Alicia A. Bergman

Context, culture and (non-verbal) communication affect handover quality

Background Transfers of care, also known as handovers, remain a substantial patient safety risk. Although research on handovers has been done since the 1980s, the science is incomplete. Surprisingly few interventions have been rigorously evaluated and, of those that have, few have resulted in long-term positive change. Researchers, both in medicine and other high reliability industries, agree that face-to-face handovers are the most reliable. It is not clear, however, what the term face-to-face means in actual practice. Objectives We studied the use of non-verbal behaviours, including gesture, posture, bodily orientation, facial expression, eye contact and physical distance, in the delivery of information during face-to-face handovers. Methods To address this question and study the role of non-verbal behaviour on the quality and accuracy of handovers, we videotaped 52 nursing, medicine and surgery handovers covering 238 patients. Videotapes were analysed using immersion/crystallisation methods of qualitative data analysis. A team of six researchers met weekly for 18 months to view videos together using a consensus-building approach. Consensus was achieved on verbal, non-verbal, and physical themes and patterns observed in the data. Results We observed four patterns of non-verbal behaviour (NVB) during handovers: (1) joint focus of attention; (2) ‘the poker hand’; (3) parallel play and (4) kerbside consultation. In terms of safety, joint focus of attention was deemed to have the best potential for high quality and reliability; however, it occurred infrequently, creating opportunities for education and improvement. Conclusions Attention to patterns of NVB in face-to-face handovers coupled with education and practice can improve quality and reliability.

Communicating about opioids for chronic pain: A qualitative study of patient attributions and the influence of the patient-physician relationship

Chronic pain poses numerous challenges for patients and providers, particularly when opioid treatment is discussed. Despite accounts of antagonistic patient–provider communication, little is known about how communication about opioids unfolds during clinic visits and, importantly, how the relationship history of a patient and physician shapes this communication. This studys objective was to advance understanding of communication about opioid treatment by recording primary care clinic visits and conducting in‐depth interviews with patients to gain insight into the patient–provider relationship and its influence on clinical communication.

I'm not abusing or anything: patient-physician communication about opioid treatment in chronic pain.

OBJECTIVE To characterize clinical communication about opioids through direct analysis of clinic visits and in-depth interviews with patients. METHODS This was a pilot study of 30 patients with chronic pain, who were audio-recorded in their primary care visits and interviewed after the visit about their pain care and relationship with their physicians. Emergent thematic analysis guided data interpretation. RESULTS Uncertainties about opioid treatment for chronic pain, particularly addiction and misuse, play an important role in communicating about pain treatment. Three patterns of responding to uncertainty emerged in conversations between patients and physicians: reassurance, avoiding opioids, and gathering additional information. Results are interpreted within the framework of Problematic Integration theory. CONCLUSION Although it is well-established that opioid treatment for chronic pain poses numerous uncertainties, little is known about how patients and their physicians navigate these uncertainties. This study illuminates ways in which patients and physicians face uncertainty communicatively and collaboratively. PRACTICE IMPLICATIONS Acknowledging and confronting the uncertainties inherent in chronic opioid treatment are critical communication skills for patients taking opioids and their physicians. Many of the communication behaviors documented in this study may serve as a model for training patients and physicians to communicate effectively about opioids.

What Is Patient-Centered Care Really? Voices of Hispanic Prenatal Patients

Variations in patient-centered care (PCC) models and approaches contribute to ambiguity in how PCC is understood and defined, especially with regard to meeting the needs of diverse patient populations. One of the biggest challenges of putting PCC into practice is knowing what elements are the most important to patients. This qualitative study privileges patients’ voices and adds a cultural dimension to existing health communication research on PCC through an empirical investigation of 48 Hispanic prenatal care patients’ understandings and expectations of PCC. Semistructured interviews with 48 patients revealed five key themes in order of frequency: (a) una relación amable (a friendly relationship), (b) la atencion médica efectiva (effective medical care), (c) Español hablado (the Spanish language spoken), (d) comprensión de la información (understanding of information), and (e) eliminación del racismo (elimination of racism). The themes reflected several different assumptions and expectations with regard to PCC as compared to those espoused in many of the existing models and frameworks, such as the extent to which friendly interpersonal behaviors (e.g., smiling, making eye contact, displaying patience, and engaging in formal greetings, introductions, and farewells) were critical to patient satisfaction with the health care experience. Not only did patients feel better understood, but accompanied by friendly behaviors, information was viewed as more believable and accurate, and thus more patient-centered. The findings suggest that implementing culturally sensitive PCC approaches to caring for Hispanic prenatal care patients can include training health care staff on the importance of displaying friendly communicative behaviors such as smiling.

Pharmaceutical Role Expansion and Developments in Pharmacist-Physician Communication

Expanded clinical pharmacist professional roles in the team-based patient-centered medical home (PCMH) primary care environment require cooperative and collaborative relationships among pharmacists and primary care physicians (PCPs), but many PCPs have not previously worked in such a direct fashion with pharmacists. Additional roles, including formulary control, add further elements of complexity to the clinical pharmacist–PCP relationship that are not well described. Our objective was to characterize the nature of clinical pharmacist–PCP interprofessional collaboration across seven federally funded hospitals and associated primary care clinics, following pharmacist placement in primary care clinics and incorporation of expanded pharmacist roles. In-depth and semistructured interviews were conducted with 25 practicing clinical pharmacists and 17 PCPs. Qualitative thematic analysis revealed three major themes: (1) the complexities of electronic communication (particularly electronic nonformulary requests) as contributing to interprofessional tensions or misunderstandings for both groups, (2) the navigation of new roles and traditional hierarchy, with pharmacists using indirect communication to prevent PCP defensiveness to recommendations, and (3) a preference for onsite colocation for enhanced communication and professional relationships. Clinical pharmacists’ indirect communication practices may hold important implications for patient safety in the context of medication use, and it is important to foster effective communication skills and an environment where all team members across hierarchies can feel comfortable speaking up to reduce error when problems are suspected. Also, the lack of institutional communication about managing drug formulary issues and related electronic nonformulary request processes was apparent in this study and merits further attention for both researchers and practitioners.

“Mr Smith's been our problem child today…”: anticipatory management communication (AMC) in VA end-of-shift medicine and nursing handoffs

Background Tools and procedures designed to improve end-of-shift handoffs through standardisation of processes and reliance on technology may miss contextually sensitive information about anticipated events that emerges during face-to-face handoff interactions. Such information, what we refer to as anticipatory management communication (AMC), is necessary to ensure timely and safe patient care, but has been little studied and understood. Objective To investigate AMC and the role it plays in nursing and medicine handoffs. Research design Qualitative thematic analysis based on audio recordings of nurse-to-nurse, medical resident-to-resident and surgical intern-to-intern handoffs. Subjects 27 nurse handoff dyads and 18 medical resident and surgical intern handoff dyads at one VA Medical Center. Results Heads-up information was the most frequent type of AMC across all handoff dyads (N=257; 108 resident and 149 nursing). Indirect instructions AMC was used in a little over half the resident handoff dyads, but occurred in all nursing dyads (292 instances). Direct instructions AMC occurred in roughly equal proportion across all dyads but at a modest frequency (N=45; 28 resident and 17 nursing). Direct (if/then) contingency AMC occurred in resident handoffs more frequently than in nursing handoffs (N=32; 30 resident and 2 nursing). Conclusions The different frequencies for types of AMC likely reflect differences in how residents and nurses work and disparate professional cultures. But, verbal communication in both groups included important information unlikely to be captured in written handoff tools or the electronic medical record, underscoring the importance of direct communication to ensure safe handoffs.

Attitudes, Practices, and Experiences with Implementing a Patient-Centered Medical Home for Women Veterans

BACKGROUND Despite the growing demand for health care among women veterans in the Veterans Health Administration (VHA), little is known about the perspectives of primary care providers (PCPs) and other primary care staff about the care they provide to women veterans. We sought to understand whether barriers to, attitudes about, and practices in caring for women veterans were associated with two measures of implementation of the VHA patient-centered medical home for women veterans (self-efficacy and satisfaction). METHODS We administered a cross-sectional survey by Internet from September 8, 2014, through April 27, 2015 (and by mail from December 16, 2014, through June 18, 2015) to all PCPs and affiliated primary care staff in 12 VHA medical centers. We used descriptive and bivariate analyses to characterize their barriers, attitudes, and practices regarding care for women veterans; and ordinary least squares regression to identify associations with satisfaction and self-efficacy regarding medical home implementation for women veterans among members of a VHA patient-centered medical home teamlet for women patients. RESULTS Of 775 surveys sent, 288 were completed (94 PCPs and 194 staff) for a response rate of 37% (33% for PCPs; 39% for staff). On average, providers had one female patient for every five patients in their panels. Lower perceived barriers, higher gender-sensitive attitudes, and being a PCP were significantly associated with satisfaction and self-efficacy of patient-centered medical home for women patients. CONCLUSIONS Training efforts focused on eliminating perceived barriers and strengthening positive attitudes toward women may be more successful than changing womens health practice characteristics alone.