Communication is the key to effective teamwork and the delivery of safe patient care.
It is fundamental for decision making, team coordination and in maintaining situational awareness.
Human factors science tells us that
the inherent limitations of our memory,
the effects of stress and fatigue,
the risks associated with distractions and interruptions
and our limited ability to multitask
ensure that even skilled experienced providers will make mistakes.
Effective communication methods create a well understood plan of care
and this can greatly reduce the chances of error and consequently patient harm.
Communication can be divided into four components.
WHAT - this is the information to be communicated
"The fact that we have been pushing now for two hours and there is no descent..."
HOW - how are you going to communicate?
"...Would you mind just grabbing a theatre pack with a consent form while I do that and then coming back with it?"
WHY - why are you communicating this?
WHO - who are you communicating with?
There are different types of communication that we use everyday.
Written communication - this form of communication needs to be clear, legible, precise and informative
as otherwise the information can be open to misinterpretation.
Verbal communication
Non verbal communication - our facial expressions, tone of voice, gestures and eye contact
help us to convey emotion and reinforce our verbal communication.
The best form of information transfer occurs during face-to-face conversations.
This form of communication is especially important for expressing concerns and finding resolutions to conflict.
Models of Communication
Beth is a junior obstetric registrar in a tertiary hospital.
She has reviewed a patient in the maternity assessment unit
and diagnosed pre-eclampsia at 37 weeks gestation.
The patient's blood pressure is 160 / 100
Beth documents her plan in the patient's notes
for a CTG and for a stat dose of Labetalol which she prescribes.
She then leaves to review an unwell patient on delivery suite.
Beth is bleeped one hour later by the triage midwife.
The patient's blood pressure is now 170 / 110.
She asks whether the Labetalol was given as prescribed.
The triage midwife was not aware of the written plan made by Beth
as she had been called away to attend another patient
and therefore not been able to read or confirm Beth's plan.
Why might this have happened?
Communication can be difficult due to both internal and external barriers.
Internal barriers are those which affect us as individuals
such as language differences,
our culture,
our expectations of the situation and our past experience.
External barriers are those around us such as background noise and distractions.
In this scenario Beth was using one-way communication.
This form of communication is relatively quick
however there is no immediate feedback
and the receiver may not pay adequate attention to the instructions given.
So, what could Beth have done differently in this scenario?
By talking to the triage midwife Beth can explain her assessment and plan for the patient
and this invites the midwife to ask any questions or clarify any information.
Two-way communication involves both the receiver and the sender, forming a closed feedback loop.
This form of communication allows for checking and correction of details,
allowing both parties to work together to achieve a mutual understanding
and prevent any misinterpretation of the original meaning of the information.
Open questions should be used by both parties
using 'what' or 'when' questions
rather than those which invite 'yes' or 'no' answers
which are likely to lead to an automatic response and be potentially biased.
Using open questions involves the recipient and means they must think about their response.
Graded Assertiveness
As any healthcare professional working within the NHS
we are exposed to increasing stress and workload.
The intrinsic limitations of our memory,
our environment and the impact of stress and fatigue
can all influence our communication with others.
Safe and effective delivery of health care
requires communication between individuals with different roles,
training, experience and perspectives on care.
But within healthcare hierarchy often prevents people from speaking up.
The ability to speak up to express concerns is a key safety behaviour we should all have.
Not speaking up, especially in junior team members,
has been shown to be a contributing factor to many patient safety errors.
Using the PACE tool could allow any healthcare professional
to challenge any action or behaviour
they may feel is inappropriate or unsafe.
Let's look at an example
Sarah is a midwife and has called the neonatology doctor to attend a Category 2 Caesarean Section.
The baby has been born and the neonatologist is attempting to resuscitate the baby.
The heart rate remains below 100 beats per minute
and the neonatologist is unable to inflate the lungs, with no chest rise visible.
Sarah is helping the neonatologist by listening in to the baby's heartbeat
and checking the oxygen saturations.
Sarah is becoming increasingly concerned about the baby,
as the neonatology doctor has become task focused
and believes that they are successfully resuscitating the baby.
What would you do in this situation?
PROBE - "Is the chest rising?"
ALERT - "James, I really can't see the chest rising"
CHALLENGE - "James, the chest isn't rising, the heart rate isn't improving, can I take over?"
EMERGENCY - "James, this is not working. The chest isn't rising, the heart rate isn't improving,
I'm putting out a 2222 call. Please can I take over?"
By using the PACE tool to challenge the unsafe actions and behaviour of the doctor,
Sarah has been able to stop the situation,
allow for reassessment and ensure the patient's safety.
Handovers and SBAR
Working frequently in shifts results in dynamic teams,
with members not being constant.
Handover of care is therefore essential in developing a shared mental model
and effective continuity of care.
Poor communication at handover is a leading cause of patient harm.
Handover should be multidisciplinary, formal and follow a consistent format.
You should have adequate time without distractions or interruptions.
Have a clear leader.
This should be the person who has maintained situational awareness throughout the previous shift.
and therefore has the knowledge to provide an accurate handover.
The leader should highlight patients who are at risk or with concerns.
Clear and unambiguous plans should be stated.
At handover, exchange of sufficient and relevant information
using standardised communication tools should be used.
SBAR is a communication tool
which allows healthcare professionals to communicate effectively and assertively;
with the right level of detail communicated
in any clinical setting.
SBAR can empower those who may feel less confident
or less experienced than a senior
to make a recommendation.
SBAR is comprised into four prompts
Situation
"Morning I am Raquel, the midwife looking after Lucy Brooks."
"She is a primigravida at 37+1 being induced for small for gestational age..."
Background
"Lucy has a BMI 42. She had serial scans in pregnancy and
a small for gestational age baby has been diagnosed."
"She's being induced for that reason."
"The estimated fetal weight is 2.4 kilograms."
"She had an ARM at 06:30 at 3cm dilated,
started oxytocin at 06:45".
"Oxytocin is currently running at 8 mls per hour".
"She is contracting two in ten and the CTG's..."
Assessment
"My assessment is that we need to increase the oxytocin as per our current guidelines
and she's not yet in established labour".
Recommendation
"I will perform the vaginal examination in the next four hours after regular contractions
unless I have got earlier concerns".
Top tips on communicating in teams.
Be explicit
Clearly state the desired action and who should do it,
using both verbal and non verbal communication.
Use names to directly communicate to someone
and ask them to report back to you when they have completed the action.
Closing the loop.
Think of your timing,
do I need to communicate this now or can it wait?
Do not communicate if someone is task focused,
unless the information is urgent.
Can you find someone else you can help you?
Speak up and be assertive if you are concerned about
another colleagues behaviour or decision making.
Be careful not to disregard the other person
or come across as being aggressive.
Asking questions to acquire more information
may be all that is required to resolve a problem.
Avoid interrupting,
trying to work out what the person will say next
or changing the subject.
Remember to actively listen to others
especially if they are trying to speak up
This is key in demonstrating effective communication skills.