Communication among the patient, physician, and

Professional Issues Kimberly Burns Nurse-Physician Rounds: A Collaborative Approach To Improving Communication, Efficiencies, and Perception of Care Communication among the patient, physician, and nurse individualizes and enhances patient care. When nurses and patients personally hear the physician s plan of care, the risk of error and potential for misunderstanding decreases (Casanova et al., 2007). To improve communication, reduce errors, increase health care provider efficiency, and improve the patient s perception of care, typical patient rounds will benefit from a collaborative approach to patient care. Problem The project unit, a 45-bed medical unit, is located in a 350-bed trauma hospital in a large midwestern city. Of the unit s nurses, 68% have less than 5 years experience. They are interested in exploring new approaches to patient care while embracing teamwork and efficiency. Over the last 2 years, the unit has improved patients perception of care. Patient falls and medical emergencies have decreased. Even with the nursing staff s attention to quality improvements and engagement in leading and sustaining initiatives, they still have opportunities to improve patient experiences and perceptions of care. Administrators have employed a hospitalist medical group to care for patients who either lack a family doctor or do not have one who practices in the hospital. The hospitalist group employs many physicians to address patients medical needs around the clock. Nurses from the hospitalist program accompany hospitalist physicians on their rounds to aid in task completion, communication, response to physician calls, and assessment of patient needs. All these tasks lead to a perception of care that is based on the response of the health care providers to the needs of the patient. The nursing staff and leaders on the medical unit wanted to improve patients perceptions of quality. They identified how to affect each key driver positively through the use of behavior modification, communication techniques, and scripting. In particular, they believed nurse-physician relationships were impacting Kimberly Burns, MS, RN, is Nursing Manager, Parkview Health, Ft. Wayne, IN. Acknowledgment: The author wishes to acknowledge the assistance of Jackie Myers, MSNC, RN, and Julia Walker, BSN, RN, for their support and contribution in the completion of this study. patients perceptions of quality and could influence improved health care provider efficiency. Literature suggested use of nurse-physician collaborative rounds offered potential positive impact (Burger, 2007). Literature Review A thorough empirical literature search was conducted using the Cumulative Index to Nursing and Allied Health Literature (CINAHL). A 10-year search (1995-2009) was reviewed using the following search terms: nurse physician relationships, multidisciplinary rounds, nurse physician collaboration, nurse physician communication, and nurse physician behavior. This review identified existing evidence about strategies or interventions that would improve patients perceptions of communication and teamwork between physicians and nurses. Limited information regarding health care provider rounds was old (Halm et al., 2003; Lehmann, Brancati, Chen, Roter, & Dobs, 1997), but supported the idea that this type of intervention may be beneficial. Lehmann and co-authors (1997) evaluated the difference in patient satisfaction and understanding of the plan of care with use of bedside case reports and conference room presentations as the primary methods for clinical teaching. Both types of multidisciplinary rounds were conducted as a team approach. An oral interview was used to measure patient perception of these rounds. Interview results showed patients believed physicians spent more time with them during bedside case studies than when physicians only participated in conference room presentations following a patient assessment. This study did not find either of the interventions to be of greater value to patients. However, a key finding from this study was the learning that occurred when physicians practiced at the bedside (Lehmann et al., 1997). Authors concluded additional clinician growth occurred when empathy was taught at the bedside: Bedside case presentations encourage physicians to view patients as actual people rather than abstract hosts of disease (p. 1150). Patients active participation in the bedside studies added value for all team members. An additional study considered the value patients place on collaborative physician communication at the bedside within a Veterans Administration hospital 194 July-August 2011 Vol. 20/No. 4

Nurse-Physician Rounds: A Collaborative Approach to Improving Communication, Efficiencies, and Perception of Care (Fletcher, Rankey, & Stern, 2005). Authors evaluated physician teams that rounded at the bedside. Patients later received a survey to complete and return by mail regarding their perceptions of bedside communication. Findings indicated patients wanted to be active participants in their care. They wanted to learn about their medical conditions and the course of available treatments. This participation made them feel valued as contributors to clinicians assessment and continued education. In two studies, Halm and colleagues (2003) and Burger (2007) discussed benefits of multidisciplinary rounds. Rounds included staff members from pharmacy, physical and occupational therapy, and nursing, but did not include physicians or patients. These rounds occurred within the intensive care setting where patients rarely are able to participate. Scheduled rounds occurred at the same time every day, making it difficult for physicians to fit the rounds in their schedules. Rounds improved patient quality, encouraged collaboration among disciplines, and contributed to efficient patient care. Members of these disciplines found working outside their individual roles in a collaborative, multidisciplinary team created an opportunity to improve outcomes, and increase satisfaction and staff retention (Burger, 2007; Halm et al., 2003). These teams worked together to identify, complete, and then assess the patient s plan of care (Halm et al., 2003). Intervention The first step to defining a solution on the study unit was to identify why current patient rounds needed to change. The problem was patient satisfaction with quality of care, with communication between physicians and nurses less effective than expected. Based on the literature review, the nursing staff and leaders planned to implement collaborative rounds to improve patient perceptions of quality of care. Implementation Before implementation of the project, an outline of expected behavior and communication tips was distributed to all nursing staff on the medical unit. The intervention was described and staff members were encouraged to offer feedback for implementation. The author met with hospitalist physicians at one of their weekly group meetings to describe the problem, provide a summary of the evidence-based literature, and discuss ideas for implementation. Proposed nurse-physician communication and behavior guidelines were reviewed and feedback elicited. The chief medical officer, rounding nurses, case managers and their supervisor, and several hospitalists participated in discussions. A pilot of nurse-physician rounds was implemented on March 1, 2010. The project lasted 4 weeks and was isolated to one unit. Nurse-physician rounds; while not new to health care, were not part of the culture on this particular unit. Focusing the rounds on one hall with a defined medical group afforded the unit control in adapting to rounding process change. The unit s assignment sheet was faxed to the hospitalist office at 6:00 a.m. each day. This provided names of nurses who were caring for patients on their service. Both unit and hospitalist managers were visible on the unit during the first several days to guide expectations and answer questions. When physicians came to the unit, they reviewed patient charts and then visited patients with the bedside nurse and rounding nurse. At first, nurses had to wait for physicians and found it difficult to modify their routines to participate in the rounds. Throughout the 4-week project, the manager met with staff members to support and encourage them while gaining additional perspective and understanding of the rounding experience. Random daily participation was recorded to monitor compliance. Leaders met weekly with the hospitalists to answer questions and encourage continued support of the project. Discussion Nurse-physician rounding compliance during the first week following the implementation of the project showed potential for success; however, perceptions from prior experience and anticipation of the change caused concerns among nurses and physicians. Many nurses initially reported a belief based on prior experience with physician rounding that physicians did not value their time or professional assessments. Nurses perceived the most significant barrier to be time. Neither nurses nor physicians believed they had time to wait for the others to complete rounds. During the next 2 weeks of the project, nurse-physician rounds became less consistent. Rounds only occurred 25%-30% of the time. Similar concerns again were communicated regarding lack of engagement of both nurses and physician due to time constraints. During this time, the hospital experienced a surge in patient census that demanded greater productivity of nursing staff and hospitalists. The increase in work production and the greater focus on tasks resulted in a general lack of urgency, sensed by all participants, to round as a team. To address this phenomenon, the author rounded daily on the unit and asked each bedside nurse to identify which patients were being seen by hospitalists and how she or he would make time to round with physicians. At the end of the day, the percentage of rounds was calculated, and opportunities and challenges were discussed. To ensure participation in nurse-physician rounds, the author spent the remaining weeks observing and coaching staff to participate. Results Nurse-physician rounding compliance initially was slow to develop. However, by the end of the 4-week pilot, both nurses and physicians began to anticipate each other s steps. As the weeks progressed, staff nurses and hospitalists needed fewer reminders from nurse leaders to complete rounds (see Figure 1). July-August 2011 Vol. 20/No. 4 195

Professional Issues FIGURE 1. Nurse-Physician Rounding Participation 100 FIGURE 2. Average Number of Hospitalist Calls per 100 Patients 50 90 45 Calls Per 100 Patients 80 40 Percentage 70 60 50 40 30 20 Average Number of Calls 35 30 25 20 15 10 10 5 0 Week 1 Week 2 Week 3 Week 4 Week 5 0 February Pre Data April Post Data The first week of the project, nurses remained with hospitalists until they both entered patients rooms. During this time, physicians reviewed the chart and discussed clinical outcomes based on treatments and findings before rounding on the patient. Despite nurses beliefs this time was not well spent, they knew it was necessary to help them gauge how long physicians typically spent preparing for patient assessment. The last week of the project, random compliance audits showed an increase in nurse-physician rounding participation to 67% (see Figure 1). Observations showed an increase in nurse-physician engagement to participate in rounds. Co-workers used teamwork to communicate physicians readiness to assess patients or free nurses who needed to give medications or perform other tasks when physicians were ready to complete rounds. The hospitalist-rounding nurses were instrumental in ensuring nurses and physicians consistently rounded together. Throughout the project, author observations indicated the rounding nurses became more assertive in finding staff nurses. They recognized nurses by name and encouraged physician engagement by frequently reminding hospitalists and nurses when rounds were about to begin. Another outcome measured throughout the rounding project was efficiency. It was hypothesized that nurses, patients, and physicians were likely to get their questions answered during these rounds; thus less paging and calling were needed after the physician left the unit. Before the project began, the rounding nurses compiled a 3-day sample of total calls received from the entire hospital. This number included calls placed to the hospitalist group throughout the entire hospital, not just on the pilot unit. An average of 50 calls per 100 patients was received. The week following project implementation, the rounding nurses again kept a tally of all incoming calls regarding hospitalist patients throughout the hospital. The average number of calls fell to 41 calls per 100 patients (see Figure 2). Results suggested nurse-physician rounding increased efficiency based on the number of calls necessary to the physician. However, this decrease in the number of calls was not perceived by the rounding nurses and hospitalist physicians. To measure nurse and physician perceptions of collaborative patient rounds, the author used a five-question survey with questions addressing perception of communication and collaboration as affected by the new process of bedside rounds. Participants were asked to score their answers on a 5-point Likert scale (5=strongly agree to 1=strongly disagree). A physician, three rounding nurses, and 16 staff nurses completed the survey (see Figure 3 for survey results). Nurses and physicians agreed the project improved quality of care and communication. However, they neither agreed nor disagreed that nurse-physician rounds decreased the number of calls regarding patient care; in fact, call volume only decreased 20%. Because the pilot unit typically had less than 10% of the daily hospitalist patients, physicians and nurses may not have noticed the decrease in the number of calls made or received. One hospitalist participant stated, It is a missing link between the physician and the patient. Most patients like to have someone verify they heard the doctor s instructions correctly. The bedside nurse can be the person to bridge the communication gap for patients and their families and the consulting physicians if they are aware of the plan of care. Another comment read, From a physician s point of view, if our habit was to find the nurse and 196 July-August 2011 Vol. 20/No. 4

Nurse-Physician Rounds: A Collaborative Approach to Improving Communication, Efficiencies, and Perception of Care FIGURE 3. Nurse-Physician Responses Regarding Rounds 4.5 4 3.5 3 4.2 4 4.1 3.8 Nurse Hospitalist 3.6 3.5 3.8 3.8 3.8 4 2.5 2 1.5 1 0.5 0 Did your communication with the physician or the nursing staff improve? Did your communication with the patient improve? Did the rounds decrease the number of calls that you placed or received? Question Did the rounds increase your efficiency as a clinician? Did the rounds improve the quality of care on 4-medical? speak with her on a routine basis, there is not an appreciable difference (between nurse-physician rounds and traditional patient rounds) for better or worse. Similar comments were identified by nurses. One nurse stated, This is an exciting idea in promoting effective nurse-physician collaboration in providing excellent health care. Another nurse commented, Nurse-physician rounds allow nurses to know more about what is happening to our patients and what the course of treatment will be first hand. Only one nurse indicated nursephysician rounds were unnecessary. A marketing research company has been used by the hospital to capture patient perceptions of the quality of care on a medical unit. The information gathered from patients was compiled into a data base (PRCeasyview, Omaha, NE) to be reviewed and analyzed by leaders to identify trends and opportunities for improvement. Over an 8-week period, patient satisfaction results were analyzed. Of approximately 20 questions, two questions were identified at the beginning of the study to serve as a measurement of the nurse-physician rounding project. The questions were: How would you rate the physician communication with you or your family member? and How would you rate the overall teamwork among the physician, nurses, and staff? Both questions were filtered separately based on nursing unit and patient discharge date. Responses to the first question ( How would you rate the physician communication with you or your family member? ) increased from the 0 percentile when the project began on March 1, 2010, to the 100th percentile the week ending March 29, 2010 (see Figure 4). Similarly, responses to the second question ( How would you rate the overall teamwork among the physician, nurses, and staff? ) began the project at the 0 percentile and finished at the 100th percentile (see Figure 5). Limitations The manner in which physician call volume was collected may not have reflected accurately the calls generated from the unit. The call volume was hand collected before the project began and 4 weeks later by the rounding nurses who worked with the hospitalist group. Call data logs kept by hospitalist-rounding nurses included all calls, not just those on the pilot unit. Therefore it was difficult to discern between unit calls and others and the impact was not great enough to change perceptions. Future studies would be needed to provide evidence linking nurse-physician rounds to improved efficiency. The survey results would have had greater value if questions had been administered before the project started. Comparisons of the perception of interdisciplinary communication with the patient before the project and following the interventions would have provided subjective data to measure the outcomes of the project. Because the survey was conducted after the project was initiated, the perception of the health care providers participation could not be compared with their perception of the quality of care, efficiency, and communication before and after the project began. Study results only portrayed the effects of nurse-physi- July-August 2011 Vol. 20/No. 4 197

Professional Issues FIGURE 4. Perceptions of Physician Communication with Patients/Families 100.0 80.0 60.0 40.0 20.0 0.0 02/01/10 02/08/10 02/15/10 02/22/10 03/01/10 03/08/10 03/15/10 03/29/10 Inpt Med Rank Trend Line* 22.9 33.5 44.1 54.7 65.3 75.8 86.4 97.0 Inpt Med % Excellent Rank* 12.3 0.0 98.3 57.5 57.5 98.3 57.5 98.3 % Excellent 40.0 20.0 66.7 50.0 50.0 66.7 50.0 66.7 Inpt Med 75th Percentile 53.4 53.4 53.4 53.4 53.4 53.4 53.4 53.4 Number of Cases 5 5 3 4 4 3 2 3 Norm Year 2010 2010 2010 2010 2010 2010 2010 2010 FIGURE 5. Teamwork Survey Results 100.0 80.0 60.0 40.0 20.0 0.0 02/01/10 02/08/10 02/15/10 02/22/10 03/01/10 03/08/10 03/15/10 03/29/10 Inpt Med Rank Trend Line* 25.0 30.6 36.2 41.8 47.3 52.9 58.5 64.1 Inpt Med % Excellent Rank* 96.3 0.0 1.0 60.1 0.0 0.0 100.0 100.0 % Excellent 60.0 20.0 33.3 50.0 0.0 0.0 100.0 100.0 Inpt Med 75th Percentile 52.7 52.7 52.7 52.7 52.7 52.7 52.7 52.7 Number of Cases 5 5 4 4 4 3 2 2 Norm Year 2010 2010 2010 2010 2010 2010 2010 2010 198 July-August 2011 Vol. 20/No. 4

Nurse-Physician Rounds: A Collaborative Approach to Improving Communication, Efficiencies, and Perception of Care cian rounds within the pilot unit. The time frame of the study was short and did not allow health care professional development to overcome challenges and improve relationships. Widening the scope of the project to include an entire unit around the clock would provide more accurate results on which to base further implementation. Implications for Nursing Practice Collaborative rounds have the potential to improve patient care and satisfaction. The key to nursephysician rounds is to implement a strategy that focuses on compliance. Nurses and physicians may have prior experience and anticipate rounds will take time away from their busy schedules. They may have memories of past rounds that prevented good communication. How - ever, physician engagement to champion the benefits of rounds and daily communication with the nurses will ensure early success. Continued support, mentoring, and coaching by nurse leaders are crucial to success and acceptance. Nurse leaders who accept the challenge of implementing collaborative rounds need to be aware that successful implementation requires significant coaching and intervention by the unit manager. Physician support is also imperative for successful collaborative rounds. the assessment and plans for treatment. When both nurses and physicians talk with patients, teamwork creates a collaborative approach to safe, quality health care (Casanova et al., 2007). REFERENCES Burger, C.D. (2007). Multi-disciplinary rounds: A method to improve quality and safety of critically ill patients. Northeast Florida Medicine, 58(3), 16-19. Casanova, J., Day, K., Dorpat, D., Hendricks, B., Theis, L., & Wiesman, S. (2007). Nurse-physician work relations and role expectations. Journal of Nursing Administration, 37(2), 68-70. Fletcher, K.E., Rankey, D.S., & Stern, D.T. (2005). Bedside interactions from the other side of the bedrail. Journal of General Medicine, 20(1), 58-61. Halm, M.A., Gagner, S., Goering, M., Sabo, J., Smith, M., & Zaccagnini, M. (2003). Interdisciplinary rounds impact on patients, families, and staff. Clinical Nurse Specialist, 17(3), 133-142. Lehmann, L.S., Brancati, F.L., Chen, M.C., Roter, D., & Dobs, A.S. (1997). The effect of bedside case presentations on patients perceptions of their medical care. The New England Journal of Medicine, 17(336), 1150-1155. Conclusion Nurse-physician rounds have the potential to improve relationships between caregivers, and positively affect communication and perception of patient care. Greater understanding may contribute to safer medical care and more satisfied patients. In this article, the successes and limitations of an implementation project for collaborative patient rounds were presented. The results in patient satisfaction regarding physician-nurse communication and teamwork are not surprising. Patients want to be active members of the health care team. They feel valued when they are included in July-August 2011 Vol. 20/No. 4 199