“The greatest problem with communication is the illusion that it has been accomplished”. George Bernard Shaw
Communication is derived from the Latin word 'communis' that means 'common'. Communication is the process of making common or known. As shown in the above video clips, communication is the activity of conveying meaningful information/message (thoughts, ideas, feelings) verbally and non-verbally by the sender and transmitted to the receiver. The communication process is complete once the receiver accepts the information and interprets it and understands the message of the sender by providing feedback. Through feedback, the sender confirms that the message was received. With the number of steps involved in the communication process, it is understandable that miscommunication can occur at any step of this process. Abstracted information, interruption, challenges in receiving the information because of psychological, cognitive, cultural factors, and lack of feedback are examples why ineffective communication or communication breakdown occurs (World Health Organization [WHO], 2009).
Communication among health professionals and organizations is a highly complex but an important function in the provision of safe healthcare. Traditionally, communication skills taught to health discipline learners focused on interactions with patients and families from their profession's perspective i.e., profession-centric communication, not on communication across professions or interprofessionally. Hall (2005, p. 194) writes that "they begin their careers with interprofessional barriers of unfamiliar vocabulary, different approaches to problem-solving, and a lack of common understanding of issues and values". According to Pecukonis et al. (2008, p. 419) "communication between practitioners or disciplines is loosely coupled as providers work independently and may or may not share information formally. The communication process is typically embedded within a prescribed leadership hierarchy".
Ineffective communication is reported as a significant contributing factor in healthcare errors and inadvertent patient harm (Victorian Quality Council Secretariat, 2010). According to the Canadian Medical Protective Association (CMPA) (2011), an organization that provides its physician members with medico-legal advice, risk management education and legal assistance related to their clinical practice, their case file data reveals that interprofessional communication issues are associated with a wide variety of medico-legal problems, including delays in diagnosis, mishaps in surgery, medication adverse events, and failures in monitoring or follow up of patients.
Effective communication requires the use of many skills. Effective interprofessional communication is communication that occurs in an open, collaborative and responsible manner. It is communication that is built on mutual trust among healthcare professionals/providers/learners, patients and their families. As stated earlier, each health discipline brings knowledge to the conversation. Some of the knowledge is overlapping, but much of it is not. Using the work developed by Barr (1998), Salvatori, Mahoney, and Delottinville (2006, p. 381), outline that the core competency for collaborative interprofessional communication skills include "sharing information, listening attentively, respecting others’ opinions, demonstrating flexibility, using a common language, providing feedback to others and responding to feedback from others". Having respect for each discipline, facilitates a positive environment for the setting of goals, creating collaborative plans, making decisions and sharing responsibilities.
Recent CMPA (2011) data summarize important interprofessional communication themes as follows:
According to Hamilton (2011, p. e200), the required interprofessional culturally competent communication skills include "interviewing, gathering information, presenting diagnoses or findings and negotiating treatment. They can include clinical skills like physical assessment and the use of electronic health documentation systems". As a means of improving communication in healthcare, individuals can develop many useful skills, including assertiveness, active listening and negotiation (Victorian Quality Council Secretariat, 2010).
The use of structured communication tools or other strategies in healthcare will improve the structure and quality of information exchanged between healthcare professionals and optimize patient health outcomes. This will be discussed further in Module 3.
Conflict is part of our nature. Constructive conflict provides opportunities to learn new skills develop problem-solving abilities and infuse energy into projects. On the other hand, destructive conflict when left unresolved/unacknowledged may lead to more conflict and fears which lead to anxieties and mistrust. In response, interprofessional communication becomes ineffective, collaboration and teamwork efforts decrease (Marshall and Robson, 2005). Early recognition and addressing the conflict are important in healthcare to prevent negative outcomes e.g., serious threat to patient safety.
For example, when differences in the professional culture of health disciplines are not embraced, confusion in role and responsibilities can occur. In response, conflicts in the form of avoidance and/or competition can occur. Unresolved conflicts can "create traps and hazards for healthcare providers and lead to undesired patient outcomes" (Marshall and Robson, 2005, p. 41). There is clear evidence that communication breakdowns as a result of interpersonal conflict contributes to further decrease in communication, increased turnover and more adverse outcomes for patients. In Module 1 we also learned that when errors do occur, a culture of blame supports the process of learned helplessness and/or the culture of fear. According to Marshall and Robson (2005, p.40), fear and conflict are safety enemies "which leads to silence and missed opportunities for learning, change and improvement".
Conflict resolution is how learners/practitioners actively engage self and others, including the patient/client/family, in dealing effectively with interprofessional conflict (CIHC, 2010). The changing and increasingly complex healthcare environment involves more specialized tasks that require new skills of all health professionals (Faculty Leadership in Interprofessional Education to Promote Patient Safety (FLIEPPS), 2004). Specialized functions require coordination and communication to prevent unnecessary complex steps that may increase the potential for error. "Increasing complexity also demands extraordinary communication and cooperation among healthcare professionals, transparent error policy, individual truthfulness, and on-going professional development" (VanGeest and Cummins, 2011, p. 8).
As stated in the previous sections, the development of interprofessional cultural competence and effective communication skills are requirements for cooperating effectively with healthcare colleagues i.e., managing conflicts. Willingness to dialogue and discuss when appropriate is the first step in developing interprofessional professional cultural competence. This is a necessary step in order to achieve the goal of interprofessional care: to do what is in the best interest and safety of the patient (Pecukonis et al., 2008).
To optimize patient safety in an interprofessional environment, each health discipline must learn the meaning and value of alternative perspectives. For this to occur, both disciplines must learn negotiation and conflict-resolution skills. Conflict resolution often requires compromise, "embracing the others' perspective and rethinking the initial formulation" (Pecukonis et al., 2008, p. 424). These are the new practice realities. Patient safety demands it.
Module 2 – Activity 4
NOTE: Each learner could also write their account of a patient’s experience, in which the learner follows that patient throughout the course of his/her treatment e.g., appointment with primary care health professional, chemotherapy session, surgery, physiotherapy etc.
Module 2 – Activity 5
Simulation in a standardized clinical scenario or role playing
The scenario presents a critically ill patient admitted via the emergency room (ER) with shortness of breath who has just been transferred onto a unit. She was stabilized, alert, and oriented when received but since that time experienced a rapid deterioration in vital signs, oxygen saturation, and sensorium. The daughter has been called and is coming to consult with the team and see her mother.
Reflective of real-life practices in an inpatient setting, each member of the team receives the information that is usual for their profession i.e., each one therefore received different information: The medical students received a brief synopsis of the current diagnosis, patient history, chief complaint, and ER chart. The recent diagnosis of metastatic cancer was not included in this information. They were told that the patient's condition was worsening, and they had just been paged by the nursing staff to see the patient and talk with an arriving family member.
The nursing students were given an introduction to the patient that included the initial nursing assessment and nursing note with the added information about the metastatic cancer diagnosis as well. They were also told that they themselves had spoken with the patient while the patient was alert and oriented. The patient had indicated to them that she knew she had metastatic cancer, had refused chemotherapy in the past, and did not want any life support.
Her written advanced directives were at the long-term care facility where she lived. The nursing student first met with the family member to provide comfort before the medical student entered.
The standardized patients were instructed to say (when asked) that they knew that their mother had metastatic cancer, had refused chemotherapy, and were looking into hospice care. However, they (as the daughter) had not yet come to terms with this decision, and they should initially insist that everything be done to “save” their mother. They were made aware of the information the nursing student and the medical student had received. These actresses were instructed to allow the team to lead them to a conclusion (either intubation or comfort care) as long as they had effectively communicated with her and each other, acting as an interdisciplinary team.
The medical student, nursing student, and family member worked together to develop a plan of care. At the end of a predetermined length of time, a patient “code blue” was called and a plan of action was required from both learner team members. Interdisciplinary communication and teamwork were essential to effectively determine appropriate next steps, that is, either intubation or comfort care. At the end of the session, all team members participated in a feedback session including the patient family member to discuss this experience and evaluate the communication between team members. Learners were given an evaluation form to complete to allow formalized input on the educational program.
Reflective Practice (record in journal)