Using Qualitative Methods to Explore Communication Practices in the Context of Patient Care Rounds on General Care Units

Background Poor communication between physicians and nurses is a significant contributor to adverse events for hospitalized patients. Overcoming communication difficulties requires examining communication practices to better understand some of the factors that affect the nurse-physician communication process. Objective To develop a more detailed understanding of communication practices between nurses and physicians on general care units. We focused on patient care rounds as an important activity in the care delivery process for communication. Design Qualitative study design Participants A total of 163 physicians, registered nurses, and nurse practitioners who worked on pre-specified general care units in each of four hospitals in the Midwest. Approach On each unit, data collection consisted of 2 weeks of observing and shadowing clinicians during rounds and at other times, as well as asking clinicians questions about rounds and communication during interviews and focus groups. A directed content analysis approach was used to code and analyze the data. Key Results Workflow differences contributed to organizational complexity, affecting rounds and subsequently communication practices, both across and within provider types. Nurse and patient participation during rounds appeared to reduce interruptions and hence cognitive load for physicians and nurses. Physicians adopted certain behaviors within the social context to improve communication, such as socializing and building relationships with the nurses, which contributed to nurse participation in rounds. When rapport was lacking, some nurses felt uncomfortable joining physicians during rounds unless they were explicitly invited. Conclusions Improving communication requires bringing attention to three contextual dimensions of communication: organizational complexity, cognitive load, and the social context. Initiatives that seek to improve communication may be more successful if they acknowledge the complexity of communication and the context in which it occurs.