The emergency department is a health care environment that seeks to provide urgently needed care, often to a large number of people, in a short amount of time.
This realm of patient care is unscheduled by design and often occurs in unpredictable surges. Acute illnesses, uncertain medical histories, and restricted work space must be navigated by multiple providers who offer care at a frenzied pace. To work safely and efficiently within these circumstances, interdisciplinary collaboration and communication are essential.1
These demands require the individuals working within an ED (physicians, physician assistants, nurses, technicians, etc.) to communicate with one another regarding patient care efficiently and effectively. Physicians and nurses represent an outsized portion of the health care workers influencing patient care in the ED.2 Due to their overrepresentation and role as the primary bedside caretakers, the communicative interactions between physicians and nurses may carry great potential to influence patient care.
In a systematic review including randomized control trials, the effect of standardizing communication methods using the SBAR (Situation, Background, Assessment, and Recommendation) format resulted in improved patient safety outcomes.3 These results indicate the value of communication with real implications for patient wellbeing.
Similar to any group of advocates or participants who share goals, when health care workers possess a shared goal, they become a health care team. Interactions between physicians and nurses especially are integral to exchanging information related to achieving the shared goal of optimizing a patient’s health. Belonging to this health care team is based upon a shared mental model, or a “perceived interdependence between the team’s determination to achieve the goals and shared satisfaction gained through goal attainment.”4 The literature is scant about more specific factors that contribute to a team member’s sense of belonging on a health care team and about the influence of that belonging on team behaviors.
Communication Challenges
Poor communication techniques can lead to poor team dynamics. In a 2010 study, nearly half of ED practitioners noted impaired collaboration and impairment to the physician-nurse relationship following incidents of yelling, condescension, or abusive language.1 Nursing staffing levels have been impacted from poor team dynamics. When new nurses feel unsupported and isolated or they feel there is no team to rely on, they are more likely to leave positions or even the profession entirely.5 During the COVID-19 pandemic, when nursing staff turnover significantly increased, measures that can contribute to staff retention became paramount.6
The global pandemic has also made communication barriers more unique, as universal masking made interactions more difficult. Specifically, facial expressions are difficult to read with masks in place and additionally N95s and PAPRs muffle voices, often requiring speakers to project further. These barriers to verbal communication have led to confusion about whether changes in vocal tone and volume are a display of negative emotion or simply an attempt to be heard more clearly. Visibility of teammates also strained the sense of belonging within the team, as the presence of masks and hair coverings leaves little remaining to identify team members and interpret their facial expressions.7
Fostering Team Belonging
Given the unique challenges health care teams faced with the COVID-19 pandemic, identifying techniques to generate or improve team belonging became of the utmost importance. The sense of belonging in an ED health care team has been associated with careful perception of team member behavior. Interviews of ED staff members revealed that appreciating team members’ motivations and effort to achieve the shared goal was associated with improved team dynamic. Additionally, growing to trust one another is associated with a greater sense of team belonging.4
Opportunities to foster team belonging and improve interdisciplinary communication may include group training. Specific methods to improve communication in an ED have included the TeamSTEPPS training program, a standardized interdisciplinary training program for health care professionals, meant to improve communication and information flow among a health care team. In a cohort study, after implementation, ED physicians and nurses expressed a consistent perception of improved teamwork and team collaboration, evidenced by entry and exit surveys.8 These results give credence to team dynamics being something that can be fostered and improved via interventions, rather than an occurrence that is solely dependent on the initial chemistry of team members.
Alternative teamwork training courses include the Emergency Team Coordination course, which has been shown in case-control studies to improve the quality of teamwork and attitudes towards teamwork.9 The timing of interventions and training is sensitive as attempting to initiate multiple interventions at once is opposed by differing staff attitudes about their importance. Improvements to teamwork are best implemented gradually, making continual training more likely to generate change.10 Teamwork training is also generally perceived positively with nursing staff, reporting an expectation that trainings will improve clinical care and communication.11
Given the established importance of communication practices on effective and safe patient care as well as the value of team belonging to staff retention, further study on factors generating improved team dynamics are valuable. This qualitative study seeks to identify communication practices between physicians and nurses within the ED that influence a sense of positive or negative team member dynamic or belonging. Identified influencers on health care team dynamic and belonging are meant to provide opportunities for personal practice reflection and future research into the interactions of ED health care teams.
Methods
Qualitative data was collected using a volunteer-based sampling of physicians and nurses working in nine emergency departments (EDs) within the state of Oregon. Respondents were given the opportunity to participate in further in-person focus group discussions about communication practices and interdisciplinary interactions. Seven focus groups were conducted among participants separated by profession, yielding 4 nursing and 3 physician groups consisting of between 4-7 participants each, for a total of 38. Throughout the focus groups a conversation guide was used and refined until saturation had been achieved. The verbal discussions of these focus groups were recorded and converted to written transcripts using the transcriptionpuppy.com web service.
A qualitative code book was constructed and iteratively refined using a grounded theory approach. The 7 written focus group transcripts were then reviewed by 2-3 trained research team members. Transcript segments that demonstrated relevant insights related to staff interactions were coded as such. Relevant coded segments were collected and compiled using MAXQDA 2020 Analytics Pro software. Once the coded segments had been isolated by their subject or speaker, segments underwent a thematic analysis related to the effect of communication on team belonging. Segments coded as team dynamic and clinician morale were used as proxies for team belonging. References to positive and negative communication techniques were compared to their effect on communication and morale. Emerging concepts that were emphasized by more than one participant were considered as primary themes. Concepts only surfacing from one participant were considered for relevance and insight but often considered outliers.
RESULTS
Positive Belonging
Proactivity and Anticipating Needs
A primary means of fostering team belonging was accomplished through considering the workflow of the entire team at once. This involved anticipating and proactively addressing the needs of other team members. Physicians specifically demonstrated proactivity by “talking to the triage (nurse), talking to the charge (nurse) about what it is that I can be doing to help.” Nursing identified anticipating the physician’s equipment and workflow needs as a helpful anticipatory task. For example, these included obtaining laceration repair supplies or underdressing patients prior to examination. These anticipatory behaviors were well received by physicians and fostered a feeling of team belonging via a shared goal.
"Those are… nonverbal things that make (me) feel like my team is totally with me and we are doing this together.” — Physician 1
Projecting Openness
Projecting openness through verbal or non-verbal techniques was associated with more open lines of communication and improved team dynamic. Physician inclusion of other team members during plan-of-care discussions helped to empower other teammates. One physician would ask the team, “What are we missing?” in an effort to make the nursing staff feel empowered and encourage collaboration in patient care. A second physician used a non-verbal technique to encourage team members to freely approach the physician workspace: keeping candy at the workstation was meant to avail staff of concerns over making unwanted advances. A nurse interpreted this gesture as the physician saying, “You can always come and tell me something.”
Less Formal Name Conventions
The importance of connecting a name to a face was identified as critical to building a positive belonging into the health care team. Maintaining a first name basis with another health care worker, especially identified between a physician and nurse, was held as an example of an especially comfortable relationship. When welcoming a new health care worker to the department, nursing identified learning their first name as a way of showing each other respect. The antithesis, a theoretical instance of a physician requesting that a nurse call them only by their title, was suggested to not represent team cohesiveness.
Concerns expressed around the habits of naming conventions were solely focused on what nurses call doctors. Nursing expressed an interest in simply knowing a doctor's first name, regardless of whether they would address the doctor as such.
Building Relationships Outside of Work
Workplace relationships and friendships had great potential for positively affecting professional and team relationships. Establishing a relationship and getting to know a team member was described as helpful when subsequent brisk professional communication is required, such as during the care of a critically ill patient.
“If you don’t have a good relationship, (you) could come across as abrupt and too overbearing. But I think if you put in the work on both sides—nursing and doctors—to develop a good relationship beforehand, I don't think that misconception is usually an issue.” — Physician 2
Large-scale social gatherings of departmental employees were identified as capable of influencing the “cohesiveness” of the physicians and nurses. Seasonal holiday gatherings were an example of opportunities to foster team belonging. Alternatively, holiday gatherings were seen as alienating when only one professional discipline was included and other disciplines were excluded.
Negative Belonging
Giving Up On or Resisting Communication
Communication habits negatively affecting team belonging and camaraderie centered around a theme of resisting communication or giving up on the pursuit of communication. These behaviors resulted in the alienation of staff members, a worsened team dynamic, and a stop to further communication.
Statements of Reluctance
A sub-theme of amongst resisting communication was the use of statements of reluctance, defined as a tepid or discontented response to another person's request or initiation of communication. When physicians were approached by nurses, and the nurses’ initial bid for conversation was met with responses such as “What do you need now?”, “What do you want?”, “Is it an emergency?” the nurses were reluctant to voice further concerns.
Resistance to Questions
Aggressive resistance to questions caused a similar response from nursing as had statements of reluctance. When a nurse asked a question of a physician and was berated in response, that nurse no longer wished to communicate with the physician. Instead, this individual sent a colleague who has a friendly relationship with the physician to ask the same question. This circumstance both underlined the damaging effects of aggressive responses to questioning as well as the positive effects of a friendly relationship, outside of the professional sphere, on maintaining open lines of communication between team members.
Roadblocks to Communication
Obstacles to communication were identified that were not the fault of the primary communicator but rather knowledge of departmental systems. When a physician found the system of nursing patient assignments or break schedule coverage too confusing to navigate, the physician gave up on navigating the system and chose to forgo the indented communication entirely.
Interactions Leading to Alienation
A general description of poor communication was associated with feelings of isolation from the health care team and led nursing staff to feeling isolation and alienation. The following quote captures the overall impact of poor communication on job satisfaction.
“(Poor communication) has a big impact on whether you feel like you're a part of a collaborative, cohesive team that's actually doing good, versus being kind of on an island … when you have bad communication … you don't feel like you're a part of a group.“ — Nurse 1
A number of situations led staff to feel alienation from their teammates. Physicians expressed this resulting from bothersome phrases such as “are you going to pick up that patient?” This phrase can be understood as clarifying whether the physician in question will assume care of a specific patient. The question was received by the physician as perceived laziness.
Nursing identified the dismissal of ideas as a source of alienation. When the patient care team discussed possible etiologies to a condition and plan of care, the suggestion of a diagnosis was met with indignation: “why would you think that?” responded the physician. Similar references were made to other clinical circumstances when ideas floated by nursing staff were not welcomed. This dismissal resulted in the nurses feeling alienated from the patient care team and ceasing to express further suggestions.
Discussion
Communication between physician and nursing staff has the potential to affect both patient care and the relationships between health care team members. The primary findings of the study can be considered in two major categories: positive or negative influences on team dynamic and belonging. Findings can also be viewed from the perspective of the professional role; which communication behaviors did physicians, nurses, or both professions identify as increasing their sense of belonging within the health care team.
Physicians emphasized anticipating needs as aiding their sense of belonging in the health care team. This was accomplished both through offering assistance to nursing staff as well as appreciating the receipt of nursing assistance. These behaviors allowed the physician staff to feel a sense of a shared goal. This sense of shared goals has defined a health care team in previous literature; Physician Quote 1 alludes to a similar definition.4
Projecting openness was identified positively by both physicians and nurses as a practice that allowed lines of communication to remain open. By maintaining open lines of communication, team members were able to maintain a sense of belonging as part of that health care team. Projecting openness was accomplished through a mix of verbal and non-verbal displays, both of which were performed by physicians. Given that these behaviors were only identified as occurring by the physician, yields questions about whether physician-nurse power dynamics favor an appreciation for physician openness over openness from nursing. The medical hierarchy may lead to imbalance in staff accessibility to one another.
Nursing identified certain naming conventions as improving their sense of belonging within the health care team. Particularly, the ability to use a physician's first name was described as both a tool for improving a relationship and a measure of the quality of a relationship. Depending on the familiarity and departmental culture, health care workers may choose to address each other by their title, such as Dr. Jones or Mr. Phillips, or by their first name. Addressing new staff by their first name was a means of welcoming new staff through a reduction in formality. Conversely, a physician’s preference towards being addressed by their title was represented as a measure of poor team cohesiveness, especially if verbally requested. Curiously, naming conventions were solely discussed by nursing staff. There was no mention of what name a physician would choose to address a nurse by. Although not explicitly stated, the lack of discussion from physicians may be due to physicians addressing nursing staff by their first names by default. Further study is warranted into the conventions that nursing and physician staff use when addressing one another (eg, identification via title, professional role, or first-name basis).
Nursing independently identified a resistance to communication and questions as their primary source of negative team belonging. This came in the form of statements of reluctance, or tepid/disgruntled responses to nurses’ request or initiation of communication (eg, what do you want, what do you need, what is it now). Such statements were detrimental to maintaining open lines of communication and to a sense of cohesiveness between the involved parties. When a nurse received such a response from a physician, there was hesitation to continue the interaction, with potential ramifications on patient care by injuring communication channels. Statements of reluctance also resulted in a future hesitation to approach the physician with further information or inquiries. Resistances from physicians to questions from nursing staff had a similar effect on the lines of communication and team dynamic. Interestingly, to preserve the channels of communication, nursing staff would invite a surrogate nurse to communicate with a physician, one who had a healthy extra-professional relationship with that physician. This was the only occasion in which participants referenced a study theme as protective against the adverse effects of another theme.
Physicians uniquely identified systematic roadblocks to communication as detrimental to team belonging. A lack of familiarity with the nursing patient assignment or nursing break schedule often left a physician unable to locate the nursing caregiver for a particular patient. Subsequently, the physician might give up on the pursuit of communication. This was likely only identified by physicians due to the distinct physician and nursing schedules. Resident physicians who routinely rotate in other departments and other institutions may find it difficult to understand the nuances of nursing staffing within each new practice environment.
Both physicians and nursing identified interactions leading to alienation as weakening their sense of team belonging. For nurses, this feeling formed from dismissal of ideas and left staff feeling as though they were isolated from the health care team. For physicians, these feelings arose from perceived accusations of laziness. A physician might be asked whether they were going to assume care of a patient unknown to them, a patient yet to be assigned to a particular physician. This question may have been received as suggesting that their work and effort was inadequate.
The identified themes have been elicited from emergency department nurses and physicians and are potentially generalizable only to similar professionals in the same practice environment. However, the heterogeneity of emergent department patients and staff offers the possibility of generalizing beyond first-floor medical care. The variety of patient concerns and diagnosis, mixed acuity, and range of health care staff members makes the emergency department a plausible surrogate for care occurring in the hospital at large. Communication between physicians and nurses is ubiquitous to any environment in which the two professions work side by side. Future research into the communication practices between nurses and physicians might consider the applicability of inter-professional communication outside of their department.
Conclusion
From the perspectives of 38 focus group participants, consisting of emergency physicians and nurses, positive and negative influences on the team dynamic, camaraderie, and belonging were elucidated. Team belonging was positively influenced by actions that maintained lines of communication and helped team members develop relationships and mutual respect. Negative influences on team belonging were associated with verbal reluctance to communicate, alienating comments, and difficulties in navigating staffing structures. These findings begin to illustrate opportunities to foster and improve team dynamic within emergency medicine health care teams. Future research into the physician-nurse communication practices might focus on naming conventions, the role of friendships between coworkers, and specific relationship damaging statements.
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