In 2007, Darryl Kirch delivered a President's Address to the AAMC entitled, “Culture and the Courage to Change.”19 In his remarks, Dr. Kirch described the “traditional healthcare culture” as one characterized by hierarchy, autonomy, individual experts, and blame. He then went on to describe the modern healthcare system and the complexity of that system, which has evolved beyond the capabilities of any individual expert. Multidisciplinary expert teams are essential for improving patient safety, as demonstrated by several recent major safety breakthroughs. The reduction and near-elimination of central line–associated blood stream infections in intensive care units across the state of Michigan,20 and the impressive reduction in surgical complications associated with briefing and debriefing checklists,21 are only possible when physicians, nurses, technicians, and others communicate effectively and work together as high-performing teams.2 Yet, most healthcare providers have not been systematically taught how to effectively communicate, particularly across healthcare disciplines. Medical, nursing, pharmacy, and other healthcare-related schools focus on clinical information and scientific knowledge, but lack a central focus on how to effectively communicate, interact, and respond to peers, patients, and other providers. This lack of a standardized approach means that graduates of different disciplines enter the same clinical care environment with different styles and vocabularies, and little knowledge about the inherent value in standardized and clear communication.22
The author's personal experience demonstrates this point. While in nursing school, classmates and I were taught to be narrative in our communication: “think about the whole person and tell a story.” This has been reinforced by the traditional nursing edict: “nurses don't make diagnoses.” Conversely, while in medical school, fellow students and I were trained to “get to the point” or “just give the 10 second version.” Neither style is right or wrong, but they are different. Having a common and predictable structure for communication is extremely important to help navigate those differences.
Teamwork training programs and curricula have been developed to address the need for improved teamwork and communication skills among healthcare professionals. TeamSTEPPS is one model for teamwork training that is used at a growing number of institutions across the country. TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety)23 is a widely accessible, evidence-based communication and teamwork curriculum that was developed by the Agency for Healthcare Research and Quality (AHRQ) and the Department of Defense (DoD). The curriculum is organized on five key principles. Team Structure provides the framework and encompasses four key skills: Leadership, Situation Monitoring, Mutual Support, and Communication.23 Implementation of TeamSTEPPS is intended as a system change in which providers gain specific skills that support team performance principles through designated training requirements, behavioral methods, human factors, and cultural change.
Whatever approach is used to enhance teamwork in the ED, leaders should be aware of common communication failures that too often lead to adverse events. Such communication breakdowns include providing care with incomplete or missing information; executing poor handoffs with relevant clinical data not clearly passed on; failing to confirm, or read back, information transmitted; and failing to share critical information or ask questions because of fear of speaking up.22 Effective ED leaders can help prevent these failures by setting a tone that encourages teamwork and by providing team members with some basic tools to facilitate effective communication.
Team leaders often set the tone for interactions informally, or even by default, but effective leaders understand that high-performing teams require an environment of mutual respect in which psychological safety is assured. Within psychologically safe environments, everyone is comfortable speaking up, every individual and what he or she has to say is treated with respect at all times, and disrespectful actions are not tolerated. Psychological safety is essential for effective teamwork24; many clinicians become tentative or defensive when they do not feel safe, and they are then less willing to participate or contribute to the team. When team members believe that they or their suggestions are being criticized, they will stop speaking up, and they might just have the piece of information the rest of the team needs to avoid unintended harm to the patient.
Within the hectic environment of the ED, communication between individuals is often informal, disorganized, and variable. In situations where specific and complex information must be communicated and responded to in a timely manner, and the consequences of omitting critical information can be dire, such as in a code or resuscitation, it is essential to consistently add structure to the exchange. Such structures can ensure that the right information is shared at the right time with the right people. It also creates predictability as to how team members will communicate.22 Following are some specific structured communication techniques that all ED care teams should be encouraged to use.
Briefings are a critical element in high-performing teams and determine whether clinicians work together as a cohesive team or simply act as a group of individuals with different ideas and goals sharing the same space.22 Briefings quickly help set the tone for team interaction, ensure that team members have a shared mental model of what's going to happen during a process or procedure, identify any risk points, plan for contingencies, and avoid surprises. When done effectively, briefings can establish predictability, reduce interruptions, prevent delays, and build social relationships and capital for future interactions.25
Debriefings. While briefings typically occur before a process or a procedure, a debriefing is a concise exchange that occurs after such events have been completed to identify what went well, what was learned, and what can be done better the next time.25 It is a valuable opportunity, not often used in the ED, to determine how team members are feeling about the procedure or event, and to identify opportunities for improvement and team learning. Debriefing is also an effective venue for problem solving, generating new solutions, and positively engaging the collective wisdom of the team.22
SBAR is an acronym for Situation, Background, Assessment, Recommendation. This structured communication technique is used to standardize an interaction between two or more people using a format that allows the receiver to anticipate the flow of information from the sender (Fig. 154-2).26 When using SBAR, the sender structures the communication in the form of situation (give a 20–30 second punch line to get the receiver's attention); background (provide additional but concise, pertinent information); assessment (requires the sender to use critical thinking and define the problem); and recommendation (requires the sender to suggest a solution, no matter what his/her rank or discipline). It is imperative that the receiver respond in a respectful tone, even if the assessment is not entirely accurate, to maintain psychological safety for the sender. SBAR helps set the expectation within a conversation that specific, relevant, and critical informational elements are going to be communicated every time a patient care issue is discussed. In addition, SBAR sets the expectation that critical thinking associated with defining the patient's problem and formulating a solution occur before the receiver is contacted. Thus, both parties have a shared mental model of the flow of the conversation.22
A closed communication loop helps improve the reliability of communication by having the person receiving the message restate what the sender has said to confirm understanding.22 A specific type of closed loop communication is a “repeat back,” which consists of four distinct actions:
The sender of the message concisely states information to the receiver.
The receiver then repeats back what he or she heard.
The sender then acknowledges the repeat back was correct or makes a correction.
The process continues until a shared understanding (a shared mental model) is verified.
When using this tool, response to a message with an “okay” or a nod is not sufficient to close the communication loop. The message must be repeated back, just as a medication order must be repeated or read back to a physician by a nurse who takes a verbal order.
Strong team performance with an emphasis on two-way communication, respect, sharing ideas, and problem solving is essential to the safe and reliable delivery of care. Not only do healthcare teams typically lack this type of interaction, but many clinicians are unaware of how poor their communication and team behaviors are.22 Training in communication and teamwork skills, though seemingly basic, is an important key to success in providing safe and reliable care to children in the emergency setting.