Article Text

Factors influencing physician responsiveness to nurse-initiated communication: a qualitative study
  1. Milisa Manojlovich1,
  2. Molly Harrod2,
  3. Timothy Hofer2,3,
  4. Megan Lafferty1,
  5. Michaella McBratnie1,
  6. Sarah L Krein2
  1. 1 School of Nursing, University of Michigan, Ann Arbor, Michigan, USA
  2. 2 Center for Clinical Management Research, Department of Veterans Affair, Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
  3. 3 Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
  1. Correspondence to Dr Milisa Manojlovich, School of Nursing, University of Michigan, Ann Arbor, MI 48109, USA; mmanojlo{at}umich.edu

Abstract

Background How quickly physicians respond to communications from bedside nurses is important for the delivery of safe inpatient care. Delays in physician responsiveness can impede care or contribute to patient harm. Understanding contributory factors to physician responsiveness can provide insights to promote timely physician response, possibly improving communication to ensure safe patient care. The purpose of this study was to describe the factors contributing to physician responsiveness to text or numeric pages, telephone calls and face-to-face messages delivered by nurses on adult general care units.

Methods Using a qualitative design, we collected data through observation, shadowing, interviews and focus groups of bedside registered nurses and physicians who worked in four hospitals in the Midwest USA. We analysed the data using inductive content analysis.

Results A total of 155 physicians and nurses participated. Eighty-six nurses and 32 physicians participated in focus groups or individual interviews; we shadowed 37 physicians and nurses across all sites. Two major inter-related themes emerged, message and non-message related factors. Message-related factors included the medium nurses used to convey messages, physician preference for notification via one communication medium over another and the clarity of the message, all of which could cause confusion and thus a delayed response. Non-message related factors included trust and interpersonal relationships, and different perspectives between nurses and physicians on the same clinical issue that affected perceptions of urgency, and contributed to delays in responsiveness.

Conclusions Physician responsiveness to communications from bedside nurses depends on a complex combination of factors related to the message itself and non-message related factors. How quickly physicians respond is a multifactorial phenomenon, and strategies to promote a timely response within the context of a given situation must be directed to both groups.

  • patient safety
  • communication
  • health services research
  • hospital medicine
  • information technology

Data availability statement

Data are available on reasonable request. Deidentified participant data are available from the first author on request.

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Introduction

The importance of communication between physicians and nurses in relation to safe patient care has been well described,1–3 and the literature provides many examples of how patients suffer when communication is inadequate.4–6 Communication has been studied in multiple contexts7–9 and during specific activities such as patient care rounds.10 11 Likewise, there are many theoretical approaches to the study of communication, because the study of communication evolved independently in many disciplines, so there are numerous theories that could be applied.12 However, gaps in knowledge on how to improve communication and prevent potential adverse outcomes for patients hospitalised on general care units remain. Nurses are the 24-hour surveillance system for hospitalised patients and therefore are often the first to detect early signs of patient deterioration.13 14 How quickly physicians respond to communications from bedside nurses about deterioration, for example, is important for the delivery of safe, effective inpatient care. Indeed, delays in physician responsiveness can impede care or contribute to patient harm,15 16 but we still lack actionable information on factors contributing to delays. Thus, we took a practical approach to try to identify actionable aspects of communication between nurses and physicians that might be more amenable to intervention.

Factors currently cited in the literature as affecting physician responsiveness include personal and interpersonal characteristics17 and differences in workflow patterns and workloads.16 However, other factors could also play a role, and these have not been explored adequately. Although face-to-face communication provides the greatest opportunity for shared understanding of a situation, nurses and physicians are rarely together in the same space and time, leaving them to rely on a variety of communication mediums (eg, electronic health records, pagers and cell phones) that may affect how a message is understood and acted on. For example, how an outgoing message is framed or ‘packaged’ by a nurse,18 how the message is received by a physician who may be engaged in other activities at the time and the communication medium used to deliver a message could all influence how and when a physician responds.

In a prior study, we described communication practices, work relationships and communication technologies broadly and noted that physician responsiveness was a particularly important concept.10 Thus, the specific purpose of the present study was to describe the factors contributing to physician responsiveness to text or numeric pages, telephone calls and face-to-face messages delivered by nurses on adult general care units in four hospitals.

Methods

Study design, site selection and data collection

This study used a descriptive qualitative design. Survey findings and telephone interviews from the prior, broader investigation were used to identify and recruit sites, all in the Midwest USA. More information about the methods for the prior study has been published elsewhere.10 19 Hospitals represented a mix of academic medical centres and community hospitals of different sizes and included one site from the US Department of Veterans Affairs health system. We collected data from physicians and nurses (ie, clinicians) who worked on general care units at those sites. Clinicians were told that the purpose of the study was to observe communication practices and work relationships. Two or three research assistants spent 2 weeks at each site. We deliberately chose the sequence of our methods, beginning with general observation, to allow clinicians to acclimate to our presence, progressing to shadowing individual clinicians and concluding with interviews and focus groups. We adapted focus group and interview questions based on what research assistants observed to develop a deeper understanding of our subject.20 As the focus of this research was on clinicians, there was no patient or public involvement.

Through observation, we saw the ‘what’: communication activities among clinicians. Observation sessions ranged from 2 to 4 hours in length. Each research assistant observed for a total of 13–26 hours at each site. They observed on various days of the week (including weekend days). Research assistants captured observations in unstructured field notes. Immediately after each observation session, they compared field notes, augmented the data from each independent perspective and created a detailed summary focusing on the main study objectives (ie, use of technology, work relationships and communication practices). Through shadowing (ie, following a single individual for a set period of time),21 we understood ‘how’ clinicians communicated. In general, four to seven nurses and three to six physicians were recruited for shadowing on each unit. Shadowing sessions each lasted about 2 hours. Hand-written observation and shadowing notes were electronically transcribed.

Focus groups and interviews helped answer ‘why’ certain patterns emerged. Focus groups or individual interviews were conducted with physicians and nurses depending on their availability. Our preference was to conduct focus groups, but if only one clinician (physician or nurse) was available, research assistants conducted an interview. Physicians participated during their workday so focus groups lasted about 25 min on average. Nurse focus groups occurred before or after scheduled shifts and were between 45 and 60 min in length. Interviews and focus groups were conducted using a similar guide (see online supplemental files 1 and 2), then were audio-recorded and transcribed verbatim by a proprietary service. We achieved data saturation by using multiple data collection methods and spending extended time in the field.

Supplemental material

Supplemental material

Data analysis

The entire data set (including field notes) was coded as part of the broader investigation and analysed using inductive content analysis.22 Three authors (ML, MH and MM) independently coded 20% of the same transcripts then met to compare codes. We created a codebook using the process of consensus. During regular coding meetings, coded transcripts were compared line by line, and through discussion, codes that most accurately reflected the data were chosen. We documented codes and definitions in a codebook and the remaining transcripts were divided and coded by individual team members. If we identified new codes, they were added to the codebook, and previously coded transcripts were reanalysed. We used NVivo to manage the data and create code reports.

Codes containing data relevant to the topic of physician responsiveness to nurses’ messages included: interpersonal relationships, role responsibilities, experience level and shared understanding. All authors, who came from different disciplines: anthropology (ML, MH and MMcB), medicine (TH) and nursing (SK and MM), participated in data analysis. To promote reflexivity among team members during analysis meetings, we discussed our insights, perceptions and potential biases to make sure they were accounted for in the interpretation of data.23 This approach also brought a high level of trustworthiness or credibility to our analysis.24 Two of the four sites invited us to present findings; those who attended our presentations validated our results through member checking.25

Results

Across all sites 155 physicians and nurses participated in shadowing, interviews and focus groups (table 1).

Table 1

Study participants by site

Two broad inter-related themes emerged that we characterised as message and non-message related factors, and within each theme, we identified several factors as contributing to physician responsiveness. Message-related factors that affected physician responsiveness included the medium nurses used to convey messages, physician preference for notification via one communication medium over another and the clarity of the message. Non-message related factors included trust and interpersonal relationships and different perspectives between nurses and physicians on the same clinical situation. We describe both message and non-message related factors in detail below.

Message-related factors

The medium used to convey messages

The medium that nurses used to convey messages affected the ability of physicians to respond in a timely way. The use of asynchronous mediums such as pagers and texts could result in longer response times, so many nurses considered the nature of the issue when determining the type of medium to use. One nurse told us,

I really don’t prefer the text paging because if there’s something that I’m really concerned about and I page them…how much time do I give them? (Registered nurse (RN) 3, site A, focus group (FG) 1)

Physicians also recognised that the use of synchronous mediums enhanced responsiveness. During observation at site D we noted,

[The hospitalists] try to stay available in the dictation room so they can have f2f [face-to-face] communication with nurses, which is easier and faster than through phone calls.

Physician preference

Physicians expressed a variety of preferences for how they wanted to be notified, and their preference affected responsiveness. In general, physicians preferred not to get a page consisting only of a telephone number because the display of numbers on a pager gave no indication of message content or urgency, so responses to numeric pages were variable. One physician told us why he preferred not to get numeric pages,

[I]f you’re in the middle of [something] and you just get a numeric page you’re like ‘is this an emergency?… Should I return this page immediately?’ Most of the time I do, just to make sure. And then, you leave the sick patient that you should be like giving your full attention to return a page. (Medical doctor (MD) 1, site C, interview)

However, nurses had to identify the preferred notification route for each physician, which could take time and delay responsiveness. During one shadowing session at Site A, a nurse presented the process to a research assistant:

RN1 shows me the process for paging MDs from the hospital intranet. During business hours, RNs can search the hospital directory to find MDs within the system. The phone numbers listed for MDs may be an office phone or hospital phone (or even their personal cell phone); it varies by individual.

Message clarity

The clarity of the message delivered by nurses to physicians was frequently obscured by two factors: the tendency of many nurses to provide information but not request that a specific action be taken and nurses’ use of indirect language in communicating with physicians. Physicians looked for direct, succinct messages that included a request for a specific action because it lessened the cognitive burden required to figure out what was needed. One physician explained,

We need to know what people want from us, because we don’t have time to sit and talk and figure out what that person needs. (MD2, site B, interview)

Physicians often could not interpret what nurses were asking for because of nurses’ use of indirect language. Nurses confirmed their use of indirect language, which physicians interpreted as not needing immediate action. One factor contributing to the use of indirect language was nurse inexperience. One nurse said,

When I was a new nurse, I was like, ‘oh, if you could please, maybe, perhaps,’ and they would say like ‘I’ll get to it when I get to it’… . (RN2, site B, FG5)

Another contributing factor may have been differences in training, because nurses are trained to provide the context surrounding an issue that physicians may not have the time for or appreciate.

During one shadowing session at site B, we were told,

In nursing school, I was trained that, when communicating with physicians, first describe the patient’s identifiable information, then problem, finally give suggestions. I did that in my practice. But I think physicians think that is stupid. They wouldn’t listen.

Non-message related factors

Trust and interpersonal relationships

Trust between nurses and physicians affected physician responsiveness and was the result of interpersonal relationships that developed over time. Interpersonal relationships were affected by the experience and skill levels of both physicians and nurses, could be positive or negative, and affected responsiveness.

Two factors affected relationship quality, and relationship quality then affected the medium used for communication, so that there was overlap between message and non-message related factors. First, both nurses and physicians acknowledged that establishing relationships and building trust took time. As one nurse said,

It gets better the longer [the physicians] are here. (RN1, Site D, focus group). Because then they learn to trust us and realize that we know what we’re doing, said another nurse during the same focus group (RN2).

One nurse quantified the time element and provided a rationale,

… [I]t takes months to develop a relationship with someone. They have to see you as competent. (RN4, Site B, FG1)

Second, relationship quality was affected by the outcome of previous interactions, which could be positive or negative. One physician noted that previous interactions with nurses influenced his relationships with them and thus responsiveness, in effect intimating that because of a poor relationship he might not respond as quickly even though a delay could be harmful:

Like there’s some nurses that just page all the time about something and you are like ‘this is not important.’ And maybe it is… (MD1, site B, focus group)

Once a relationship was established, nurses could better interpret physician’s lack of responsiveness, because nurses recognised the lack of responsiveness as being outside of physicians’ usual pattern of behaviour.

Once you know a doctor’s style you know this is pretty unusual that they didn’t get ahold of me pretty quick. (RN3, site A, FG1)

For some physicians, the relationship with the nurse influenced the physician’s preferred route and timeliness of their response:

If it’s one of the nurses that has my direct number… I can just text them back an answer. That’s only with nurses that I’m more familiar with. (MD3, site A, interview)

Physicians described how nurse experience contributed to the development of trust. One physician said, ‘You don't trust that many people…and [the ones you do trust are] almost invariably people who have greater than 10 years of experience’ (MD1, site B, focus group). According to another physician, ‘The nurses that have been around longer tend to…have a lot more input and a lot more insight, which is really helpful’ (hospitalist1, site A, interview). Having trust in nurses meant that the physician could act on the information provided by the nurse without having to go to the bedside and see the patient, thereby improving responsiveness. As one physician noted, ‘There are sometimes when a nurse tells you that the patient is sick, you don’t ask a question’ (site D, interview). In contrast, a lack of trust in nurses could compel a physician to go to the bedside to see firsthand what was happening.

And so… I know the ones that I don’t trust and if there is some kind of questionable information… I’m going to the bedside… I need to see that for myself… I can’t trust that everything’s okay or that everything’s going terribly… (MD2, site B, focus group)

Both nurses and physicians believed that experience was important to responsiveness, whether ‘experience’ referred to the number of years in training or in the organisation. One nurse explained how contacting an inexperienced physician could cause a delay in responsiveness.

Some [physicians in training] say ‘I’ll talk to my attending.’ And then 30 minutes later you’re like ‘hey, did you talk to your attending about this?’ And they’re like ‘no, I haven’t found him yet’. (RN2, site B, FG)

Physicians were aware of their own lack of experience and its effect on responsiveness. As one physician said,

[The intern] has less of an idea of what an emergency is than I do. I have less of an idea of what an emergency is than an attending does. (MD1, site B, focus group)

A nurse recognised how responsiveness could be affected by experienced physicians who were new to the organisation.

Providers that are new don’t manage their time as well, so they’re overwhelmed by pages. They might not get back to you as quickly. (RN1, site A, FG4)

Different perspectives on the same clinical situation

Physicians and nurses had different perspectives on the same clinical situation that affected perceptions of what was important or urgent and in turn could affect responsiveness. Nurses’ sense of urgency derived in part from being with patients for longer periods of time than physicians. One physician confirmed this saying, ‘they obviously spend a lot more time with the patients than the physicians’ (MD2, site A, interview), while another physician from the same site said, ‘I’m seeing them for maybe 15, 20 minutes a day, you know?’. Nurses acknowledged that their sense of urgency was not always based on objective clinical data but often on their subjective knowledge of the patient. During a shadowing session at site B, a nurse clarified differences in perspectives:

I asked her if she thinks RNs and physicians define ‘emergency’ differently, that is, something a RN thinks is urgent may not be urgent to a physician. She said, ‘Oh, yeah, definitely. I mean for something, like at 5 or 6 am, if a patient’s Potassium level is 3.6. It is not urgent. It can wait until day shift. But if a patient keeps asking about a stool softener 4–5 times, it is urgent to me, because he wants it now’.

As a result of this difference in perspectives, when physicians did not respond to nurse perceptions of urgency, some nurses activated the rapid response system that brought the rapid response team (RRT) to the bedside. We heard from several nurses how they called the RRT when physicians did not respond to their messages. As one nurse told us,

I ended up calling Rapid and everybody else because he [the physician] wasn't giving me any help. And I don't know if it was because he was busy doing other things and he didn't feel that it was as big of an issue as I felt it was. (RN2, site B, FG3)

Some physicians described strategies for dealing with these differing perceptions and how they responded to a situation. One physician, in acknowledging the differences in perceptions of urgency for the same situation, described a strategy he used to mitigate the difference, saying

[W]hen they’re concerned about something that I may not be as concerned about or there may be a conflict, I try to listen to them and get their viewpoint’. (MD2, site A, interview)

Going to a patient’s bedside was another strategy that some physicians used and which improved their ability to understand the nurse’s perspective, as in the story recounted by one physician who did not believe what the nurse was telling him about a patient, ‘then I witnessed what she was talking about. Something I never dealt with before’ (MD4, site D, interview).

Discussion

Our results showed that physician responsiveness depended on a complex, inter-related mix of message and non-message related factors. In terms of message-related factors, we found that nurses and physicians were thoughtful when choosing communication mediums, considering factors such as the situation and time allotted for response. However, messages themselves could still lack clarity and cause confusion, even when delivered via text or alphanumeric page. Our study demonstrates how physician responsiveness was associated with trust and positive interpersonal relationships, which then influenced physicians’ preferred medium for response. Different perspectives on the same clinical situation led to different perceptions of urgency and thus responsiveness in our study.

While our results demonstrate how different message and non-message related factors can affect physician responsiveness, they also confirm findings from other studies demonstrating that both the medium and the messages currently in use for communication purposes are far from ideal. One study examined the content of alphanumeric pages sent to surgical residents during a 3-month period, finding that a significant number lacked sufficient information and did not indicate the urgency of the page.26 In another study where an email system for communication was instituted, 50% of nurses’ requests for email response went unanswered.27 By including non-message related factors and including a broader range of mediums, our study provides insights into why nurse requests for response may go unanswered and why pager messages lack depth. Because of differences in training and socialisation, nurses do not ‘speak’ the same language as physicians and communication mediums may not translate nurses’ words into language physicians understand.28 29

Previous investigations have also found a gap in perceived urgency between nurses and physicians. In one, time-sensitive and contextual issues (such as angry family members) were labelled ‘urgent’ by nurses but not by physicians,16 while in another almost half of nurses’ pages that brought physicians to the bedside were for routine–not urgent—matters.30 In our study, the physician’s responsiveness to the situation depended on factors not explored in previous research such as the relationship that the physician had with the nurse and prior experience in responding to other situations that the nurse brought forward.

For example, one potential consequence of the inability to bridge unique perspectives in our study was that nurses called the RRT to the bedside. RRTs were developed as a mechanism to address preventable adverse events,31–34 yet some nurses told us they called the RRT to circumvent lack of physician responsiveness to nurse concerns. This unintended use of the RRT is a new finding and represents a workaround to bypass poor interdisciplinary communication with implications for patient safety.

Our findings provide further justification for the use of direct language by noting an association between the use of indirect language and delays in physician responsiveness, possibly posing a risk to patient safety. Nurses’ use of indirect language is not a new finding, having previously been characterised as ‘hint and hope’,35 meaning that by hinting at what they want from physicians (rather than making an explicit request), nurses hope to get what they are really asking for. There is a large emphasis in the literature on standardising communication, achieved through the use of tools such as checklists36 and hand-offs.37 The ‘Situation, Background, Assessment, Recommendation’ (SBAR) tool is one example of such a tool developed specifically to help improve communication.38 However, the effectiveness of SBAR and other standardised communication tools has been variable.39 40 When viewed in light of our findings, a possible explanation emerges. While such tools do provide nurses with a structure for communicating with physicians, they do not address how to bridge the unique perspectives of separate groups of healthcare professionals.

We found that while physicians preferred information such as patients’ physiological parameters to determine how quickly they should respond, nurses’ sense of urgency did not always derive from the same type of information. Others have found that nurses use a limited amount of objective physiological data when deciding on a situation’s urgency41 despite the value of this type of information to physicians.18 Interestingly, our study showed how once a physician had established a good relationship with and had trust in that nurse, the nurse’s perspective, although different from the physician’s, was valued. This finding suggests that different perspectives and the development of trust can be inter-related and provides added significance to the importance of establishing trust through positive interpersonal relationships.

Implications for practice include adopting strategies such as encouraging nurses to use synchronous mediums such as face-to-face or telephonic communication for urgent matters whenever possible, as we and others42 43 have found that asynchronous mediums delay responsiveness. Teaching nurses to use direct language29 and present quantifiable evidence of deterioration to physicians18 is another strategy. ‘Numbers’ such as vital signs succinctly describe deterioration and are unambiguous because they are not open to interpretation and thus are valued by physicians.18 Finally, building relationships possibly through colocating hospitalist physicians on dedicated units with nurses44 is another strategy with the potential to improve responsiveness if for no other reason than the physicians are close at hand and can respond quickly.

There are numerous strengths of this study. We conducted the study at multiple sites, used sequential qualitative methods and embedded ourselves for 2 weeks at a time at each site. Multiple study team members representing various disciplines were involved in data analysis, which helped to reduce bias; results were member-checked by two of our four sites. In addition, including sites with various organisational, technological and communication characteristics may make our findings transferable to similar contexts.

There are also several weaknesses. There may be selection bias because participating units were chosen by hospital leadership. Our presence on study units may have contributed to a Hawthorne effect, but our prolonged engagement at each site along with data analysis from multiple sources likely minimised it.

Conclusions

Physician responsiveness to communications from bedside nurses depends on a complex combination of inter-related factors related to the message itself and non-message related factors. How quickly physicians respond is a multifactorial phenomenon, and our study suggests several avenues for intervention development that might help improve responsiveness. Importantly, our study demonstrates that it is not enough to target only one group of clinicians. To promote a response that is timely within the context of a given situation interventions must be directed to both groups.

Data availability statement

Data are available on reasonable request. Deidentified participant data are available from the first author on request.

Ethics statements

References

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

Footnotes

  • Twitter @mmanojlo, @Sarahlkrein

  • Contributors MM conceived the idea. MM, ML, SLK were involved in data collection. All authors were involved in data analysis and interpretation. MM drafted the article. All authors were involved in critical revision of the article and gave final approval of the version to be published.

  • Funding This project was supported by grant number R01HS022305 from the Agency for Healthcare Research and Quality (AHRQ).

  • Competing interests TH, SLK and MM reports grants from the AHRQ during the conduct of the study. TH and SLK reports grants from the Department of Veterans Affairs, Health Services Research & Development Service, during the conduct of the study.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.