When Washington Hill, MD, was planning a day-long conference in April to focus on issues impacting the management of high-risk obstetrical patients in South Florida, he made certain that communication was high on the agenda.

 

“Simply talking … is very important from the standpoint of patient safety,” said Hill, medical director of the Maternal-Fetal Medicine Department at Sarasota Memorial Hospital in Sarasota, Fla. “Here’s an example: A nurse calls over and says, ‘Dr. Hill, this patient’s heart rate monitor doesn’t look real good.’ And I look at it and say, ‘it looks fine.’ Yet she’s still worried. The appropriate thing for me to do is go over and take a look at it and see what her concerns are.”

 

The Joint Commission has looked several times at the biggest breakdown in patient safety, Hill continued, and it’s always been communication—whether between doctor and nurse, nurse and patient, doctor and patient, and others in the labor and delivery area or operating room.

 

“In the old days, the doctor was the captain of the ship, so his thought might be, ‘be quiet, nurse, I’m in charge,’ but now,” he said, “it’s very important for everyone to communicate effectively and collaboratively to improve patient safety.”

 

Sage Lambert Graham, PhD, a University of Memphis professor whose research centers on the intersection between language and social phenomena, published an article last year addressing the ways that healthcare providers on medical teams interact and effectively communicate in hospital settings. In particular: How do members of caregiving teams navigate disagreements, challenges to authority, and norms of expected behavior within the hospital hierarchy when trying to assure quality patient care?

 

“Hospital hierarchy plays a striking role in how non-MD healthcare providers give input and attempt to negotiate patient discharge decisions,” said Graham. “This is an extremely complex environment with important ramifications for patient care. This study only begins to scratch the surface in unraveling the complexities of shifting roles and institutional structures at play.”

 

Graham began studying medical communication in 1997 as a doctoral candidate at Georgetown University. Working on the “Hospitalk” project, she was part of a team tasked with studying communication problems at a major urban teaching hospital and providing strategies for better cooperation and communication among medical teams. Its nursing school had received complaints from experienced registered nurses who didn’t believe hospital physicians recognized their contributions. 

 

Feedback from one-on-one interviews with RNs ranged from simple irritation to notable frustration.

 

“Medical residents,” said one, “are for the most part … in big need of learning how to talk to people. (They) think they walk on water. And they’re the lowest on the totem pole. They are at times rude … and obnoxious. Some of us are old enough to be their mothers. You just don’t do things like that.”

 

Another nurse described a situation with an intern who had ordered a medication dose she recognized as potentially lethal “and probably should never have been ordered.”

 

After confronting the intern, “he said to me, ‘I suggest that you read up on that a little bit more and that you call the pharmacy and work it out,’ which then … puts the red flags up. And if you have a license at stake, then you have to be … really aware of … the right thing to do,” she said.

 

Graham also observed morning rounds, and was particularly interested watching the way a registered nurse from Germany in her early fifties inserted herself into a session—and medical students’ reaction.

 

“When the attending physician comes out of a hospital room during morning rounds, the interns and residents typically make a circle around him/her to discuss the patient’s status, while the RN caring for that patient usually stands nearby in case there are questions,” said Graham. “But this RN stood inside the circle, and it clearly made the interns very uncomfortable. Physically, they inched away from her. They never looked at her. They talked to one another and the attending physician, but never to her. It was clear they didn’t know how to deal with her. It’s consistent with the institutional hierarchy that puts even third and fourth year medical students above RNs in the social/expertise hierarchy.”

 

After the Georgetown team’s initial observations, the hospital implemented a system allowing teams of caregivers to work together more consistently instead of rotating to different floors on different days. “That seemed to help minimize some of the tension and disagreement,” said Graham. 

 

In addition to her work on communication between healthcare providers, Graham’s research also examines doctor-patient interactions. She recently received a grant from the Tennessee Board of Regents to study healthcare disparities in minority populations, which she claims can often be a direct result of communicative differences. “For example, African-American patients in the South will sometimes say, ‘I’ve got the sugar,’ meaning they have diabetes,” explained Graham. “A doctor unaware of that expression may disregard it and miss a very important diagnostic variable, and this can have a dramatic impact on the plan of care. We don’t want that to happen.”

 

Graham also plans to replicate the “Hospitalk” study at a non-teaching hospital in the mid-South to determine if the patterns of communication between doctors and nurses are consistent with her earlier findings. “Everyone involved wants the same thing,” she said. “The challenge is to figure out how communication can be improved to make sure that the patient gets the best care and the best outcome possible.”