Introduction

The critical importance of effective communication in achieving positive patient outcomes is heavily recognized.[1][2][3] Argued as the most influential factor in team provision of healthcare, communication affects all aspects of care delivery from the professional performance of skills to patient safety.[4] Moreover, poor communication has shown to result in patient harm.[5] Considering this significance, multiple ways of developing the practitioner and team have arisen to improve individual and team communication. As both simulation and tools/algorithms are already used with effect in medical education, the potential for incorporating these approaches has been explored, resulting in the potential for the improvement of patient care and reduction in adverse patient events.[6][7]

Function

Traditionally the clinical abilities of the medical practitioner were thought to be the most significant factor in delivering effective care.[8] This focus on the individual failed to account for other factors often needed for patient care and also created a hierarchical structure for care.[5] Resultingly, this has meant that poor decisions have not been challenged, and the inability to feed information up and down the hierarchy has been a barrier to communication.[9] Furthermore, an assumption of the ability to communicate has occurred, culminating in a paucity of communication training. The hierarchical approach has shown to have a detrimental impact on all those involved – physicians, nurses, and ultimately patients.[4]

One way in which the negative impact of hierarchical care is now being challenged is through encouraging assertion abilities amongst all staff members.[1] Literature has supported that appropriate assertion training is essential within hierarchical systems.[10] The term flat hierarchy has, therefore, been developed and identified as a positive step to reducing patient harm.[9]

Issues of Concern

The nature of communication is in itself complicated as it encompasses aspects of culture, language, and non-verbal skills, and this has proven a challenge for developing ways of overall improvement.[11] Within health care communication, extra stresses can adversely impact the ability of an individual to communicate effectively. These can range from individual factors such as the specific professional’s experience in communicating with team members to environmental factors such as overall staffing stress levels, and the emotional workload of particular aspects of care.[12] Effective communication skills can also reduce the burnout of the provider in emotive situations.[13]

Training Tools

Training tools are historically embedded in medical education. Traditionally found within practical skills teaching, they have been used with effect to demonstrate anatomy, technique, and familiarization with procedures.[14] These have been varied in approach from human cadavers, animal models, and specimens, to simplified tools for practice.[14]

In the field of communication, training tools have proven to promote clear communication and avoid the negative consequences of poor communication.[15] These training tools have been developed and used with positive effect in multiple sectors – most notably within aviation.[1] The lessons learned within these non-medical sectors have provided valuable insight into the demands of individuals and groups when working to tackle challenging situations[5]. The tools developed within other non-medical sectors have, therefore, been analyzed and adapted for use within medical education. Such tools are now being used within medical practice to help reduce communication errors and improve care delivery.

Procedural Skills Assessment

The role of simulation training in medical education is well established.[6] A review concluded that medical simulation training resulted in an overall positive effect on learning, knowledge, and skills and that these effects are transferrable into clinical practice.[16] Moreover, the benefits of simulation training can be seen across the whole team and even improve team cohesiveness. It has been shown that when the simulation was practiced within operational teams, a reduction in error and improvement in positive outcomes for the patient have been recorded.[9]

More specifically, the role of medical simulation within the improvement of communication is now better understood. It has been emphasized that effective communication skills can be taught through simulations training and can include starting/finishing consultations, following a logical communication pathway, and identifying and delivering information at an appropriate patient level.[17]

Clinical Significance

Multiple training tools now exist for use, particularly within the simulation to improve both team and individual communication skills.

SBAR

One type of communication tool that has proven to have a positive effect on communication is SBAR ('Situation,' 'Background,' 'Assessment,' 'Recommendation').[18] The tool is designed for clear communication between different professionals and has been used to the greatest effect when used for raising concerns regarding a deteriorating patient. It asks the communicator to consider:

Situation – what is occurring with the patient

Background – what are the relevant background details /clinical context

Assessment – what do I believe the problem is

Recommendation – what needs to be done

An example of its use could be when a surgical nurse wishes to contact the surgical doctor as a patient under their care is deteriorating. In an example, SBAR could be used as such:

Situation – Dr. Wright, I am calling about Miss Green in bed, K4, who is having increasing pain postoperatively.

Background – She is an 18-year-old who is normally well, and this afternoon had an open appendectomy for a perforated appendix.

Assessment – She has a heart rate of 120, a blood pressure of 95/50, a temperature of 38.9, and a tight, painful abdomen.

Recommendation – I'm worried she has a complication after her operation, possibly a perforation/leak.

Concisely, SBAR delivers an essential set of information while actively promoting critical thinking by the message conveyor. One systematic review suggests that fundamental patient safety improved through the implementation of SBAR, particularly when used in non-face-to-face communication, such as when bleeping/paging a physician.[19] Its standardized approach can also give confidence to its user, therefore helping breakdown the barriers by enabling communication between different team members. However, although this tool promotes independent thinking, and prompts information gathering before communication, a degree of confidence is required to initiate this form of communication.

Appropriate assertion

One tool that specifically addresses the role of confidence, and therefore assertion within cross-professional communication, is the appropriate assertion tool.[5] It is often the responsibility of a nurse to contact the physician to request they see a patient. However, given the different communication styles between nurses and physicians, this is often fraught with difficulty.[5] A cycle was developed with stages to address this [5]:

1. Get a person's attention
2. Express concern
3. State problem
4. Propose action
5. Reach decision

They also put forward the argument that a nurse should be able to contact a physician and plainly state, "I need you to come now and see this patient," and that the physician should respond each time.[5]

Huddles

An additional tool used to promote clear communication across teams delivering health care is the implementation of huddles.[20] Huddles may be defined as a "tool for communicating changes in a plan of care."[21] Huddles are multidisciplinary, usually set at specific intervals within a shift or after an event, and provide the opportunity to gain group focus. Variances between different huddle formats exist; however, they usually require the following general structure: 

• Set times – e.g., beginning and end of shifts, or on the hour throughout a shift
• Mandatory attendance – across different roles
• Limited time – usually less than 15 mins
• Clear structure – same structure followed each huddle

An example of a huddle would be in the Emergency Department, where a brief huddle (< 5 mins) every hour to go through the minors patients and check there are plans in place for the patients, and any safety concerns/deteriorating patients are flagged up. However, although improvements can be shown by implementing huddles, Montague et al. (2019) argue that a multitude of factors affects the ongoing sustainability of such interventions past the initial set up.

Debriefing

Both team and individual debriefing is another tool used for improving communication, notably within simulation training.[22] Debriefing is a two-way discussion between facilitator and student, most often held at the end of a simulation session.[23] Multiple strategies for debriefing exist; however, in general, the aim is to hold a conversation whereby the facilitator guides learning and reflection so the team can learn both from themselves and one another. The most commonly seen methods are instructor guided debrief and reflective oral and video-assisted.[22]

Enhancing Healthcare Team Outcomes

In summation, good communication within health provision is imperative in ensuring that both team members and patients are operating in and promoting a safe environment.[1] Many barriers to effective communication exist, in part from the complex nature of human communication, and hangovers of historical medical care. However,  as these barriers now become more recognized, and as the importance of team communication in safe delivery care is in focus, means to address and ultimately overcoming adverse communication can be achieved. Foremost, in this push for effective communication is the training of all team members. Achieved through simulation, and through implementing the training tools outlined above, medical care is moving towards better, safer care.