathering pertinent information performed the SBAR report better than teams that did not. We also assessed the elapsed time to the first call to the doctor as an indicator of rapid situational awareness and astute decision making. The teams that performed well had a shorter time to the first call to the doctor than the teams that did not. This is consistent with the study of De Meester et al. (2013), where SBAR communication was related to the ability to recog- nize the situation and collect information about the patient.

The SBAR technique is a simple technique, but it requires clinical reasoning beyond communication. To formulate information at an appropriate level, situation awareness, ability to make decisions, and assessment skills are required. Conversely, the SBAR technique helps health care personnel to anticipate the information that their colleagues need and to gather and formulate appropriate levels of information.

The second phase of team task performance, successful performance after verbal instruction, was related more to verbal read-back than to the initial team task performance. This result suggests that, particularly for novices with little clinical experience, the ability to complete crucial clinical actions in a timely way without missing information or making a mistake is strongly linked to the read-back for clarifying verbal orders. This is in accordance with Boyd et al. (2014), who noted that knowledge of transferred in- formation during a simulated crisis was significantly improved if the receiver repeated back the information. Us- ing the read-back technique may increase the information transfer between team members, which increases the

pp 44-50 � Clinical Simulation in Nursing � Volume 43

Communication and Team Task Performance 49

chances of successful team performance without mistakes and should therefore improve patient safety. The use of read-back to ensure that communications are both sent and received is an important factor in reducing or prevent- ing medical errors (National Coordinating Council for Medication Error Reporting and Prevention, 2001), but it is not being implemented continuously in health care set- tings (Miller, Riley, & Davis, 2009). The skill and timing of using read-back should be part of training and should be encouraged as part of critical team behaviors.

In our study, the SBAR-R performance rate was 62%, which is higher than that reported by other studies. Chapelain et al. (2015) observed that the performance score of SBAR communication by nursing students was 35.4% in a simulated emergency. Miller et al. (2009) found that SBAR and read-back skills of nurses were not consistently observed during critical events, in which key behavioral markers of closed-loop communication occurred <15% of the time. The reason for the relatively high performance rate of SBAR-R in our study is pre- sumed to be that students received SBAR-R training before participating in the scenario. In particular, because read-back is the ability to read information again for veri- fication but not to require the synthesis of knowledge (Perry, Wears, & Patterson, 2008), read-back skill may be easily improved by training.

The recommendation performance rate was 30%, which was the lowest of SBAR-R elements in our study. Nurses must be able to use the ‘‘recommendation’’ to communicate exactly what they need from the physician (Woodhall et al., 2008). However, even if they did not know how to resolve the situation, the technique of recommendation may help empower training nurses to formulate a recommendation given to the doctor (Woodhall et al., 2008).

Based on the results of this study, further research is proposed. First, empirical studies are needed to verify the effectiveness of SBAR-R training on performance level or error in various clinical conditions. Second, because SBAR- R communication may help health care staff learn how to judge situations and collect critical information, we suggest that empirical studies are needed to determine whether SBAR-R training can improve reasoning skills.


First, this study was conducted in a university, so the results cannot be generalized to the wider health care setting. Second, we measured only those SBAR-R communication behaviors required in the scenario, and our findings are limited by not being able to measure the quality of SBAR- R, such as the systematic nature of the delivered informa- tion or occurrences of misreported information. Similarly, we observed only the expected task performance of each team in the scenario and did not directly assess any errors. Third, although the data were collected for 2 years, the

number of teams was small for detailed analysis. Neverthe- less, our results demonstrated clear relationship between SBAR-R communication and team task performance.


Our study provides evidence supporting the use of SBAR-R communication by health care professionals during a clinical crisis. The result of our study showed that communication among nursing students was directly related to successful team performance. Although SBAR communication correlated with initial team task perfor- mance, verbal read-back was crucial for successful team task performance without missing information or making mistakes. These findings suggest that the SBAR-R commu- nication is an important factor for ensuring consistent team performance. This is a crucial skill for nursing students to learn to ensure effective communication and patient safety during a clinical crisis.


Andreoli, A., Fancott, C., Velji, K., Baker, G. R., Solway, S., Aimone, E.,

& Tardif, G. (2010). Using SBAR to communicate falls risk and man-

agement in inter-professional rehabilitation teams. Healthcare Quar-

terly, 13(13), 94-101.

Boyd, M., Cumin, D., Lombard, B., Torrie, J., Civil, N., & Weller, J.

(2014). Read-back improves information transfer in simulated clinical

crises. BMJ Quality & Safety, 23(12), 989-993. https://doi.org/10.


Chapelain, P., Morineau, T., & Gautier, C. (2015). Effects of communica-

tion on the performance of nursing students during the simulation of an

emergency situation. Journal of Advanced Nursing, 71(11), 2650-2660.


De Meester, K., Verspuy, M., Monsieurs, K. G., & Van Bogaert, P. (2013).

SBAR improves nurseephysician communication and reduces unex-

pected death: a pre and post intervention study. Resuscitation, 84(9),

1192-1196. https://doi.org/10.1016/j.resuscitation.2013.03.016.

Foronda, C., MacWilliams, B., & McArthur, E. (2016). Interprofessional

communication in healthcare: an integrative review. Nurse Education

in Practice, 19, 36-40. https://doi.org/10.1016/j.nepr.2016.04.005.

Grbach, W., Vincent, L., & Struth, D. (2008). Reformulating SBAR to ‘‘I-

SBAR-R. Retrieved from https://qsen.org/reformulating-sbar-to-i-sbar-r/.

Institute of Medicine. (2003). The Future of the Public Health in the 21st

Century. Washington, DC: National Academies Press.

Kesten, K. S. (2011). Role-play using SBAR technique to improve

observed communication skills in senior nursing students. Journal of

Nursing Education, 50(2), 79-87.

Kostiuk, S. (2015). Can learning the ISBARR framework help to address

nursing students’ perceived anxiety and confidence levels associated

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Kostoff, M., Burkhardt, C., Winter, A., & Shrader, S. (2016). An interpro-

fessional simulation using the SBAR communication tool. American

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tion. (2001). Recommendations to reduce medication errors associated

pp 44-50 � Clinical Simulation in Nursing � Volume 43

Attachment 5

Original Manuscript

Ethical perspectives in communication in cancer care: An interpretative phenomenological study

Paola Melis University of Cagliari, Italy; Universitat Rovira i Virgili, Spain

Maura Galletta University of Cagliari, Italy

Cesar Ivan Aviles Gonzalez University of Cagliari, Italy; Universitat Rovira i Virgili, Spain

Paolo Contu University of Cagliari, Italy

Maria Francisca Jimenez Herrera Universitat Rovira i Virgili, Spain

Abstract Background: In cancer care, many clinical contexts still lack a good-quality patient–health professional communication about diagnosis and prognosis. Information transmission enables patients to make informed choices about their own healthcare. Nevertheless, disclosure is still an ethically challenging clinical problem in cancer care. High-quality care can be achieved by understanding the perspectives of others. The perspective of patients, their caregivers, physicians and nurses have seldom been simultaneously studied. Objective: To investigate the phenomenon of diagnosis and prognosis-related communication as experienced by patients, their caregivers, and both their attending nurses and physicians, to enlighten meanings attached to communication by the four parties. Methods: A qualitative study using interpretative phenomenological analysis was performed. Participants and research context: Purposive sampling of six patients, six caregivers, seven nurses and five physicians was performed in two oncological hospitals in Italy. Ethical considerations: Local Ethics Committee approved the study. It was guided by the ethical principles of voluntary enrolment, anonymity, privacy and confidentiality. Results: Three main themes were identified: (a) the infinite range of possibilities in knowing and willing to know, (b) communication with the patient as a conflicting situation and (c) the bind of implicit and explicit meaning of communication. Conclusion: The interplay of meanings attached by patients, their caregivers, and their attending oncologist and nurse to communication about diagnosis and prognosis revealed complexities and

Corresponding author: Maura Galletta, Department of Medical Sciences and Public Health, University of Cagliari, SS 554 Bivio per

Sestu, Monserrato, Cagliari 09042, Italy.

Email: [email protected]

Nursing Ethics 2020, Vol. 27(6) 1418–1435

ª The Author(s) 2020 Article reuse guidelines:

sagepub.com/journals-permissions 10.1177/0969733020916771


ambiguities not yet settled. Physicians still need to solve the ethical tensions in their caring relationship with patients to really allow them ‘to choose with dignity and being aware of it’. Nurses need to develop awareness about their role in diagnosis and prognosis-related communication. This cognizance is essential not just to assure consistency of communication within the multi-disciplinary team but mostly because it allows and enables the moral agent to take its own responsibilities and be accountable for them.

Keywords Cancer, communication, diagnosis and prognosis, ethics, interpretative phenomenological analysis, meanings, multi-perspective


In Western countries, the process of diagnosis and prognosis-related communication in cancer care is

approached as a phenomenon related to information exchanges between patient and clinician and

within healthcare professionals, as well as to the relationships occurring among all the speakers,

including caregivers. 1

This suggests that quality of health professional–patient communication is

linked to the quality of communication and coordination within the team, 2

and that informal care-

givers also play a crucial role in managing patients’ cancer disease. 3,4

Nevertheless, literature high-

lights that many clinical contexts are still lacking a good-quality patient–health professional

communication regarding end-of-life preferences and prognosis disclosure, 5,6

and information prefer-

ences for patients with advanced cancer are still unmet. 7

As information transmission enables patients

to make informed choices about their own healthcare, it can be said that, in cancer care, disclosure

issue is still an ethically challenging clinical problem. Moreover, although there has been advance-

ment in cancer treatments, cancer is still associated with suffering and death. Perceptions and beliefs

surrounding cancer disease still hamper regular interactions and communication. 8,9

There is evidence

that the main barriers to effective communication and information sharing are fragmented commu-

nication, uncertainty around patient consent and the unacknowledged existence of overlapping care

plans. 10

On the contrary, prognostic disclosure has been associated with more realistic patients’

expectations of life expectancy, 11

and discussions on prognosis seem to strengthen the relationship

between patient and oncologist. 12

Literature has also shown that good collaboration among health

professionals is essential for high-quality care 4

and that patient-centred care is enhanced by both good

inter-professional communication and acknowledgement of the interdependence of each one’s role. 13

However, the perspectives of patients, caregivers, physicians and nurses have been seldom studied all

together. 14

Dyadic 15

and triadic 16

communicative interactions have been investigated in some previ-

ous qualitative studies, but they limit the analysis to a portion of the context of care. Interpretative

phenomenological analysis is a qualitative method used in health-related research to understand

human experiences that are essential to the participants. Interpretative phenomenological analysis

contributes to move beyond a biomedical model of the disease to get insights about self-reported

experiences and the meanings that individuals assign to those experiences. 17

Studies with a multi-

perspective design and adopting interpretative phenomenological analysis are quite recent and still

few. 14,18

In our research, we focused on the communication experience by investigating simultane-

ously the perspectives of patients, their caregiver, their attending oncologist and their attending nurse.

This study is part of a larger research aimed to explore communication issues related to diagnosis and

prognosis in oncological wards.

Melis et al. 1419


This study intended to investigate the phenomenon of diagnosis and prognosis-related communication as

experienced by patients, their caregivers, and both their attending nurses and physicians, in order to

enlighten the meanings attached to communication by the four groups of participants.


This study was conducted using an interpretative phenomenological analysis, which is a qualitative research

approach that values ‘a detailed experiential account of the person’s involvement in the context’ (p. 196). 19

Interpretative phenomenological analysis allows for catching communication meanings through narration

of participants’ experiences within a cultural, social and personal world, 19

so, it can be said that the method

implies an interpretative approach enriched by descriptive notes. 20

Following interpretative phenomeno-

logical analysis philosophical roots – that come from Heidegger’s philosophy – meanings are always

created through interactions, including those with researchers. 21

According to it, the researchers’ pre-

conceived concepts and personal world cannot be kept apart from the investigation, but they can represent

a tool to conduct the analysis. 22

On this basis, interpretative phenomenological analysis develops a

double-hermeneutic circle where ‘the participants are trying to make sense of their world; the researcher

is trying to make sense of the participants trying to make sense of their world’ (p. 53). 23

According to the

idiographic focus of interpretative phenomenological analysis, this study explores the perspectives of

individuals in their unique context of life. Besides, this study adheres to interpretative phenomenological

analysis’ request to illustrate and describe themes by a rich reporting of excerpts from participants’

accounts. 19

Study inclusion and exclusion criteria

The main inclusion criteria for patients were to be at least 18 years old and being diagnosed with cancer. An

inclusion criterion for nurses was attending on the interviewed patient for at least two shifts. An inclusion

criterion for physicians was attending on the interviewed patient. Caregivers were selected upon indication

of the interviewed patients. General exclusion criteria were to be less than 18 years old and have cognitive


Study participants

Patients were recruited upon introduction by the interviewer of the research purpose. Eligible nurses

and oncologists were purposively enrolled after the patient. Patients were enrolled based on homo-

geneity of patients’ life expectancy of less than 1 year, according to the attending oncologist. This

selection criterion for patients was used to pursue a fairly homogeneous sample, as suggested by

Smith for interpretative phenomenological analysis studies. 19

Successively, available caregiver was

selected and the physician and nurse who attended on the patient during his or her disease trajectory

were selected. A total of 24 participants corresponding to six groups of four members each (patient,

his or her caregiver, and his or her attending physician and nurse) were recruited. According to Reid

and colleagues, 24

exploring a phenomenon from multiple perspectives is a kind of triangulation that

can help researchers to develop a more detailed and variegated description of that phenomenon.

Nevertheless, this is possible only with a small sample (5–10 participants). 25

Therefore, based on

this suggestion, six participants for each role (patients, caregivers, physicians and nurses) are con-

sidered as a very good sample.

Table 1 shows the characteristics of the study participants.

1420 Nursing Ethics 27(6)

Ethical considerations

The study complies with the principles of the Declaration of Helsinki and the Italian Privacy Law (GDPR

679/2016). The study was approved by the Independent Ethics Committee of the Azienda Ospedaliero-

Universitaria di Cagliari, Italy (Act n.2.27; 25 July 2016). At the enrolment stage, researchers provided

written and oral information about the purpose of the study. Participation was voluntary and anonymous;

confidentiality was assured and guaranteed to all participants. All the interviewees gave their written

informed consent and were informed that they could leave the study at any time without penalty. Pseudo-

nyms were used for all patients in order to preserve anonymity. Moreover, the researchers paid attention to

the participant’s emotional status and respected it by shortening and finishing the interviews when needed.

Data collection procedure

The study was conducted in two oncology departments of two big hospitals from southern Italy. Narrative

interviews were carried out in the departments in which the patients were treated. A researcher expert on the

topic performed interviews from August 2016 to February 2017. A set of interview guiding questions was

developed (see Figure 1), based on previous pilot interviews; questions were used very flexibly in order to

Table 1. Summary of participants’ characteristics.

Patients (n ¼ 6) Caregivers (n ¼ 6) Physicians (n ¼ 5) Nurse (n ¼ 7)

Gender Man ¼ 4; woman ¼ 2 Man ¼ 0; woman ¼ 6 Man ¼ 2; woman ¼ 3 Man ¼ 1; woman ¼ 6 Age 19 years ¼ 1

56 years ¼ 1 63 years ¼ 1 64 years ¼ 1 65 years ¼ 1 77 years ¼ 1

Average age ¼ 57 years

52 years ¼ 1 55 years ¼ 1 62 years ¼ 1 67 years ¼ 1 68 years ¼ 1 72 years ¼ 1

Average age¼62.7 years

40 years ¼ 1 42 years ¼ 1 45 years ¼ 2 55 years ¼ 1

Average age¼45.4 years

36 years ¼ 1 37 years ¼ 1 46 years ¼ 1 47 years ¼ 1 54 years ¼ 1 58 years ¼ 1 59 years ¼ 1

Average age¼48.1 years School

level Primary school ¼ 2

Secondary school ¼ 2 Master degree ¼ 2

Primary school ¼ 2 Secondary school ¼ 2

Master degree ¼ 2 Tenure Experience as

oncologist: 6 years ¼ 1 12 years ¼ 1 16 years ¼ 2 23 years ¼ 1

Average tenure ¼ 14.6 years

Experience in an oncological ward:

3 years ¼ 1 10 years ¼ 2 16 years ¼ 1 19 years ¼ 1 20 years ¼ 1 27 years ¼ 1

Average tenure ¼ 15 years

Cancer type

Breast cancer ¼ 1 Rare cancer ¼ 2

Abdominal cancer ¼ 2 Lung cancer ¼ 1

Interview length

Minimum: 13 min; maximum: 60 min

(mean ¼ 35 min)

Minimum: 12 min; maximum: 48 min

(mean ¼ 24 min)

Minimum: 13 min; maximum: 26 min

(mean ¼ 17 min)

Minimum: 20 min; maximum: 68 min

(mean ¼ 39 min)

Melis et al. 1421

F ig

u r e

1 . In

te rv

ie w

gu id

e q u e st

io n s

fo r

th e

d if fe

re n t

p ar

ti ci

p an

ts .


elicit the participant’s experience. Prompt questions were used to encourage the interviewees to elaborate

their thought based on their experience. All the performed interviews were audio recorded and verbatim

transcribed, including a brief description of non-verbal aspects of the interviewees.

The patient was always the first one to be interviewed, but it was not always possible to follow a

scheduled sequence for the other participants of the subgroup, because of their unpredictable temporary

unavailability. In any case, all the four parties of each subgroup were interviewed within 2 or 3 days from

each other, except for one group in which the interview time span was of 3 weeks, due to organizational

problems. In a case, two nurses who attended on the same patient desired to be interviewed at the same time;

all the other interviews were conducted separately. During the recruitment process, one physician refused to

be part of the study. Thus, our final sample of 24 participants included six patients, six caregivers, seven

nurses and five physicians.

Data analysis and rigour

Data analysis was conducted according to the procedure indicated by Smith et al. 19

for interpretative

phenomenological analysis studies. According to this procedure, an inductive approach has been used to

process data. In a first step, each researcher did an attentive reading of each transcript following the

interviews’ chronological order for each group unit (patient, caregiver, nurse and physician). Second, once

an overall sense of the data was gained, each researcher wrote initial textual notes describing any relevant

issue; in the following step, emergent themes were developed by each researcher, via abductive reasoning.

In a fourth step, the researchers looked for connections across emergent themes; this process included a first

analysis in which data from each participant were analysed separately, and then they were analysed for each

group unit and across the group units. This process intended to privilege the comparison of the four parties

across the six groups and, at the same time, safeguard the connection of the four participants at the group

level. Moreover, it allowed the researchers to better interpret each single part in relation to the whole and

vice versa. Until this point, the researchers proceeded separately: each researcher produced a list of few

main themes. Then, the researchers met and triangulated their findings conciliating them by retracing back

all the previous steps. This final discussion allowed the researchers to identify the final main themes, by

following a subsumption process. In fact, according to Brocki and Wearden, 17

in contrast with content

analysis that produces ‘a quantitative analysis of discrete categories from qualitative data’, in interpretative

phenomenological analysis ‘the importance of the narrative portrayal is dominant’, and its aim is to provide

‘a detailed interpretative analysis of themes’ (p. 99).

Data analysis was supported by using Atlas.ti version 7.5.7. To achieve credibility, a constant engage-

ment with the data was maintained throughout the entire data analysis process and a rich amount of

interview quotes has been provided. Confirmability was attained through triangulation of all the steps of

data analysis by the researchers. Transparency was achieved by highlighting the study’s challenges and


Researchers also paid attention to self-reflexivity with respect to their own values and orientation, as it is

required by interpretative phenomenological analysis method. The multi-disciplinary team fostered com-

parison of their personal and professional background and the attention on how those could influence on

different phases of the study. Moreover, the researchers have background and expertise adequate to conduct

this kind of study and to manage potential method bias. Specifically, P.M. is an expert clinical nurse, she

also earnt her master degree in Philosophy and worked for many years with people with cancer. C.I.A.G. is

an expert clinical nurse and worked in mental health contexts. M.G. is psychologist and associate professor

in Nursing. She is PhD and expert of quantitative e qualitative research. M.F.J.H. is associate professor in

Nursing. She is PhD and expert in bioethics. P.C. is full professor, PhD and expert of research in Health

Promotion. Almost all the researchers have been also caregivers of a close relative affected by cancer.

Melis et al. 1423

Operational tools used to foster self-reflexivity were (a) field note – taken after interviews – including

reflections on both feelings and emotions of the interviewer, which were commented with the other

researchers during the data analysis procedure, and (b) audits conducted among the researchers during the

different phases of the study.


The results have identified three main themes: (a) the infinite range of possibilities in knowing and willing

to know, (b) communication with the patient as a conflicting situation and (c) the bind of implicit and

explicit meaning of communication. The first theme is represented in all the four parties and describes the

mix up of cognitive and emotional reactions arousing communication related to diagnosis and prognosis.

The second theme is related to the role of health professionals: how nurses and physicians interpret their role

and how the patient and his or her caregiver perceive it. The third theme concerns an experience of

communication as expression of a personal and intimate world. This theme takes shape in patients and

caregivers as a silent but expected request of recognizance of the existential dimension, and it emerges in

nurses and physicians as a fundamental part of care and cure relationship. Figure 2 summarizes main

perspectives of the four participants for each theme.

The infinite range of possibilities in knowing and willing to know

Patients and caregivers describe their experience about diagnosis and prognosis-related communication as

an experience that admits an infinite range of possibilities in knowing and in the will to know. Angelo,

Daniela and Nella, in fact, describe themselves both as informed and uninformed, willing to be informed

and wanting to know no more. Nella, different from the other two patients who were diagnosed few months

ago, is under treatment since almost 2 years, she values a lot her autonomy and admits that what cost her the

most is to ask for help, she also recognizes to have contrasting feelings and attitude towards communication

and information transmission and says,

The results (for my examinations) were always picked up by me, I read them, but I don’t understand them and I

ask the doctor [ . . . ] I mean [ . . . ] I don’t want to understand them; it’s not that I don’t understand them, that’s


Daniela, who – according to her caregiver – should well understand her health status because she has a

high school–level education, declares a willing to know and recalls all the questions she already asked the

doctors; she refers to have always received a proper answer, but she recognizes that all those questions are

not so significant and concludes,

Even now [ . . . ] I don’t find the courage to ask it [ . . . ] maybe one day I will try to ask it to my oncologist.

Some other patients, like Sergio, Piero and Mario, present their decision to receive limited medical

information as a shared decision with their oncologists and relatives. Mario, who is very young, is aware that

he does not exactly know what is happening to his body, but he values this ignorance as the price to ‘stay

calm’. He knows that his disease is a very serious one: he tells that he has been diagnosed more than 2 years

ago and has undergone several chemo treatments. He explains his choice like this:

I prefer to be like this [ . . . ] because if I would know more I would have more worries . . . and maybe this could

worsen my condition [ . . . ] maybe [ . . . ] better not to know anything and have minimal details that only can


1424 Nursing Ethics 27(6)

F ig

u r e

2 . S u m

m ar

y o f th

e p e rs

p e ct

iv e s

e m

e rg

e d

fr o m

th e

fo u r

p ar

ti e s

fo r

e ac

h th

e m

e .


: p at

ie n t;


: re

gi st

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e ; C

G : ca

re gi

ve r;


: p h ys

ic ia

n .


Other patients, like Sergio, who is already retired, show difficulty to conciliate what they have been told

and what they know. He is attending the oncological ward since few months and concludes his interview by


Sooner or later, I should know the truth, only that [ . . . ] I’m afraid of truth [ . . . ] do you understand?

But previously he had already admitted that

They [the doctors] said me that [ . . . ] they told me clearly [ . . . ] do you understand? He called me in his office –

there was my wife too – and when he said it [ . . . ] the world fell on me! Do you understand?

Many caregivers also describe communication related to diagnosis and prognosis as an experience of

contrasting willing and feelings and as a knowledge not possible to confine into the opposite poles of

knowing or not knowing. Nella’s caregiver describes her loved one’s attitude towards communication as the

display of contrasting behaviours, but she does not interpret it as an inconsistency:

Of course there is an inconsistency [ . . . ] but I’m not sure whether it is an inconsistency; you would like to know

more and more because you would like to discover that [ . . . ] your worries are excessive [ . . . ] that after all [ . . . ]

the situation can be seen in a [ . . . ] way . . . , but if you are searching more, you’re afraid to discover the contrary.

So, you prefer to stay in a limbo in which you would like to know, but you can’t.

Caregivers recognize that patient needs to know what is happening, but at the same time, they underlie

that patient also seeks and needs continuous reassurance. In the caregivers’ stories, the patient’s character

and the emotional costs of knowledge appear to be important factors to understand the patient’s attitudes

and to decide which communication approach is more suited for him or her. Angelo’s caregiver declares that

her loved one and she are perfectly aware of the seriousness of his health conditions because they were

informed of the advanced stage of his disease by the oncologist. Nevertheless, to the question if she

considers it is better to know or not to know, she answers,

I don’t know, I don’t know: knowing too much is upsetting, but maybe knowing too little is also upsetting. Who

can say which the right measure is? In between knowing and not knowing there are an infinite range of


The theme of the various degree of knowledge emerges in physicians’ narratives (and in some of the

interviewed nurses) either as the patient’s capacity to understand the real meaning of the information

received by physicians or a partial information received by them. Physicians refer this capacity as the

patient’s will to confront himself or herself with bad news. Concerning that point, Sergio’s physician says,

It has been the head physician to tell him that the surgery he underwent couldn’t eradicate the tumour. Therefore,

he knows the diagnosis, namely a disease that is not cured by the surgery but that is still there and that is a quite

severe disease, because his liver has been affected. I told him that he had to be treated just by chemo and by oral

therapy. So, it has not been told anything unreal [ . . . ] if one should tell all and everything [ . . . ] I don’t believe

that this would be the rightest thing to do [ . . . ] I don’t know [ . . . ] anyway, the patient understands what he wants

to understand! Anyway, the patient was thoroughly informed of the disease.

In addition, Piero’s and Sergio’s nurses consider awareness disconnected by any kind of intellectual

capacity. Piero’s nurse is working in an oncological ward since many years; she loves to talk with patients

and thinks that almost all her patients know their diagnosis but, at the meantime, notices,

1426 Nursing Ethics 27(6)

In our ward there were physicians that didn’t understand any (!) [ . . . ] I mean, once they have become patient,

they, that were physicians and nurses [ . . . ] well, once they were admitted in our ward, they forgot to be

physicians, they forgot all the staff they studied [ . . . ] like if they knew nothing.

Communication with the patient as a conflicting situation

The interviewed physicians talk about their communication approach as an information-giving to let the

patients know what is going on: the diagnosis and the therapeutic course they should undergo. This

information transmission is perceived as something that they need to modulate because it is also a potential

harm to patients’ psychological well-being. This position is well presented by Mario’s physicians, an expert

oncologist, who explains his communication approach with his young patient:

I believe that we have been quite detailed [ . . . ] in one case and in the other, that is both towards the patient and

towards his relatives. It is a situation in which the psychological implications are very heavy [ . . . ] and [ . . . ] the

[ . . . ] let’s say that the fuzziness that we have maintained in providing information to the patient is motivated by

the need not to create an excessive psychological distress that could lead him to dismiss therapy.

On this basis, physicians consider as a duty to inform the patient about his or her diagnosis, but they also

maintain that it is upon them to decide, case by case, the extension and the timing of information. They

declare to generally conform to the norm to inform the patients in order to obtain their informed consent to

therapies, but they also take into account that knowledge has the power to provoke huge emotional reactions

such as hope or despair. These reactions are deemed a big resource or, vice versa, an insurmountable

obstacle to treat and cure the patient. A practice solution adopted by most physicians to both preserve hope

in patients and fulfil their duty to inform the patients is to avoid talking about prognosis if not requested. The

conflictual situation is so approached by Daniela’s physicians:

I think it’s essential to know [ . . . ] but it’s evident that not anybody can bear the information so I think

information should be, how to say it, adjusted upon emotional sensitivity, upon the patient’s capacity to manage

this kind of information but, anyway information should be given to patients in a complete way, absolutely! but

one can be less explicit about prognosis, especially with regard to the advanced stages of the illness.

Only Nella’s physician, by highlighting a correspondence between the missed knowledge of prognosis

by the patient and the missed knowledge of the patient’s will about end-of-life care by the physician, speaks

of physicians’ ethical responsibility in conciliating contrasting urgencies and needs implicated in diagnosis

and prognosis-related communication. She explains,

[ . . . ] what is still problematic [to make the patient understand] [ . . . ] is the choice [ . . . ] between not to do

anything, because actually there is no chance to get anything better and therefore [ . . . ] just to undergo palliative

care, or undergo therapies until the last days. This issue, perhaps, was not faced with my patient. In some patients,

this may be due to a communication problem, I mean, the difficulty to make the patient understand it and help

him/her to make an aware choice, while preserving his/her dignity.

All the nurses state that they usually do not investigate if the patient knows or does not know his or her

diagnosis and …

Attachment 6

In Our Unit

80 CriticalCareNurse Vol 36, No. 6, DECEMBER 2016 www.ccnonline.org

C ommunication among team members on a critical care unit is

integrally linked to patient safety.1 When the critical care unit at

Chambersburg Hospital (Chambersburg, Pennsylvania) moved

into the new wing in December 2012, it became apparent that the new

layout was less conducive to facilitating staff interactions than the old

layout had been. The team needed to adapt to preserve patient safety.

The prior unit was designed with a hub-and-spokes layout. Nurses

congregated in the central nursing station to view the cardiac monitors,

document, and obtain medications, enabling constant interactions. The

new critical care unit was constructed in a horseshoe arrangement, with

small working pods between each pair of patients’ rooms—complete with

computers for documentation and medication drawers. Nurses were

encouraged to stay in their “pods” to remain closer to their patients.

Although this new design improved the environment for patients,

critical care staff began struggling with open communication. Thus,

staff made efforts to overcome the hurdles created by their new envi-

ronment. Communication boards were developed within the break

room, e-mails were sent, and staff meetings were held, despite the fact

that bedside staff members’ schedules were not well-suited to structured

meetings.2 Meeting attendance was low, not all e-mails were read, and

boards were infrequently updated. Communication barriers prevailed.

Staff voiced concerns regarding their lack of knowledge about the

environment. Each nurse knew a great deal about his or her 2 assigned

patients in the 18-bed unit, but the nurses were no longer passively

acquiring information about the census of the unit, patients with safety

concerns such as fall risks, patients requiring mechanical ventilation,

or the number of nursing attendants available on the floor. Everyone

was working in relative isolation,

which was not conducive to func-

tioning as a team.

Implementing a Solution After multiple strategies to improve

communication had failed, unit lead-

ers decided to implement an informal

morning huddle to review staffing.

The unit’s nurse manager had used

this type of effective communication

while leading another unit, and she

was excited to begin using it in the

critical care unit. The new huddle

format began in October 2013, but

was noted to be infrequent and

dependent on which staff member

was in the resource role. Despite the

infrequency, multiple staff members

realized the effectiveness of the brief

staffing huddle, especially in the

way it enabled staff to work together

more cohesively in the decentralized

unit. The positive feedback drove the

team to make the infrequent huddle

a more permanent event. By June 2014,

the preshift huddle was performed

at every shift change, becoming stan-

dard work for every resource nurse

or clinical manager.

This routine gathering of off-going

and oncoming shifts presented an

opportunity to share more than just

staffing information. Material that had

previously been distributed solely in

e-mail format—such as patient safety

Colleen Kylor, RN, BSN, CCRN Teresa Napier, RN, PCCN Amber Rephann, RN, BSN Sara Jane Spence, RN, BSN, BSE, CCRN

Implementation of the Safety Huddle

Authors Colleen Kylor, Teresa Napier, Amber Rephann, and Sara Jane Spence are nurses, Chambersburg Hospital, Chambersburg, Pennsylvania.

Corresponding author: Amber Rephann, RN, Chambersburg Hospital, 112 N. Seventh St, Chambersburg, PA 17201 (e-mail: [email protected]).

To purchase electronic and print reprints, contact the American Association of Critical-Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, [email protected]

©2016 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn2016768

www.ccnonline.org CriticalCareNurse Vol 36, No. 6, DECEMBER 2016 81

or unit initiative information—

started to be reviewed, facilitating

discussion and increasing retention

for the auditory learners. E-mails

were printed and kept in a “huddle

folder” at the nursing station. Each

printout was dated with a start day

for the specific topic and the date

to retire it. Initially, the folder dura-

tion was 2 weeks for each item, so

that even those staff members work-

ing occasionally would be exposed

to the information. However, it was

noted that the quantity of printouts

became excessive and was perceived

as cumbersome to most staff mem-

bers present, so the “folder time” was

decreased to 1 week. In January 2015,

the decision was made to place all

retiring information into a binder,

thus allowing occasional staff, as

well as those on leave or vacation,

to have access to the information.

The huddle binder also serves as

an archival resource.

Once the safety huddle was in

full swing, it became common

procedure for staff to present to

the nursing station before their

shift. Leaders (formal and informal)

would announce the start of huddle,

signaling everyone to gather and

give their attention to the speaker.

The team was encouraged to become

engaged. A standardized start time

of 5 minutes before the start of the

shift was initiated and upheld. When

a clinical manager was not present

on the unit, the huddle was being

completed by resource staff. It was

incredible to see how the huddle

developed into a standard part of

the work day.

Evolution of the Process Allowing for continuous feed-

back is necessary to maintain a

sense of buy-in. Although things ran

smoothly, there was some feedback

that information presented focused

on mistakes or near misses that

occurred on the critical care unit

or on other units. Although this

information is crucial for preventing

future events and encouraging staff

involvement in developing solutions,

some staff felt they were bombarded

with “all the things they do wrong.”

Because the intention of the safety

huddle was to share information and

create a positive, collaborative envi-

ronment, leaders were concerned with

the new perception. Success stories

and education were incorporated

into the daily huddles and thank

you cards from patients and families

were shared to provide a balance.

With the addition of so many

types of information, huddle dura-

tion started to run longer, resulting

in an increase in overtime for many

nurses. In response to this dilemma,

the length of the huddle was limited

to 5 minutes. Any item not addressed

within the time frame was skipped,

although exceptions were made for

constructive discussions.

As the huddle developed into a

well-functioning communication

tool, attendance at staff meetings

dropped—all of the information

provided at these monthly meet-

ings repeated what had been

shared at huddles. Thus, in April

2015, the nurse manager aban-

doned the traditional model and

implemented the monthly “virtual

staff meeting.” The contents of

the huddle binder were scanned

and uploaded to the department

intranet on a monthly basis. These

data were condensed into a sum-

mary and distributed via e-mail

as a virtual staff meeting.

Expansion of a Culture As time passed, the change-

of-shift huddle model spread through-

out the facility. When other manag-

ers, including top nursing leaders,

learned of the critical care unit’s

successes, adoption of this format

was encouraged on all other units.

Through invitation, other disci-

plines began to get involved in the

nursing huddles as well. Providers,

quality management staff, and other

guest speakers now attend on a reg-

ular basis—both to present informa-

tion and to participate in discussion.

Throughout the hospital, the safety

huddle has become the reference

standard for disseminating informa-

tion and is being adapted into other

areas of practice, including postfall

assessments, initial skin assessments,

and pressure ulcer identification.

Many important factors must

be considered to create and sustain

a new practice, and team buy-in is

arguably one of the most important.

Although team buy-in can be elusive,

and achieved in varying degrees,

success lies in management. When

managers encourage feedback from

front-line staff, and adapt to that

feedback, staff are empowered and

are more likely to participate in new

initiatives. The entire process is and

continues to be a journey.

Conclusion The Joint Commission has iden-

tified communication failure as the

cause of more than 80% of serious

medical errors.3 Communication

in the busy acute care setting can

sometimes be challenging, and its

value overlooked. The huddle

increases effective communication

among members of the heath care

team,4 reducing errors due to

82 CriticalCareNurse Vol 36, No. 6, DECEMBER 2016 www.ccnonline.org

miscommunication and supporting a

culture of patient safety. The critical

care unit at Chambersburg Hospital

is proud to share our huddle journey.

Together, we have created and con-

tinue to develop this strategy for

effective communication, focused on

team work, safety, and quality. ���

Financial Disclosures None reported.

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References 1. Brady PW, Muething S, Kotagal U, et al.

Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events. Pediatrics. 2013; 131(1):e298-e308.

2. Traynor K. Pharmacists say safety huddles aid problem solving. Am J Health Syst Pharm. 2015;72(10):766,768.

3. The Joint Commission. About the Center for Transforming Healthcare. http://www .jointcommission.org/about_us/about _cth.aspx. Published February 20, 2013. Accessed December 22, 2013.

4. Glymph D, Olenick M, Barbera S, Brown E, Prestianni L, Miller C. Healthcare Utilizing Deliberate Discussion Linking Events (HUDDLE): a systematic review. AANA J. 2015;83(3):183-188.

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