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Effective Communication and Te PDF
Effective Communication and Te PDF
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DEVELOPMENT
effect of systems, environments, equipment on around them and what actions are required.
and processes on human cognitive abilities Cognitive overload may occur if the situation
and limitations (Catchpole 2013). is complex, for example where constantly
Human cognition is a dynamic process changing circumstances require intense cognitive
that allows people to perceive, interpret attention to process what is happening (Endsley
and make decisions about required actions 2012). Several cognitive processing failures may
(Gluyas and Morrison 2013). The cognitive then arise, including attentional tunnelling,
load is relatively low when undertaking confirmation bias, memory failures (slips and
well-known tasks in familiar situations. In such lapses) and inaccurate mental models (Endsley
instances, humans are able to carry out tasks 2012) (Table 2). These limitations in cognitive
in a somewhat automatic manner with little processing may be precipitated or exacerbated
conscious thought. However, in unfamiliar or by workload pressures, time pressures, stress,
complex situations, humans must use increased anxiety, fatigue, poor team relationships,
conscious attention to process what is going constant interruptions and changing situational
requirements (St Pierre et al 2011).
TABLE 1 The cognitive load of the individuals involved
Teamwork skills and required behaviours in the communication may affect their processing
of the information. Communication failures
Skill Required behaviours may occur if an individual is in a situation where
Leadership Communicate awareness and understanding of the there is cognitive overload, for example because
desired outcome. of the volume of data they are trying to process.
Communicate understanding of purpose, team Transmission failures may arise from incomplete,
roles, responsibilities, task requirements and plan. incorrect, ambiguous or unclear messages,
Plan and allocate tasks. while reception failures may arise because the
message is misinterpreted, disregarded or not
Mutual support Provide feedback to other team members when
processed and retained in memory (Endsley
required.
2012). Therefore, it is important to recognise the
Provide and request assistance when required.
context of communication and the individual
Trust in other team members and have confidence
in their actions and intentions.
stresses that might affect the communication
process. The communication process itself is
Situation monitoring Review ongoing team performance. only one aspect of effective communication;
Adjust, adapt and reallocate tasks and there are additional barriers that may lead to
responsibilities as required. communication failures.
Communication Share information with other team members.
Communicate clearly using objective language, Barriers to effective communication
correct terminology and structured processes or General factors that can increase the likelihood
tools, where available. of communication failures in any setting
Acknowledge communication and check for correct include differences in gender, culture, ethnicity,
interpretation (closed loop communication). education and styles of communication.
Also, there are contextual and cultural issues
(Miller et al 2009, Baker et al 2012, Gluyas and Morrison 2013)
specific to healthcare settings that may affect
communication in healthcare teams.
BOX 1 One major difference between health care
Case study 1: Mary and many other environments is the existence
of a hierarchical system, both among different
Mary presented to the GP feeling unwell, with pain in her right leg of several
health professional groups and among senior
days’ duration. On examination the GP identified that Mary had tenderness
and swelling in her right calf; she denied any falls or other incidents that may
and junior staff in the same professional group
have caused this. Since Mary had recently taken a flight overseas, the GP (Nugus et al 2010). This hierarchy results in
suspected a deep vein thrombosis (DVT). The GP ordered an ultrasound scan an authority gradient; those further down the
and blood test, which were positive for DVT, and Mary was commenced on hierarchy may be hesitant to challenge those
oral anticoagulation therapy. Later that day, she presented to the emergency further up the hierarchy, raise concerns or ask
department with acute shortness of breath and was admitted with a diagnosis questions. In a situation where one member
of pulmonary embolus. She was commenced on parenteral anticoagulation of the team feels there may be a patient safety
and respiratory support. After several days, Mary improved and was issue, or has concerns of some kind, they may
discharged into the care of the GP for monitoring of ongoing anticoagulation not feel comfortable raising this or discussing their
therapy, and the community nursing service, which would provide home visits
concerns with the team (Makary et al 2006,
and support during the recovery phase.
Reid and Bromiley 2012).
In health care, teams are often not fixed form of a pre-procedure or pre-shift pause,
or established, but have come together for during which team members articulate their
a specific purpose. They have not had time roles and responsibilities and discuss the
to establish roles and responsibilities or to intended outcomes. This may identify agreed
articulate clearly the apparent objectives of the protocols that are intended to alert team
team (Wachter 2012). This can lead to different members to changing conditions or other
perceptions or mental models of the situation important information (Brady and Goldenhar
and the required outcomes. Shift work, long 2014).
hours leading to fatigue, and other common Huddles are ongoing team briefings that
factors in health care, such as distractions, occur throughout the period the team is
interruptions, workload and time pressures, working together. They involve team members
add to these different perceptions. Therefore, coming together frequently for short periods
it is not surprising that poor communication to review and make plans for ongoing care.
within teams contributes to errors and poor If used effectively, this strategy addresses
patient outcomes. It is imperative to develop problems with overload or limited short-term
strategies that decrease the likelihood of memory capacity, establishes safeguards in
communication failures arising from authority the process and improves the effectiveness
gradients, from differing professional of communication in the team. The essential
communication styles and from cognitive elements of a huddle are that it is short, it has a
failures such as those listed in Table 2. team facilitator, discussion is encouraged based
on data and the focus is on problem solving and
Strategies to improve team communication solutions planning (Goldenhar et al 2013).
in health care Debriefings involve the team coming together
Many strategies to improve communication at the end of a shift or procedure to discuss
rely on organisational structures and what went wrong and what went well (St Pierre
processes. These strategies include education et al 2011). Team performance is improved
and training programmes that focus on through the lessons learned. Debriefings enable
improving communication in teams and team members to recognise opportunities to
developing an understanding of barriers to speak up in critical situations, or instances of
effective communication, such as authority communication failure, for example, attentional
gradients and different communication tunnelling, confirmation bias, memory failures
styles. Such programmes have been shown to and inaccurate mental models. Facilitation
improve teamwork and communication (Stead and leadership are essential to ensure a safe,
et al 2009, Gorman et al 2010, Baker et al 2012, blame-free environment for debriefing, in which
Bunnell et al 2013). Other organisational all team members feel comfortable to discuss
strategies to improve communication include aspects of the team performance explicitly
implementing practices such as checklists (Wachter 2012).
and read-back protocols for different
clinical situations, instigating structured Structured communication tools Structured
communication tools and introducing briefing communication tools address problems that
and debriefing procedures in teams (Lepman may arise as a result of authority gradients,
and Hewett 2008, Gorman et al 2010, different professional communication styles
Knox and Simpson 2013, Brady et al 2013, and cognitive limitations. These tools establish
Goldenhar et al 2013, Lyons and Popejoy 2014). safeguards in processes, reduce the steps
These steps require commitment from the and variability in processes and increase the
organisation’s leadership team and provision of likelihood of effective communication (Lee
resources. However, healthcare professionals et al 2012). Many different tools have been
can still use many of these strategies, even in the developed to provide an objective framework for
absence of formal organisational support, as is structured communication between clinicians in
discussed in this article. response to concerns about a patient’s condition
(Gluyas and Morrison 2013). For example, the
Team briefing and debriefing The purpose SBAR tool, where the mnemonic (Gluyas and
of team briefing, huddles and debriefing is Morrison 2013) indicates:
to diminish authority gradients and enable Situation: what is going on with the patient?
common agreement on the team’s objectives Background: what is the clinical background
and intended outcomes (Wachter 2012, or context?
Goldenhar et al 2013). Briefings may take the Assessment: what do I think the problem is?
for actions when there may be cognitive back the information and/or checking for
overload related to situational factors, such correct interpretation reduces the risk of
as complex tasks or rapidly changing clinical confusion. The use of phonetic alphabets (for
situations (Beaumont and Russell 2012). example, Alpha, Bravo, Charlie, Delta…) is
It is imperative that tools such as checklists not common in health care. However, their
and read-back protocols are used mindfully, introduction and/or the use of standardised
with full attention from the participants quotes or phrases could mitigate the
involved (Gluyas and Morrison 2014). There risk of inaccurate communication and
are many examples in the literature of errors misunderstanding (Prabhakar et al 2012).
and adverse events resulting from automatic, Checklists with check-off provisions are
non-mindful responses to checklists. Toft less prone to slips, lapses and omissions of
and Mascie-Taylor (2005) give an example essential items because they lead the checker
in which a patient received the same dosage through the correct sequence and identify all
5 Review your error ten times, despite three different staff the items that should be checked (Degani and
organisation’s checklists members using a checklist to prevent this type Wiener 1990). The challenge with checklists
and read-back protocols. of error. and read-back protocols is to design them to
Identify if they are Read-back protocols for telephone reduce the likelihood of automatic responses.
designed to reduce laboratory or radiological reports, medication Checklists and read-back protocols that require
automatic responses by orders, clinical handovers and surgical counts the checker to state ‘check’, ‘yes’ or ‘okay’ are
ensuring that the checker are imperative to prevent communication susceptible to inaccurate automatic responses,
is asked to state what failures that may result in errors. It is easy to whereas those that are designed so that the
they see or if there are confuse the sound of one letter or number checker states what they are seeing are less
check-off provisions. for another, especially in stressful and noisy prone to such errors (Dekker 2011).
environments (Youngberg 2013); repeating Complete time out activity 5
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