Doctor – Nurse Collaboration as a Means for Improving Healthcare Quality

Research Methodology

Background for the Study

Physician–nurse communication is one of the basic guarantees of a successful treatment process and effective outcome. Interprofessional collaboration ensures a detailed analysis of the case from different angles, including unique patient care perspectives (Maxson et al., 2011). Each expert viewpoint is important. Every professional enters the medical practice with a set of various skills and abilities (Keller, Eggenberger, Belkowitz, Sarsekeyeva, & Zito, 2013). The possibility to share this knowledge can increase the quality of care (Shen, Chiu, Lee, Hu, & Chang, 2011).

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However, in contemporary treatment practice, physician–nurse collaboration is at a low level. The recent research proves that physicians cooperate with nurses reluctantly and try not to discuss the treatment process. For example, Henkin, Chon, Christopherson, Halvorsen, Worden, and Ratelle (2016) state that quality healthcare is impossible without successful physician-nurse collaboration. The authors raised the problem since such interaction is usually suboptimal and does not meet the daily needs of the treatment process.

On the other hand, successful interprofessional collaboration proves to be effective in the hospital settings since it promotes the motivation for the better service implementation and helps in defining problems faster (Wershofen, Heitzmann, Beltermann, & Fischer, 2016). Moreover, if treating patients in collaboration, nurses and physicians will remain on the same page. Effective collaboration guarantees similar actions and the same treatment process, which is important in any sphere of the healthcare service. In such a manner, nurses and physicians can ensure fast service delivery and provision of correct treatment (Kieft, de Brouwer, Francke, & Delnoij, 2014).

In the case nurses are not informed about the basic principles of treatment, they can either interfere with or slow down the process. Since physicians possess all the data and make the final decisions about the treatment process, they should share this information with nurses. The lack of collaboration makes nurses remain inactive and do not engage in the treatment process at all.

Collaboration is one of the basic principles of successful patient care. In terms of healthcare, collaboration involves the teamwork that aims at meeting the mutual goal while treating patients. Healthcare services should be provided on the basis of an interprofessional and multidisciplinary approach (Bridges, Davidson, Odegard, Maki, & Tomkowiak, 2011). Only effective teamwork can successfully meet patient needs. The teamwork not only involves the provision of some basic services but also focuses on communicating goals, assessment strategies, and planning techniques, as well as evaluating patient needs (Nancarrow, Booth, Ariss, Smith, Enderby, & Roots, 2013).

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The patient progress depends on many aspects and collaboration, while implementation of the patient care plan is one of the most important issues. However, not all doctors share the full treatment information with nurses; this issue prevents the last from taking part in clinical rounds. Therefore, the delays occur in the medication review, dressing, and further investigation. Having created patient care plans, nurses can conduct most rounds daily. However, the lack of proper communication prevents them from on-time collaboration, which leads to delays in treatment.

Missing some data from the treatment plan, nurses remain ignorant of patient vital signs, intake and output charts, pain management, and patient complaints. All these aspects influence the treatment process and quality of care and result in insufficient and low-quality treatment. Therefore, collaboration should become a key aspect of the way of providing quality care to patients and ensuring their successful treatment (Institute of Medicine, 2010).

Much research has been conducted on changes in the current state of physician-nurse collaboration with reference to the fact that nurses are usually not involved in planning the patient treatment and implementing procedures (Sayed & Sleem, 2011; Fewster-Thuente, 2015; Streeton, 2016). Joubert, Du Rand, and van Wyk (2005) warned about the high level of verbal abuse of nurses by physicians. Sayed and Sleem (2011) have reported the low level of positive attitude in physician-nurse collaboration from the side of physicians.

Sometimes, it acquired a form of disrespect. Meanwhile, nurses have expressed a more positive attitude to such instances while referring to the increased quality of care. Since nurses and physicians have the same goal in patient treatment, Fewster-Thuente (2015) has tried to investigate collaboration as the basic social process. As a result of this research, seven stages of physician-nurse collaboration have been identified; they all targeted the same goal. The stages of the process include attention, communication, personal relations, cooperation, experience exchange, action, and monitoring (Friese & Manojlovich, 2012).

Despite the communication and desire to achieve a common goal while implementing a treatment plan, collaboration covers the issue of responsibility, as well (Brault et al., 2014). Nurses bear responsibility for the outcome of the treatment. However, it is impossible due to the absence of full knowledge of the treatment plan and the consequent inability to provide the necessary procedures. Excluding nurses from clinical rounds and leaving them unaware of the information concerning the progress of treatment may lead to worse patient outcomes (Amsalu, Boru, Getahun, & Tulu, 2014).

The Joint Commission (formerly, the Joint Commission on Accreditation of Healthcare Organizations [JCAHO]) conducted the research of 2,455 sentinel events. The findings reported miscommunication or the absence of any communication in 70% of cases. In 75% of these cases, the failure to communicate led to deaths (Leonard, Graham, & Bonacum, 2004). Therefore, adequate collaboration between nurses and doctors is a guarantee of successful treatment. However, the contemporary situation in the physician-nursing collaboration questions the possibility of providing patients with the top-quality services and guarantees of fast and effective outcomes.

The Problem Statement

Working in a surgical unit, nurses are excluded from many clinical rounds (Morris et al., 2012). One of the main reasons as to why nurses do not actively participate in daily procedures is the fact that doctors do not consider them acknowledged enough to follow the treatment plan and be aware of the recent changes in the patient condition (Mitchell, Lavenberg, Trotta, & Umscheid, 2014).

Such clinical rounds as taking patients’ vital signs, managing the pain, resolving patient’s complaints, preparing patients in exam rooms, monitoring the weight, observing and reporting about any health changes in patients’ behavior and activities, administering care, filling out health histories, handling medications and prescriptions, assisting with minor bedside surgical procedures, handling the medical insurance issues, coordinating medical records, and keeping records of intakes and outputs should be the responsibility of nurses (Nelson, King, & Brodine, 2008; Aswegan, 2007; Wolfson et al., 2012; Brooker, Nicol, & Alexander, 2013; Phillips, 2016; Carroll, Antognoli, & Flocke, 2011; Ridgers, Carter, Stratton, & McKenzie, 2011; Fukuda, Shimizu, & Seto, 2015; Funnell, Koutoukidis, & Lawrence, 2008; Anderson, 2010). However, to implement these procedures effectively, nurses should be aware of the recent changes in the treatment plan and any other operations and procedures conducted in their absence.

As soon as patients arrive at a hospital, they receive instructions from nurses. After it, doctors make the primary examination, prescribe necessary tests, and medications if applicable. Nurses receive some notes about the treatment plan and a list of procedures to be accomplished. All the basic information about the treatment plan and other necessary issues are left behind them. Doctors do not have an opportunity to share all details about the patient treatment with nurses. Inline, nurses perform their tasks without seeing the whole picture of the treatment. They remain ignorant of the major signs and symptoms that patients have; nevertheless, such an attitude may result in inadequate care. Having assisted doctors in taking vitals and having accomplished other responsibilities, nurses do not see the need for their actions (Siedlecki & Hixson, 2015).

At the same time, nurses constantly monitor the patients’ temperature and their pulse and measure the blood pressure if needed. These activities can be important in the treatment plan, but doctors can notice them too late to be able to do anything. Still, nurses cannot react appropriately, as they do not see the whole treatment process. Having raised the demands for nurses and their knowledge, the healthcare reform did not change the rights of nurses in terms of influencing the treatment procedure. Therefore, it appears that despite being professionals in their field, nurses have to be satisfied with some general tasks without having a clear understanding of the reasons for some actions and procedures.

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According to recent investigations, doctors do not consider it necessary to inform nurses about their actions at all. In many cases, they do not have adequate tools and possibilities to inform nurses about some important issues. Having numerous patients and different shifts, nurses and doctors sometimes do not have any physical possibility to report their actions and share considerations about a particular patient. Therefore, a need for the development of specific communication tools and their further implementation in the working environment should become a priority for all medical establishments.

Moreover, nurses spend much more time with patients than doctors do. It is a considerable problem since because of being always near patients, nurses cannot make adequate judgments about any changes in the treatment plan and reactions of the patient body to it. The situation has to change since inadequate communication between patients and doctors can cause patients serious problems. Nurses are professionals in their field of knowledge, and they play a very important role in patient management as they spent more time with them than any other healthcare workers.

Nowadays, when providing any procedures, doctors do not feel any responsibility before nurses in informing them of nature and reasons for their actions. Research confirms that nurses should assist doctors in their daily duties in order to ensure that the treatment plan is developed with reference to all necessary aspects (Lyons et al., 2013). However, it is not the case for most hospital settings. Nurses and doctors should conduct daily rounds together in order to share personal experience and skills and ensure the top quality treatment and healthcare service in general.

According to Elliott and Coventry (2012), “The interpretation of data from assessments is vital in determining the level of care a patient requires, providing treatment and preventing a patient deteriorating from an otherwise preventable cause” (p. 625). However, doctors and nurses usually have other responsibilities apart from patient rounds; thus, they usually fail to manage time and make everything together. Therefore, doctors and nurses may accomplish their tasks separately; as a rule, such a situation leads to the lack of communication and failure to exchange vital information concerning the treatment.

Therefore, the issue of nurse-doctor communication and collaboration should be reconsidered in light of contemporary healthcare. Having a lot of responsibilities and being overloaded with patients, nurses and doctors cannot deal with the same person simultaneously. Therefore, the development of the treatment plan, as well as its implementation and monitoring, is accomplished in different periods of time and by different people. It creates a number of problems, which should be overcome. Doctors and nurses are supposed to find the best way to overcome the problem by means of employing different technology tools. It is not a problem in the contemporary world of information. Therefore, the major problem of the failure to communicate their own actions and decisions between nurses and doctors can be resolved.

Purpose of the Study

The main purpose of the study is to access the influence of the use of technology tools for the effective collaboration of nurses with doctors (Messmer, 2008). Since the lack of communication between doctors and nurses has appeared to a problem for the quality service delivery, the detailed analysis should be conducted with the view to finding the ways out of the situation. The implementation of effective collaboration can bring much profit not only to patients but also to the overall healthcare process. Inadequate decisions and wrong treatment are the most common issues that healthcare providers face in the case of the failure to collaborate.

Top-quality healthcare can be achieved by means of collaboration between nurses and doctors. The lack of such teamwork can negatively influence the treatment plan (Rosenstein, Russell, & Lauve, 2002). Patients can receive healthcare services with delays; the failure to communicate effectively can lead to adverse patient occurrences and put at risk the patient safety (Miller, Riley, Davis, & Hansen, 2008). The improvement of collaboration between doctors and nurses is one of the main goals of the current research.

Having identified that one of the main reasons for the issue is the inability of personal contact and communication while taking vitals and handling other procedures, it is important to refer to the information technologies. Information technologies are an effective tool in sharing any data. While being away from each other, doctors and nurses still can share their ideas about a particular patient, taken vital, followed procedures, and general changes in the patient condition and behavior. In such a manner, information technologies can help nurses and patients to collaborate and be able to share their ideas about the treatment plan.

The main goal of the study is to improve communication between doctors and patients for the purpose of enhancing the quality of healthcare in the hospital settings, reducing the level of failures, and decreasing the time of reaction to changes in the patient behavior and condition (Tschannen & Kalish, 2009). Smaller objectives of the study presuppose the use of a specific tool for information sharing in the healthcare facility and assessing how this tool can contribute to positive patient outcomes. The assessment of the effectiveness and positive influence of the information technology on patient outcomes will help one understand the overall effectiveness of the selected tool.

ISBAR (Identify, Situation, Background, Assessment, and Recommendation) is the information technology tool that has been selected for the study. The main task of this software is to share clinical information under the top security and allow doctors and nurses to remain updated about any changes in the patient condition, behavior, or activities. The selected tool provides a framework for comprehensive and easy information sharing. This tool is helpful in promoting fast communication between healthcare providers in hospital settings.

The collaboration of doctors and nurses can be built with the help of this tool, which will reduce the possibility of mistakes and will increase the time of the reaction to the recent changes in the patient treatment plan. The research was conducted in the format of the evidence-based practice. It involved nurses and doctors in the experiment in order to assess the level of patient care with the implementation of the tool and without it. The research questions whether the use of the ISBAR tool positively influences doctor-nurse collaboration as compared to the traditional way of information sharing in healthcare settings that involve nurses and doctors.

Overall, the study aims at assessing the effectiveness of the offered tool as compared to the control group, which will continue using the traditional means of communication. The purpose of the research is to assess the effectiveness of the selected strategy both quantitatively and qualitatively.

The Research Question and Hypothesis

The research questions developed for the study have allowed structuring the design and identifying the main focus of the study. The correct choice of the research questions is the first step towards a valid and reliable research design, which can help improve the general healthcare system and promote patient safety, as well as improve the level of healthcare services. The search questions developed for the current study are as follows:

  1. Does the use of information technologies increase collaboration between nurses and doctors?
  2. How positive are the changes in doctor-nurse collaboration due to the use of information technologies?
  3. To what extent does the use of the ISBAR tool reduce the possibility of a mistake in patient treatment?
  4. To what extent does the collaboration of nurses and doctors increases in regard to a particular patient?
  5. To what extent does patient safety increase with faster doctor-nurse collaboration?
  6. To what extent does the reaction time reduce with the use of the ISBAR tool?

Significances of the Study

The study under consideration is of considerable significance to the improvement of healthcare quality. Nurses are considered the main providers if the care plan is prescribed to patients by doctors. Therefore, an effective process is impossible without the particular reference to the notes and considerations of each party to the process. Having set the final goal of the study as overcoming challenges that consider the collaboration of doctors and nurses, the ISBAR tool that was utilized in all conversations aimed at reducing the tension between nurses and doctors, increase the reaction to different changes in the behavior and treatment plan, and improve the healthcare quality, in general. Collaboration is an effective means of healthcare.

Consequently, nurses and doctors should share the experience and knowledge that they have earned in order to ensure quality care. Under the conditions of the lack of communication and inability to structure the working process in order to allow nurses to accompany doctors in seeing patients and making prescriptions due to the increased number of tasks that each of them has to perform, the application of the information technology can help save the situation and protect patients from possible mistakes.

Usually, nurses are too scared to start the conversation about their role in patient treatment. Also, nurses may not be ready to conduct the rounds. Therefore, the use of this technology will help nurses be on the same page with doctors and help them promote quality healthcare without a considerable personal intervention to the treatment plan. Nurses will also improve their knowledge and skills in the treatment practice while tracking any changes in the patient condition and decision-making. Another task of the research is to allow nurses to communicate their advice and understanding of the situation. Nurses will be allowed to make notes about the current condition of a patient and influence the decision-making process, as a result.

One of the serious challenges on the way to the effective collaboration of doctors and nurses is the inability of the last to take part in the discussion of the patient's condition with the former. Following the patient treatment plan and providing appropriate care, nurses are the first to see changes and reactions of patients to the treatment. However, nurses do not have an opportunity to share their vision of the situation and utilize their knowledge since doctors neither communicate their plans nor discuss patient management with them. The use of the ISBAR tool is the right step towards equipping nurses and facilitating the change.

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Research Design

With regard to the above-presented objectives and debated problems, the field experiment best suits the research objectives. The purpose of the field experiment is to explore the outcomes of interventions in a real-life situation. The field experiment compares randomly selected subjects to control groups and assesses the outcomes of interventions between these groups. It can also have some differences with laboratory experiments under scientific control by evaluating it in artificial and controlled settings. The evaluation of the results of the study relies both on the qualitative and quantitative dimensions

A qualitative part outlines skills that can be developed during the session by both nurses and physicians, the knowledge and experience they received, as well as perceptions and concerns being highlighted while examining and treating patients. A quantitative part will provide the assessment of the percentage of positive improvements by means of interviews conducted before and after the program implementation.

The ISBAR tool will be implemented in the real healthcare environment in order to regulate the collaboration of nurses and physicians. To begin with, the naturalistic environment will be chosen for the research – the surgical unit, in which nurses are working. As it has been briefly outlined, the patient care plan will encourage a nurse to go through five stages of the treatment process – identification of symptoms, analysis of the patient’s history, provision the background of the medical record, assessment, and identification of actions carried out by nurses, and subsequent treatment investigations.

Further, the plan will be associated with the clinical examinations, practicing communication skills, clinical knowledge of nurses acquired during the experiment. Being of qualitative nature, the field experiment can allow observing any shifts in nurses’ attitudes, perceptions, concerns, and adjustment under new healthcare conditions with additional responsibilities being imposed on them. It can also provide physicians with a new vision of the clinical practice, in which duties and responsibilities are reasonably distributed with the view to minimizing the time for delivering an expert help to patients, as well as providing new strategies for facilitating and improving the quality of the treatment process.

The task of the program coordinators is to integrate a new collaboration framework and encourage nurses to learn more about pain management, communication with patients, control of input and output charts, experience exchange with physicians, and acquisition of the in-depth theoretical knowledge.

Physicians and nurses will be notified about the details of the research procedure in a written form in order to receive official consent from them. It can also provide an ethical consideration regarding the privacy of information about the patient’s medical record and background. In order to conduct a clinical round, nurses for a new patient care program will be selected from the surgical unit for the purpose of enhancing the working collaboration and patient management. Before they are involved in the program itself, they will be interviewed in order to define their current attitude and ideas concerning the clinical practice and the very concept of collaboration, as well as the ability to interact with patients and listen to the patients’ complaints.

They should also express their opinion regarding any challenges in communication with physicians to fill out these gaps in the future. As soon as interviews are conducted, nurses will be introduced to the major aspects of the program – the clinical round of dealing with patients during pre-, in-, and post-operational procedures (Hunter New England, NSW Health, 2009).

ISBAR

The framework is called ISBAR; it comprises the following stages:

  1. Identification

At this stage, nurses will have to diagnose a patient, evaluate the level of his or her stability, and note major concerns via the primary examination and further communication with a patient. The stage also presupposes the knowledge exchange with physicians. The task of nurses will be to report any signs and symptoms of a possible disorder. The task of physicians will be to keep nurses informed about any changes in the treatment process for them to be able to respond immediately in the case of contingency.

  1. Situation

This stage implies the analysis of the patient history, as well as writing down the date of admission, patients’ complaints, and medications that were taken before the admission. A list of all problems and interactions with patients’ relatives and friends should be provided, as well. The same information should also be reported to physicians. At this point, a physician should communicate openly with nurses and be able to check whether they are encouraged to take the initiative in the case.

  1. Background

The task of the nurse is to talk to a patient and his or her relatives in order to expand the knowledge about the patient’s social and cultural background, which is essential for post-operative procedures. Moreover, at this stage, nurses can discuss the prognoses and predictions regarding future treatment.

  1. Assessment

In most cases, this stage of patients’ evaluation and treatment is mostly assigned to physicians, while the nurses’ access to it is limited. However, the task of the framework is to involve nurses and allow them to discuss the patient’s current behavior and vital signs, which are to be recorded on a chart. Nurses could also communicate their opinion regarding the possible ways of treatment. Physicians should provide nurses with the space for action, for example, assisting during the surgery and keeping control of a patient after the surgery period. Nurses could also regularly report to physicians what they plan to do during the assessment of the patients’ conditions.

  1. Recommendation and Response

This stage is usually the responsibility of physicians, but it can also engage nurses, for example, in reporting about the patient’s general conditions and concerns. At this point, nurses could be intermediaries between patients and physicians. They can also propose certain options for patients to do after the treatment process, which can save physicians from the necessity of the constant control of the patient and allow them to focus on the development of a treatment plan instead. In this case, the medical reporting and interaction between physicians and nurses will be ensured.

This type of experimental program should provide a tangible outcome in order to define the difference before and after interventions. Physicians will also be interviewed before and after the program is implemented in order to make sure that the evident improvements have been implemented in the clinical rounds. During clinical rounds, the task of the researcher is to make sure that physicians regularly inform nurses about any changes in patient’s conditions in order to be aware of the corresponding response to be introduced with the view to improving the situation in the case of physician’s absence or business in another surgery.

The direct collaboration will also be assessed in terms of frequency of interactions between nurses and physicians, the depth of information delivered to nurses, and nurses’ response and initiative in solving critical problems individually. The success of the venture will also be evaluated in terms of written reports and instant messages. The use of technological gadgets could be investigated in order to understand whether it contributes to the improvement of the research problem or not.

In terms of the timeline accomplishment, the program will be divided into three major studies. The first one will last for two weeks, during which nurses will be interviewed and provided with all necessary theoretical information regarding the upcoming program, including the duties and responsibilities of the involved parties. Physicians will also be notified of any changes in the treatment process. The second stage will last for two months, during which nurses will be divided into two teams, while physicians will supervise those groups and assess their professional advances. Researchers will also control those groups and physicians in order to make sure that all research procedures are accomplished in a consistent manner.

The final outcome of the research will provide more information about the cultural and professional environment of a hospital, challenges and barriers to the communication, nurses’ concerns regarding the extent, to which they can be involved in therapy sessions in the pre- and post-operational period. Hence, this aspect can be evaluated on the basis of the quality of communication and simulation of conversations on different professional topics. ISBAR offers a relevant approach, which is directed at enhancing effective communication as a portable tool that can be used for advancing the service delivery.

Indeed, communication is a common practice for all professionals in the healthcare sector, and it involves all members of a healthcare unit, including nurses, the pharmacy staff, health managers, and physicians. Therefore, the task of the program is to explain the necessity of such internal communication (Hunter New England, NSW Health, 2009). Collaboration and effective communication are a sort of proficiency skills that are an obligation and responsibility of every member of a healthcare team. The task of the research will be to identify every single situation, in which communication and collaboration play the most critical roles.

The final step of the research process is developing and providing possible recommendations for the cultural and behavioral change with the view to improving the quality of the interaction and treatment. The gaps and drawbacks will be discussed and addressed appropriately by improving communication and introducing technological innovation. Such an approach will also provide implications for the further implementation of new programs that underscore the importance of face-to-face communication and regular collaboration with the emphasis on a holistic approach to the treatment process.

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Operational Definition of Keywords

  • Clinical rounds are daily activities that nurses and doctors conduct in relation to the treatment plan in order to perform any possible actions that aim at examining or treating a patient. Clinical rounds include the medication review, taking vitals, dressing, and further investigation of a patient (Close & Castledine, 2005).
  • The patient management is the implementation of the basic treatment strategies in relation to a patient; it is provided both by nurses and doctors. Patient management involves the use of treatment strategies, dealing with documents, and providing patients with any operations and facilities.
  • Collaboration is a cooperation between nurses and doctors; it involves communication and sharing knowledge and experience.
  • Taking vital signs is a notion that covers all procedures, which can be provided to a patient while taking any material for testing and measuring the body temperature, pulse, and blood pressure (Elliott & Coventry, 2012).
  • Intake and output charts are the way of handling the patient documentation with the list of all provided procedures and medications (Ling, 2011).
  • Pain management is the ability to understand and mitigate patient pain by means of special nursing procedures and medications (Barr et al., 2013).
  • A patient complaint is the “expression of grievance and dispute within a health care setting” (Reader, Gillespie, & Roberts, 2014, p. 1)
  • Patient outcomes “encompass the whole cycle of care — including health status achieved (e.g., survival, functional status, quality of life); the time, complications, and suffering involved in getting care; and the sustainability of benefits achieved” (Porter, Larsson, & Lee, 2016, p. 504).
  • A healthcare treatment plan is a set of all procedures and interventions in the patient's health for the purpose of providing top-quality healthcare services and helping a patient recover (Perkinson, 2016).
  • ISBAR is a “mnemonic created to improve safety in the transfer of critical information” (ISBAR, 2012).
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