Poor communication none of us have a flipping clue

Given the number of professions trying to operate as a multidisciplinary team with the division between services, competing guidelines, priorities and responsibilities it was not surprising to find that the communication system between them left much to be desired. Figure 4 shows a snap shot of some of the ideas generated regarding communication under both strengths and limitations. Each square represents a post-it note place by the group on flip charts.

Figure 4 Post-it notes regarding communication issues

Strengths

Limitations

This showed that there were conflicting experiences within this group, which was understandable as there were representatives from different service delivery teams along the care journey. However, it helped the group see the different perspectives and recognise the risks inherent in the present approach to care.

Communication between doctor, ward nurse, theatre staff and patient

Consultant Ortho-geriatrician input i.e. case planning two meetings per week MD team discussion patient

participation/ awareness Improved communication

between sites Communication prior to transfer

Early planning on admission

Patients & relatives expectations very high Relatives can be demanding about

what they want for patients Back up from team

members

Communication within MDT – sharing of information re patients’ progress etc.

Good rapport with team members

Team good skill mix different skills in past experiences

Team working – ability to speak easily within professions

Poor communication between patients/staff/ theatre staff/consultants & anaesthetists Inaccurate information or difficulty obtaining information Reliance on ‘brain’ for transfer of information

Good liaison between hospital and home

Lack/poor communication due to impact of 12hr shifts Lack of communication Good communication

with relatives Communication with patient and relatives

Involving carers in decision-making

Some patients feel they are treated all the same rather than individuals

Some staff do much more for patients than you would expect

Lack of staff time to enable patients to carry out rehab tasks e.g. easier to bring commode to patient than to help them practice walking

Poor communication between disciplines and patients

I’ve heard some staff raising their voices at patients Lack of UPR

Inter-hospital communication for increased care needs to be arranged prior to transfer

The tactic of focussing on their specialist knowledge and their priorities enforced by the employer allowed the team to deflect difficult issues. In reality it was ‘difficult access to information and facilities’ (FC4). Much time was wasted gathering and checking information from different places. The quotes below demonstrate the cross discipline experience of these issues

………..but the upshot of it is that their care is not as good because none of us have a flipping clue. I mean if communication was perfect, which it never is going to be, but if it was a hell of a sight better than it is now then the patient care would be better automatically because none of us would be wasting time trying to gather information, phone calls, faxes and all of this, and we’d all know what we’re talking about so when a patient asks us a question we’d be able to answer it instead of saying oh I’m not sure. (5.936 Geriatrician)

This view from the geriatrician was mirrored by the surgical nurse who equally rehearsed problems of searching for information and wasting time which was not able to be spent practicing her professional skills to improve the experience of particular patients.

…… there’s an awful lot of wasted time. Wasted time for getting information or duplicating things or trying to find the right phone number and if we actually had more of that, you know, ready available and to have more time to do some of the other things. (2.447 Surgical nurse)

So we do waste a lot of time which could be spent on patient care….it can be dangerous; you are trying to manage somebody’s medical problems without having information about them. You might repeat investigations unnecessarily; you might not do one that you should do. (6.542 Geriatrician)

This is reflected in the case records. An example of the key issues presented by the group observers is shown below.

…bundle of un-filed notes showing lack of order. Some records not completed. Large scope for error. Little personal information about the patient. Highlighted variability of information and how this makes it difficult for us to deliver good care…….Difficult to make sense of what has happened to the patient. Time is wasted filing notes……..

(AR5 group reflections).

The set of quotations below reveal that the problems with communication were a universal reality for the participants.

Pressure which comes out from the amount of communication and the repetition (1.679 Theatre nurse)……..the repetition? (1.681 Facilitator)....Oh that is crazy, how many times do you have to do something? (1.683 Theatre nurse)....The communication between patients and between teams as well (1.685 OT3)....and relatives (1.686 Rehabilitation nurse 3)……….and the media (1.686 Physio 2) (loads of laughter)….Its that guy in the evening news (laughter) (1.687 Community Nurse)…hospital and media or just the hospital? (1.691 Facilitator) ...The hospital and media (1.693 Surgical nurse).

Finally, the example given by the community nurse (below) shows exactly what ensues when poor communication is acted upon and what it means for an individual patient and his carers. This was the first time that those they were caring for had been mentioned.

I mean I had a patient panicking the other day because he had been sent home with a discharge letter to hand into the GP with the wrong GP name on the top and panicked‘; does that mean they don’t know anything about me?’ wrong GP name, wrong spelling of your surname, wrong date of birth and that can really knock their confidence………..The accuracy is very important…….The accuracy of the updating……The accuracy reduces fear or can increase fear if it is inaccurate (7.1183 Community nurse)

At this point in the data analysis it was becoming abundantly clear that despite a system which was trying to be cost effective and efficient was failing to do just that in fact the frustration demonstrated by the various staff members would indicate that it was in fact having the opposite effect. The mixed messages and poor communication were creating confusion and the overwhelming amount of information was contributing to a lack of understanding.