Turn entangled boundaries into better care: Coordination with less aggravation

The nurse is really frustrated. She thinks the medication for the patient may be wrong, something she learned at a recent patient check-in.

She tried to talk to the MD multiple times. She could put in another order, but he’ll see that as a takeover.

The MD has new clinical locations and responsibilities now. She and others have helped free up the MD’s time. He needs that: he’s younger, new to the practice and was overwhelmed.

But the doctor doesn't return calls. She feels ignored. She feels disrespected. She knows the patients better than the MD! And she’s been at the job for a long time.

She writes a complaint to the practice: you don’t respond to multiple calls and, even when you do, you rarely listen to her. You always think she’s wrong.

Now the MD is embarrassed. He has a problem, an unwanted problem.

What do you as the MD want to happen here?

• To deliver excellent patient care by relying on your team
• To stop complaints! That means repairing this relationship with the nurse
• To assure the nurse that you didn't intend to disrespect her
• To clarify how and when you’ll assist and support her. That means more efficient communications
• To make it easier for you to be consulted and get essential patient information the first time so
  • Conversations are more effective and
  • You make better decisions faster.

Conversations that coordinate and connect

1. Set an intention to treat the nurse as a critical colleague.

• Remind yourself how you depend one her to be the physician you want to be.
• Create one small way you can treat her the way you’d want to be treated.
  • Perhaps: check in with her daily before leaving? Look into her eyes with a relaxed posture when you see her? Ask her a question about the patient? You’ll know.
• Do that for a week and see what happens.
  

2. Arrange a conversation with her soon. The aim is to agree on how you’ll communicate and cooperate more successfully.

• State how you value her perspective and her strengths in patient care. Identify the situations where you really rely on her knowledge.
• Ask her to explain her suggestion. Listen. Then say the reason for your original decision. Things are so complicated now that these explanations can prevent future misunderstandings
• Then ask to discuss how you can communicate so that each of you gets what you and the patient need in a timely way. Write out a specific list. It can be small things
  • Signal urgency in the subject line
  • Specify when each of you can be reached live
  • Identify clearly what each of you needs in the communication – the data, the problem itself, the newest development, the format of the information etc.
  • Talk about what each of you will do if you cannot talk in real time
  • Discuss expectations of which responsibilities/tasks can be done autonomously and which kinds require live agreement. Now there are many possible overlaps and blurry boundaries. This is foundational for successful coordination and cooperation
• Close the conversation with each of you saying what you learned – about the patient’s care and working better together. Take a breath and be sure you use a tone and body language that shows sincerity and respect.
• Set a date and time to talk again (perhaps in 2 weeks?). You’ll check in to see how you are doing in communicating and connecting with her as a colleague.

Tips

• Use “I” sentences and root your comments in your own experience. The relationship will heal when you work toward shared aims like better communication and cooperation. Not by blaming
• Focus on what needs to happen now, who does what and what you can agree on.
• A great question for one another – How else might I help you?
• This is a great example of how slowing down can enable you to go faster!

What does this do for you? For your colleague? For your patients?

1. You will make better decisions.

• MDs critically need others to give them reliable, up-to-date information more than ever before to treat increasingly fragile patients with multiple chronic illnesses in the exceptionally volatile care context. MDs rarely have enough time to become as familiar with patient needs as nurses do. Quality patient care now demands shared responsibility.
• Nurses and other clinicians can also fill in any blind spot so you’ve got a fuller picture.
• Clear understanding of what you need from the nurse will enable you to make smarter decisions quicker. The professions tend to communicate differently – reporting different clinical information in differing ways. Clear agreement on the elements and structure for communication enable you to speak the same language. So you can act faster and more effectively.
• Rapport, mutual respect and agreed communication guidelines improve care outcomes.

2. Changing care workflows, organizational shifts and locations and sicker, less resilient patients increase the confusion over task boundaries and overlaps and raise the risk of mistakes.

• You’ll coordinate patient care better with clear agreement about who does what when.
• When nurses can’t depend on an MD callback , there’s friction, resentment, withdrawal, or withholding…And it festers. Discussing what and how to collaborate shows your respect for the nurse and reveals shared aims. The nurse will feel she’s seen as a contributor. You also reduce conflict and its costs.

3. Clearer patient communications and connection between the MD and nurse give them chances to learn from one another - both about medical problems and processes. That enables each to do more and be wiser when similar situations arise. The relationship fosters knowledge and professional development for both.

The aim here is a win-win-win – MD, nurse and patients.

Tip:

One or two efforts will not likely erase the residue of feeling ignored and disrespected for perhaps a long time. Gaining her generosity and trust requires you to repeat your efforts and intention consistently over time.

Do you have inefficient conversations with clinical staff? I’d really like
to know about you and your experience. Email me to tell me about it: nance.goldstein@post.harvard.edu

Resources:
The Interprofessional Education Collaborative (IPEC) has introduced Core Competencies for Interprofessional Collaborative Practice to guide education for interprofessional communication and collaboration. https://www.ipecollaborative.org/ipec-core-competencies

The SBAR framework structures clinical communications to make clinical conversations more efficient. Situation-Background-Assessment-Recommendation allows easy-to-remember and focused patient information exchange. It streamlines communication and improves patient safety. Yet it does not replace the need for clinicians’ understanding one another’s roles and needs and the cooperation that connection offers in changing, complex care. The SBAR tool: https://forms.ihi.org/tools/sbar-toolkit?utm_referrer=https%3A%2F%2Fwww.ihi.org%2F