Communication with physicians in hospital rounds: An interview with nurses

Abstract

A hospital round is a long tradition in which nurses and physicians communicate to develop an integrated plan of care together with the patient. There is insufficient knowledge of care professionals’ experiences of communication during hospital rounds, particularly in surgical units, where the physician is frequently absent during daily care. Hence, the aim of this study was to describe nurses’ experiences of communication with physicians during hospital rounds in a surgical unit. Nine qualitative unstructured interviews with nurses were conducted and analysed using Burnard’s description of content analysis. ‘An encounter involving opportunities for and challenges to teamwork’ was found to be the predominant theme. The hospital round in a surgical unit is a short encounter that can be challenged by missing patient care goals, difficulties in transmitting messages and frustration over unshared information. Further studies are needed to overcome existing knowledge gaps about communication during hospital rounds.

Introduction

A hospital round is a long tradition in which nurses and physicians communicate to develop an integrated plan of care together with the patient.^1,2 Patients, however, are often not able to participate in hospital rounds to the same extent as the nurse and the physician. Effective communication between the nurse and physician during hospital rounds could be a prerequisite for the quality, safety and efficiency of patients’ care.^2,3 However, it has been shown that various circumstances contribute to impaired cooperation and difficulties in resolving conflicts in communication^4,5 but few studies have focused on nurses’ experiences of communication during the hospital round.

Hospital round communication is a highly interactive process in which nurse and physician mutually exchange and interpret verbal and nonverbal messages. ³ Communication failure is a common cause of insufficient patient safety. ⁶ If a nurse and a physician understand each other correctly, it contributes to safe, positive and productive communication in practice. ⁷ However, if this understanding is missing, the foundation for creating teamwork during hospital rounds is threatened. ⁸ Multidisciplinary teamwork relies on communication that consists of mutual trust and common goals.^8,9 In cases of an accurate combination of nurses’ caring and physicians’ medical competence, communication bias is likely to be less present.^10,11 Leonard et al. ⁶ discuss the idea that effective communication depends on personality as well as situation. Because hospital rounds involve substantial communication between a nurse and a physician and there still appear to be misunderstandings in the communication between these categories of professionals, more knowledge is needed of nurses’ experiences of this kind of communication. Nurses are often the communicative link between physicians and patients, and effective communication during the hospital round might be even more crucial for nurses.

Hospital rounds are sometimes the only time during the day when nurses, physicians and patients can exchange information, and if hospital rounds are malfunctioning, this creates possible threats to patient care.^1,12 O’Leary and colleagues ¹³ as well as Al Sayah and colleagues ⁸ have stated among other things that a lack of communication is related to a lack of common goals, due to misunderstandings. When communication between nurses and physicians is failing, the formulated goal of care for the patient is affected.^2,14,15 A hospital round constitutes a situation in which the three parties have an opportunity to communicate and form a goal for continuing care. This notwithstanding, the care is not always based on a communication structure with a formulated goal. There is still little evidence of nurses’ experiences in the literature, but nurses may be caught between absent physicians and patients who are expecting to receive information from the hospital rounds. To improve care efficiency, it is important to describe nurses’ experiences of communication during hospital rounds.

Lewin and Reeves ¹⁶ found that communication during hospital rounds is influenced by various contextual factors, such as heavy workload or organisational changes. Furthermore, it has been shown that the organisational context and the way hierarchy is understood could limit communication between nurses and physicians.^3,8,10 However, the authors of these previous studies did not discuss the impact of the nurses’ relationships with the physician, or the influence of the communication circumstances that could be important for the content communicated during hospital rounds.

A dialogue uniting nursing and medicine is often absent during hospital rounds,^4,17,18 resulting in the nurse becoming frustrated and unsatisfied with patient care. It is essential that nurses be allowed to share their perspective and knowledge regarding the patient with the patients’ physician. However, in some situations, communication and collaboration during hospital rounds are characterised by nurses and physicians working in parallel or even against each other. Such a lack of cooperation can be caused by a lack of understanding of each other’s competencies^5,19 and responsibilities ²⁰ due to insufficient interprofessional education ²¹ or differences in language or cultural norms. ⁶ Nurses and physicians, who are trained to see different perspectives in the care of the patient, are expected to communicate effectively and explore each other’s knowledge.^12,18,20 A lack of respect in nurse–physician communication has been reported to threaten the dialogue during hospital rounds.^4,20,22 The dialogue is threatened if physicians do not respect the nurses’ knowledge, if the delivered information is changed or if communication becomes side-tracked during the hospital round.

There are few studies investigating communication between nurses and physicians during hospital rounds, particularly from nurses’ perspective. Most studies have focused on units in specific contexts, such as intensive care or emergency care units where nurses and physicians work closely together. Thus, there is insufficient knowledge of nurses’ and physicians’ experiences of communication during hospital rounds, ² particularly in surgical units where the physician frequently is not present ²³ and where the hospital stay is short. The aim of this study was to describe nurses’ experiences of communication with physicians during hospital rounds in a surgical unit.

Methods

Design

A qualitative study design was adopted, with a naturalistic approach using unstructured interviews ²⁴ that were interpreted using content analysis inspired by Burnard. ²⁵ The naturalistic approach argues that there are multiple interpretations of reality. This study investigated nurses’ experiences of communication during hospital rounds in their entirety. The study focused on nurses’ individual experiences, in which context and relationships with others contributed to the results of the study. ²⁴

Setting

This study was conducted with nurses working in a surgical clinic in a medium-sized city in southern Sweden. The clinic consisted of two units that generally cared for a maximum of 60 patients. The hospital rounds began with a meeting between the nurse and the physician in a separate room sitting together communicating about the patient care plan. After the meeting, both the nurse and the physician informed the patient bedside.

Participants

The inclusion criteria required each participant (P) to have worked as a registered nurse for at least two years. Both leaders and staff in the unit were informed of the purpose and procedures of the study. Sixty-eight nurses were employed at the clinic at the time of the interviews. The informants were ten nurses, who all gave their consent to participate in the study. One nurse, after reading the written information, chose to decline to participate. The sample in this study consisted of nine (n = 9) nurses, and this sample was estimated to be sufficient to reach data saturation. All the informants were women, with an average age of 37.9 years (range 24–56 years). The nurses each had 2–28 years of work experience as registered nurses and had worked in the surgical units for between 1.5 and 14 years.

Data collection

Unstructured interviews were conducted ²⁴ in which the nurses were asked to describe their experience of communicating with physicians during hospital rounds. The interviews were initiated with the following question: ‘What is your experience of the communication between nurses and physicians during hospital rounds?’ The interviews were audio-taped, which gave the first author an opportunity to focus on the content and dynamics of the interviews. Follow-up questions were used to further explore the nurses’ perspectives. ²⁶

The first author, who conducted the interviews, is a nurse who had some pre-understanding of the context. This pre-understanding generated an understanding in the dialogue with the nurses and facilitated asking relevant follow-up questions. ²⁴ The interviews lasted 16 to 42 minutes (an average time of 25 minutes). After completing each interview the first author wrote a short summary. The nurses were able to ask questions regarding the interview. ²⁴ The audio-taped interviews were transcribed verbatim. When transcribing the interviews the first author benefited from becoming familiar with the material and was able to clarify particular statements, emotional and social aspects of the material. ²⁴

Data analysis

The transcribed texts were analysed using a content analysis method developed by Burnard. ²⁵ Content analysis was a suitable method for extracting meaningful content from the nurses’ experiences of communication during hospital rounds. ²⁷ The content analysis method involves four steps in which codes and categories, important meanings and predominant themes from the text are identified. In the first step, the transcribed texts were read to obtain an overall understanding of the content. The texts were then reread, highlighting parts of the text that were related to the aim of the study. In the second step, the highlighted parts were condensed, and considerations were taken to preserve the central meaning. The third step involved the categorisation and arrangement of codes with similar meanings into themes and subthemes. The fourth step included an additional processing of the material to determine whether the themes and subthemes reflected the original texts, to ensure credibility. If there were any doubts about whether a sequence had been taken out of context, the authors referred back to a copy of the transcribed material. To ensure trustworthiness, the first author discussed all steps in the analysis and the emerging theme and subthemes of each text in an open and critical dialogue with the second author. ²⁵ After revisions, consensus was reached about the most credible interpretation of the transcribed text, and the subthemes and theme were interpreted to describe the nurses’ experiences of communication with the physician during hospital rounds (Table 1).

Table 1.

Theme and subthemes.

Subthemes	Theme
Common goals facilitating communication Transmission of the message	An encounter involving opportunities for and challenges to teamwork
Frustration with unshared information

Ethical considerations

The Ethical Advisory Board of Southeast Sweden was consulted about this study. An ethical self-review was made and confirmed that no ethical approval from the committee was necessary for this study. In accordance with the Declaration of Helsinki, ²⁸ the participants gave written consent after receiving written and verbal information about the study, including its purpose and the procedures involved, the voluntary nature of participation and the option to withdraw at any time. The confidentiality of the participants was assured; no names or places are mentioned in the text.

Results

An encounter involving opportunities for and challenges to teamwork

The theme ‘An encounter involving opportunities for and challenges to teamwork’ expressed the nurses’ experiences of opportunities for and challenges to communicating with physicians during hospital rounds. The communication between the nurse and the physician was influenced positively if a professional relationship was present and if a common goal was present in the communication. However, communication between nurse and physician was characterised by frustration when there was unshared information and when the nurses experienced that their information was not valued or understood by the physician.

Common goals facilitating communication

The nurses noted that if they and the physician had a common goal for patient care during hospital rounds, communication was facilitated. This led to fewer misunderstandings in their communication. If nurse and physician could discuss a patient’s care, the nurse felt that she was involved and felt satisfied with the communication. Nurses preferred the physician to have some knowledge of the patient’s anamnesis and current care in establishing the goal for the patient’s care. The nurses also noted that if there was a common goal, they experienced communication with the physician as a dialogue and that the physician appreciated their knowledge.

I think it’s working when the nurse and the physician have the same goal for the care. You have a common goal and work together for the benefit of the patient. (P2)

If nurse and physician had the same goal for the patient’s care in the dialogue during hospital rounds, communication and decision-making were easier. The feeling of being a team was more present.

Transmission of the message

The nurses stressed the fact that it was difficult to reach out to the physician while communicating. The importance of respect in communication and acknowledgement of the nurse’s competence and profession was also emphasised.

Nurses sometimes felt disrespected in the communication and not trusted to form a part of the dialogue regarding the patient. Sometimes the physician was more interested in what the computerised patient records contained than listening to the nurse’s point of view. When a professional relationship existed, the physicians were more likely to provide the nurses with explanations and listen to the nurses’ perspectives. Then the atmosphere between the nurse and physician was experienced as being more open, and the nurses could ask questions. This allowed nurses to be more active in the communication during hospital rounds while asserting a nurse perspective in the patient care.

Then, if you’re building some sort of relationship, you eventually get to know the physicians during the hospital rounds and then it is easier to discuss. (P1)

If a professional relationship was not present, the nurses felt they had to adapt their communication during the hospital rounds to the physician present. The nurses also reflected that the body language of the physician sometimes showed an attitude of lacking interest. If this attitude was present, the nurses experienced that the physician expressed him/herself in a distant and condescending way. This situation made many nurses feel inferior in the communication.

Then, I feel rejected, he doesn’t respect me. I don’t feel confirmed, he’s not taking me seriously. (P5)

To avoid a feeling of inferiority in the communication the nurses needed a substantial amount of professional security and the courage to challenge the hierarchical situation during the hospital rounds. Some of the nurses felt that disrespectful attitudes decreased their confidence when communicating.

Frustration with unshared information

Many of the nurses experienced frustration when information, such as from routine procedures and the monitoring of patients, was not shared between nurse and physician during hospital rounds.

The nurses felt that they often had to be persistent during communication to have their opinion heard. However, the difficulties they experienced in communication did, at times, cause the nurse not to communicate observations regarding the patient; thus, important information regarding the patient did not reach the physician. Some ordinations and routines made by the physician were not mentioned; it was assumed that the nurse would have this knowledge. Another example of unshared information was the physicians’ use of complicated medical terminology. On the nurses’ part this led to difficulties in understanding and a subsequent lack of courage to ask for clarification. The nurses noted that this unshared information was a threat to communication with the physician during hospital rounds. The threat included missing observations due to no one having been designated with a certain responsibility.

Unshared information also included physicians writing different kinds of prescriptions that did not reach the nurse responsible.

And then after the hospital rounds I can find new prescriptions in the medical records. Aha, the patient is supposed to have a blood transfusion as well. Then, they have informed someone else, but the information had not been forwarded. (P8)

Current and updated information is a foundation of nurses’ work in patient care. Information that is not communicated or altered before reaching the nurse responsible causes frustration. Being unaware of unshared information could lead to irritation in the communication between the nurse and the physician.

Discussion

This study indicates that communication between nurses and physicians during hospital rounds in a surgical unit is a short encounter influenced by several factors that affect the nurses’ experiences of teamwork. An interesting circumstance is that the nurse and the physician often lack a common goal, a fact that constitutes a challenge when formulating a relevant care plan together with the patient during the vulnerable time after surgery. Another finding not clarified in earlier research is the fact that nurses often experience difficulties transmitting their valuable observations to physicians. Communication during hospital rounds in a surgical unit is complicated when information is not shared between physicians and nurses; a situation that may delay prescriptions and impact on patients’ care.

The nurses emphasised the importance of a common goal to facilitate functional teamwork during hospital rounds in a surgical unit. Narasimhan and colleagues ¹⁷ as well as Al Sayah and colleagues ⁸ have noted that goals must be clarified to benefit teamwork. In addition, good teamwork requires all health professionals (in this study nurses and physicians) to understand each other’s roles, and the importance of teamwork, communication and collaboration in order to deliver safe and high quality patient care. ²¹ This study contributes the new knowledge that this clarification may be an even more crucial need in a surgical unit where the encounter between nurse and physician often is short and where important decisions regarding patients’ care after surgery must be considered. The nurses described the need for dialogue regarding patients’ care, and without a common goal this dialogue was rendered difficult. If the goals were obvious, the dialogue was facilitated and the nurses’ perspectives of the patient were taken more seriously. Robinson and colleagues ²⁹ have underlined that a functional dialogue during hospital rounds is characterised by discussions in an open climate about the patients and that dialogue improves when nurses’ and physicians’ knowledge is combined. This study shows that teamwork and a common goal have to be linked during hospital rounds to prevent misunderstandings. However, common goals for patients’ care are often omitted in the dialogue during hospital rounds in a surgical unit. Narasimhan and colleagues ¹⁷ found that communication amongst the various members of a team is essential for the entire team to clearly understand the daily goals of their patients’ care. A lack of communication within the team might be a threat to patient safety. Thus the use of techniques, such as standardised tools and communication training such as Situation, Background, Assessment and Recommendation (SBAR) ³⁰ could facilitate safety in the care environment ⁶ and promote interprofessional education. ²¹

Additionally, it has been shown that professionals who are confident in their assessment and role and who have a clear direction for care are more disposed to discuss and participate in patients’ care. ⁸ In addition, it is well known that unwanted or ineffective care occurs if goals are not clearly expressed.^12,17 For the newly operated patient, this lack of communication might lead to complications that could delay recovery. Furthermore, the consequences of an unexpressed goal include added costs and the increased likelihood of medical errors, factors that affect the organisation as well as the patient in the unit.

We also find it interesting that nurses often experienced difficulties transmitting messages to physicians during hospital rounds in the surgical unit. Nurses’ observations of the patient were often not heard or considered in the care planning of the patient during the critical days following surgery. Such a situation during hospital rounds made it more difficult for nurses to be a part of the dialogue and form a team in which they could feel free to share knowledge about the patient’s situation. Jones ¹⁰ and Wagner and colleagues ¹⁸ have stressed that nurses and physicians, who see different aspects of their patients’ care during hospital rounds, have to explore each other’s perspectives in order to benefit the team. Furthermore, we noted that nurses’ and physicians’ different perspectives on care (nursing and medicine) are not sufficiently explored by the team and are not combined during hospital rounds. The nurses experienced, on several levels, that they were not respected and that the value of their knowledge was neglected during communication with physicians. It has been shown that nurses and physicians have to respect each other to avoid a lack in communication.^5,6,31 This want in communication might be prevented if education for both nurses and physicians emphasised the importance of interprofessional learning. ⁶ Tabak and Koprak’s ⁵ study also reflected that in successful communication the hierarchical relationship between nurses and physicians was absent. The feeling of disrespect during communication may be a demonstration of an existing hierarchical structure.

Another interesting finding is the presence of unshared information. For instance, uncommunicated prescriptions or prescriptions made through the computerised patient records were frustrating for the nurses. Previous studies have discussed the fact that information can be altered or not directly communicated during hospital rounds.^4,20,22 The situation could be even more frustrating in a surgical unit because the physician often leaves the unit after the hospital rounds and consequently is not available for further questions. The information may then be delayed, which may also cause delays in the patient’s care. Correct information at the appropriate time is crucial in patient care in a surgical unit since the patient is often fragile after surgery. Thus, in order to improve teamwork during hospital rounds, changing the traditional stereotypes of the nurse and the physician might be a goal, ³² since the nurse and the physician are supposed to work together as a team in caring for the patient. Consequently, when the nurse experiences that the nursing profession and the nurse’s knowledge of the patient is not valued, information might be lost and not shared with the physician. ² This circumstance impedes teamwork. Accordingly, nurses and physicians, who are trained to have different perspectives on patient care, ²³ have to find a way to strengthen and respect each other in their communication in order to improve teamwork during hospital rounds. This aim is important in formulating a relevant and distinct care plan for each patient based on a clear goal of the care following surgery.

To reduce the risk of subjectivity, ²⁴ two of the authors reflected on the results of the content analysis to guarantee trustworthiness. ²⁵ Quotations are presented to enable transparency of the analysis and to underline the credibility of the study. ²⁵ The selection process was purposely conducted, and was homogeneous with regard to gender (female) and work context (two surgical units). However, the sample includes variation within the nursing profession. A strength of the study is the fact that the nurses who were interviewed, depending on the inclusion criteria, have substantial experience of their profession and consequently have extensive experience communicating with physicians during hospital rounds. ²⁴ However, a limitation of this study was the inclusion of only nine informants. Nevertheless, the sample was estimated to be sufficient to reach data saturation. The physicians’ experiences of communication were not illuminated by this study. This is of course an important factor in order to get a general picture of the communication between the professionals during hospital round, but was not the purpose of this study. Unstructured interviews were conducted ²⁴ to encourage the informants to express their experiences of communication with physicians during hospital rounds.

Conclusion

Hospital rounds in a surgical unit are encounters involving opportunities for and challenges to teamwork. Communication between nurses and physicians during hospital rounds is crucially important in a surgical unit where care time is short and the physician is absent during daily care. Findings indicate that communication during hospital rounds does not always include a structure or a common goal permeated by a spirit of teamwork, a fact that could jeopardise patient safety. The nurses emphasised the importance of a successful transmission of their information and observations regarding the patient to the physician during hospital rounds. This information was valuable in formulating goals for patient care after surgery. Further research is needed as the results are based on a limited number of nurses. In addition, good communication between professionals is an important element in improving the involvement of patients and their next of kin in the patient care dialogue.