An inexperienced nurse receives an order that she believes was intended for a different patient. Rather than asking the oncologist directly, she goes to her nurse coworkers for direction. She “polls” the nurses and receives feedback on their interpretation of the order. She chooses to proceed without discussing the issue with the oncologist, and a medical error occurs.

The Institute of Medicine stated in its report, 

, that medical errors account for between 44,000 and 98,000 hospital deaths per year in the United States.

 This information should not be new to anyone, as this report was released more than 10 years ago. What you may not know is why these errors occur. The Joint Commission suggests that organizational culture, availability of resources, staffing ratios, and education and training are top contributors to errors.

 It also identifies lack of communication or miscommunication as the number one root cause of sentinel events. 

I have been a nurse for 15 years and have progressed from a novice new graduate nurse who did what I was told, to an experienced oncology nurse who thinks critically and asks questions. I have worked with oncologists who have discounted my knowledge, some who have yelled at me, and many who have collaborated with me as a peer to care for our patients. I have worked in healthcare facilities where the executive leadership team ignored unprofessional behavior from physicians, and I have worked in facilities where skilled communication and true collaboration have not only been encouraged, but expected and fully supported from the executive team. 

I can personally reflect on these experiences and identify which were healthy and satisfying and which were not. I can also remember experiences that resulted in medical errors and those that were potential errors that did not reach the patient. I do not believe that it was coincidental that potential errors were caught when professional communication occurred within the interdisciplinary team—and when all roles were respected and valued. 

In 2005, the American Association of Critical-Care Nurses (AACN) partnered with VitalSmarts, a corporate training organization, to conduct a study titled, 

Silence Kills: The Seven Crucial Conversations for Healthcare Professionals

 The study found that healthcare professionals fail to have crucial conversations when there are broken rules, mistakes, lack of support, incompetence, poor teamwork, disrespect, and micromanagement. Other barriers to having crucial conversations were identified as lack of ability, belief of “it’s not my job,” lack of time, and fear of retaliation.

Not having these conversations, or having the wrong conversations, can have an impact on medical errors, patient safety, quality of care, staff commitment, employee satisfaction, discretionary effort, and turnover. Improvement in communication could not only contribute to a significant reduction in errors, but also improve the quality of care. 

It seems simple: if we communicate effectively, we can improve patient safety and patient outcomes. So why are we not doing it? Why did the nurse in the first scenario not speak with the oncologist directly and question the order? There were several reasons, or “barriers”: the nurse was inexperienced, the oncologist had a reputation of yelling at nurses for “being stupid,” the oncologist was busy, the nurse did not want to bother him, and the organization did not support nurses questioning physicians. 

As a result of those findings, the AACN made a commitment to actively promote the creation of healthy work environments that support and foster excellence in patient care wherever acute and critical care nurses practice. They identified six standards for establishing and sustaining healthy work environments

Regarding the first two, skilled communication requires that nurses be as proficient in communication skills as they are in clinical skills. In order to have true collaboration, nurses must be relentless in pursuing and fostering true collaboration, and nurse managers and medical directors must be equal partners in modeling and fostering true collaboration.

Scenario 2 reflects an effective oncologist-nurse relationship in which communication is clear, uninhibited, and encouraged—and directly affects the quality of patient care.

An inexperienced nurse receives an order that she believes was intended for a different patient. She speaks to the oncologist and says, “I was looking over Mrs. Jones’s orders and noticed that she is scheduled for a head CT, but I wasn’t sure why. Also, when we rounded together this morning, you mentioned that Mrs. Smith needed a head CT today, but I didn’t see that ordered for her. Was this ordered on the wrong patient?” The oncologist responds, “No, both patients need a head CT. I must have missed ordering that on Mrs. Smith. Thank you for bringing that to my attention. Great catch. Now let’s talk about Mrs. Jones. You said you weren’t sure why it was ordered on her. Tell me what you see with her and why you think a head CT would or would not be important…”

The culture of the nurse-physician relationship has changed dramatically over the past years and is one of the most important drivers of a healthy work environment. Magnet research has demonstrated the importance of healthy nurse-physician relationships on outcomes for nurses, physicians, and patients.

 It is much easier to have a crucial conversation with someone with whom you have an established, respectful working relationship. 

Policies, procedures, and workflow are essential in healthcare facilities to provide safe care of our patients. However, shortcuts will be taken, resources will be stretched, and emotions will run high. We will all make mistakes, and we will all see mistakes about to be made. How we respond to those situations will make or break our safety mechanisms and directly impact our patients. 

My advice to both nurses and oncologists is: Treat each other with dignity and respect, get to know your coworkers’ professional strengths and weaknesses, build off one another’s strengths to further your own professional development, and mentor others to increase their knowledge and expertise. 

Articles

The culture of the nurse-physician relationship has changed dramatically over the past years and is one of the most important drivers of a healthy work environment

Melissa Andres, BSN, RN, OCN, CBPN-C

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