Journal of Psychiatric and Mental Health Nursing, 2015, 22, 298–305
Communication elements supporting patient safety in psychiatric inpatient care A . K A N E R VA 1 R N M H S P h D - c a n d i d a t e , T. K I V I N E N 2 J . L A M M I N TA K A N E N 3 Ph D
Ph D
&
1
Clinical Nursing Specialist, 2Head of Research and Development on Nursing, Central Finland Health Care District, Jyväskylä, and 3Professor, Department of Health and Social Management, University of Eastern Finland, Kuopio, Finland
Keywords: communication,
Accessible summary
interpersonal skills, qualitative methodology, quality of care
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Correspondence: A. Kanerva Central Finland Health Care District Keskussairaalantie 19 40620 Jyväskylä Finland E-mail: [email protected]
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Accepted for publication: 9 October 2014 doi: 10.1111/jpm.12187
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Communication is important for safe and quality health care. The study provides needed insight on the communication elements that support patient safety from the psychiatric care view. Fluent information transfer between the health care professionals and care units is important for care planning and maintaining practices. Information should be documented and implemented accordingly. Communication should happen in an open communication culture that enables discussion, the opportunity to have debriefing discussions and the entire staff can feel they are heard. For effective communication, it is also important that staff are active themselves in information collecting about the essential information needed in patient care. In mental health nursing, it is important to pay attention to all elements of communication and to develop processes concerning communication in multidisciplinary teams and across unit boundaries.
Abstract The study aims to describe which communication elements support patient safety in psychiatric inpatient care from the viewpoint of the nursing staff. Communication is an essential part of care and one of the core competencies of the psychiatric care. It enables safe and quality patient care. Errors in health care are often connected with poor communication. The study brings needed insight from the psychiatric care view to the topic. The data were gathered from semi-structured interviews in which 26 nurses were asked to describe the elements that constitute patient safety in psychiatric inpatient care. The data were analysed inductively from the viewpoint of communication. The descriptions connected with communication formed a main category of communication elements that support patient safety; this main category was made up of three subcategories: fluent information transfer, open communication culture and being active in information collecting. Fluent information transfer consists of the practical implementation of communication; open communication culture is connected with the cultural issues of communication; and being active in information collecting is related to a nurse’s personal working style, which affects communication. It is important to pay attention to all the three areas and use this knowledge in developing patient safety practices and strategies where communication aspect and culture are noted and developed. In mental health nursing, it is important to develop processes concerning communication in multidisciplinary teams and across unit boundaries.
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Communication supporting patient safety
Introduction Patient safety has been emphasized in national and international health policies over the last decade (World Health Organization 2004, 2010, Legido-Quigley et al. 2008, Ministry of Social Affairs and Health 2009). Strategies for enhancing patient safety have been formulated and implemented in order to provide good quality care, and the body of research has increased substantially in recent years. However, in the field of psychiatric nursing care, patient safety is a less studied topic (Kanerva et al. 2013). Most studies are done in general hospital settings, in different fields of somatic care, where different topics connected to communication are introduced. Studies from psychiatric nursing care are needed to see if there are specific communication issues to be noted in this field. In providing safe care staff professional competencies need to be constantly developed (Gilje et al. 2007, Priest et al. 2008, Blegen & Severinsson 2011, Cleary et al. 2011, Wauben et al. 2011, White 2012). For patient safety, an important competency is communication (Calleja et al. 2010, Fallowfield 2010, Fernandez et al. 2010). It is also one of the core competencies in psychiatric care and plays an important role in structuring care and in establishing therapeutic relationships (Gilje et al. 2007, Timmons 2010). Communication is the transfer of information and forming a shared understanding between people (Gillespie et al. 2010). It is practised on several levels (Curtis et al. 2011) and should be clear and collaborative (McCaffrey et al. 2011). As multidisciplinary staff may view communication issues differently (Nathanson et al. 2011, White 2012), regular collaboration is needed to ensure effective communication (Simpson 2007). This can be enhanced, for example, through such practices as multidisciplinary discussion forums, which offer a safe forum for the multidisciplinary staff to share their views (Lown & Manning 2010). Open dialogue, verbal and written, is important (Gilje et al. 2007), but there is research showing that the time staff spend in open verbal dialogue has decreased and that more time is spent on patient records (Westbrook et al. 2011). Errors in patient records have also been noted: incomplete charts, documentation omitted, unsigned forms, incomplete checklists and missing patient contact details (Tran & Johnson 2010). Clear guidance for anticipated patient events may also be missing, and records are not always updated at handover (Bump et al. 2011). Communication at clinical handover is important for safe care, but it does not always happen adequately (Tran & Johnson 2010): it may be incomplete or fragmented, or there may be information overload. Opinions may be sought, but are not always followed up on (Nagpal et al. 2012). Barriers to effective communication at handover © 2015 John Wiley & Sons Ltd
include an inability to access accurate information, interruptions and idle chatting during handover. It can be improved by standard communication protocols (Street et al. 2011). In addition to breakdowns in multidisciplinary communication, there are also breakdowns in nurse-to-nurse communication (Tran & Johnson 2010): not recording observations, not passing on previous observations, not providing clinical history and not communicating concerns effectively (Beaumont & Russell 2012). As nurses are often the first to notice changes in patient status, they need to have a strong focus on communication and continuing the flow of information (Deacon & Fairhurst 2008, Chang et al. 2011). Staff–patient communication is influenced by shared language, the right timing and, for example, opportunities given for communication (Fakhr-Movahedi et al. 2011). The current health care, where care encounters are short, and which have adopted a production-line approach to it, can affect to communication towards patients and alienate them if the staff does not identify the opportunities for communication and compassion (Crawford & Brown 2011, Crawford et al. 2013). The role of staff in relation to patients is to ensure that communication is appropriate to the patient’s understanding and values, and enables patients to empower themselves (Blegen & Severinsson 2011). Communication between staff and patients can be enhanced with practices such as bedside handovers, thereby including patients as partners and active participants in communication (Maxson et al. 2012). Encouraging two-way communication between the staff and patients has been also noted in patient safety initiatives (e.g. National Patient Safety Agency 2004). Communication is essential for patient safety, but it has been noted that effective communication is often assumed, and training and evaluation in this area have been lacking (World Alliance for Patient Safety 2008). Psychiatric care has also been seen to have a rhetoric of good communication and needs to develop processes which enable effective communication (Simpson 2007). Dysfunctional communication cultures can compromise patient safety (Nathanson et al. 2011, Garon 2012). When communication improves, staff are also more aware of patient safety problems (Auerbach et al. 2012). Through learning new communication protocols, more attention is paid to skills related to communication (Fernandez et al. 2010).
Aim The aim of this study is to describe communication elements in inpatient psychiatric care that support patient safety from the nursing staff’s point of view. 299
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Methods The data for this study were gathered in semi-structured interviews in September and October 2011. Interviewees were selected from two psychiatric hospitals in Finland, which provide specialized psychiatric care for adult patients with any psychiatric diagnosis. In Finland, municipalities have the responsibility to organize the mental health services. They include outpatient, inpatient and rehabilitative services. One weekday was selected randomly, and nurses working the morning shift that day were asked to participate. A total of 34 nurses (27% of the total nursing staff) were contacted by e-mail and asked whether they would be willing to take part in the study. Out of the 34 nurses who were contacted, 26 agreed to take part in the study and those 26 were interviewed. Their ages ranged from 23 to 60; their mean age was 39. They had 1–30 years’ work experience, with a mean work experience of 11 years. Ten of the nurses were men and 16 women. At an earlier stage of the study, we performed a literature review on the concept of ‘patient safety’, and this guided our formulation of the questions. The literature review identified organizational culture as a basis for patient safety: within this culture, the roles of the organization’s management, staff and patients are formed in interaction with each other (Kanerva et al. 2013). In the interviews, the nurses were asked to describe patient safety in general, and how they see management’s role, the staff’s role and the patient’s role in patient safety in inpatient psychiatric care. The previously done literature review was not discussed with the interviewed nurses. In this paper, the focus is on the communication elements interviewees described as part of patient safety. Data gathered through semi-structured interviews provided the opportunity to compare the information provided by the participants, but also allowed the interviewer to vary the wording of the questions or their order in the interviews. The material thus gathered was systematic and comprehensive, but the interviews could be quite informal (Eriksson & Kovalainen 2008). The interviews were digitally tape recorded and lasted approximately 51 min each. The interviews were transcribed verbatim and the data analysed inductively from the perspective of communication. The process included coding, creating categories and abstraction (Elo & Kyngäs 2007). The written material was read through, and a word or sentence was chosen as a unit of analysis. Coding was done by underlining the expressions corresponding to the research theme. At the categorizing stage, similarities and differences were sought, and data were categorized according to the similarities in groups. Expressions with the same meaning 300
formed categories that were named using contentcharacteristic words.
Ethics Ethical approval for the study was obtained from the Central Finland Health Care District Ethical Committee. The interviewees were informed about the research and its purpose in the contact e-mail and again before starting the interview, and that their participation was voluntary and they had the right to withdraw at any time. Interviewees were able to ask more about the research before signing an informed consent form. With informed consent, interviewees can decide whether or not to participate (Eriksson & Kovalainen 2008). To protect the privacy of the interviewees, no identifiable information is presented here.
Results The literature review highlighted fluent information transfer inside the ward and between wards as part of the communication dimension of patient safety. In the interviews, the nurses discussed these aspects in more detail. The issues the nurses described formed a main category of communication that supports patient safety in psychiatric inpatient care, and it comprises three subcategories: fluent information transfer, open communication culture and being active in communication (Fig. 1). Fluent information
Fluent information transfer - Documentation of essential information for care planning - Reading and implementation of essential care documentation - Active nurse-to-nurse transfer of information about patients - Active information transfer between multidisciplinary staff - Active transfer of information about changes in ward practices - Active information transfer between wards
Open communication culture
Communication that supports patient safety in psychiatric inpatient care
- Openness of communication - Opportunities for open debriefing discussions - All staff members feeling that they are heard
Being active in communication
Figure 1 Communication that supports patient safety in psychiatric inpatient care.
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Communication supporting patient safety
transfer comprises the implementation elements of communication; open communication culture consists of communication culture issues; and being active in communication is part of a personal working style.
Fluent information transfer Fluent information transfer is made up of six subcategories: documentation of essential information for care planning, reading and implementation of essential care documentation, active nurse-to-nurse transfer of information about the patients, active information transfer between professional groups, active transfer of information about the changes in ward practices and active information transfer between wards. The nurses described it as important for the patient safety that the essential care planning information is documented appropriately. They said that the up-to-date documentation makes care planning easier and safer. Confusion and inaccurate documentation can lead to problems such as incorrect medicine dosages and thus cause harm to the patient. Documentation can sometimes be quite vague: you can do a lot of interpretation, even when it is clear in principle, but mistakes can be made if the instructions look a bit funny. (Nurse 10)
The nurses also said that the reading and implementation of essential care documentation was important, but they saw that the documentation was not always read or used appropriately in care planning, and one of the reasons for this could be their hectic work schedule. The nurses also saw that sometimes information was not used appropriately and guided care planning in the wrong direction. Sometimes it feels like parts of good documentation disappear somewhere along the way. Someone was responsible for documenting the information and considered the situation, but certain things might have gone unnoticed. (Nurse 5)
Active nurse-to-nurse transfer of information about patients was described as another important issue in communication. Reporting was seen as a way to ensure this, together with an active discussion of observations about the patients and the activities performed with them. In some wards, information transfer between nurses had been improved by simplifying it so that the information would be communicated as straightforwardly and clearly as possible. During the reports you can see a kind of continuity that then brings safety to the patients, that all issues are taken care of and information about what has happened © 2015 John Wiley & Sons Ltd
is transferred, and that’s the way, I think, patient safety is best handled. (Nurse 1)
Furthermore, the nurses said that active information transfer between multidisciplinary staff was important. When information was not communicated, the nurses felt that this made it more difficult to implement the care plan and keep the patient informed. The nurses were afraid that they might pass on inaccurate information, and they felt it was also problematic to discuss adverse events when not all the multidisciplinary staff were present, as this meant that issues could not be discussed thoroughly. I don’t know about other professional groups, but sometimes it feels as if the communication is quite nursingcentred. (Nurse 13)
In the nurses’ experience, the active transfer of information about changes in ward practices was also vital so that everyone working in the ward could follow them. There had been situations when some of the staff did not know about such changes or, when changes were made frequently, did not know what the current practice was. These situations had led to confusion and sometimes caused needless frustration for patients. It is a big problem that you might not get information until after it has been in effect for a week. – And when the changes happen often, we often laugh about what the rules are for today. Think about it, about how it sounds to a patient when you say something as if it were a fact and then hear that it has been changed. (Nurse 24)
In addition, the nurses considered active information transfer between wards to be important, so that the care facility the patient was being transferred to would receive the latest information on the patient’s situation. The nurses saw that the distance between the wards had a negative effect on the transfer of information. Also because of shift work, the nurse accompanying patient did not always have all the essential information. Often, time was seen to be a threat, as the accompanying nurse did not have time to stay and share relevant information. Some of the wards had developed structured ways of handling these situations to ensure that the information was transferred along with the patient. Situations where there is a distance, and if there is a nurse accompanying the patient, there are these situations where one can imagine us getting enough information. The ideal would be to sit around the same table. (Nurse 19)
Open communication culture Culture of open communication was described as important for patient safety and formed three subcategories: openness of communication, the opportunity to have open 301
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debriefing discussions and the entire staff felt they were heard. Openness of communication was described as important by the nurses: everything connected with patient care and ward practices should be discussed openly and immediately. Nurses described a culture of blame could threaten patient safety and make open discussion challenging. With adequate openness, we are honest and brave actors. This is the challenge, I think. As there is still this mentality that it’s necessary to find out who made the mistake: that sucks. (Nurse 25)
The opportunity to have open debriefing discussions was something the nurses felt was important so they could openly discuss their experiences, as well as possible causes of harm. Some of the wards had had weekly debriefing sessions, and at some this was the practice only when the situation was more serious (patient seclusion, restraint or resuscitation). The nurses felt that debriefing sessions were important and hold them in a more informal way among their other work duties. These discussions usually took place only among nurses: the rest of the multidisciplinary staff were rarely present. We used to have this kind of venting hour every week led by a psychologist, and then the people who were at work took part, and you could talk about the past week and what it had been like. If there had been some difficult situations, violence especially, then they were discussed there. (Nurse 4)
The nurses described it as important that all staff members felt that they were heard. They saw it as necessary for good care that all staff are equal and everyone’s opinion was heard on patient care and other ward issues. Nurses felt not being heard could cause them frustration and could lead to situations in which staff did not talk to each other: this could have a negative effect on patient care. It frustrates you to see that most of the team shares a view of what good care is like but then we can’t reach a consensus and feel that our own message is not heard. It leads to situations where we just don’t talk anymore. Disregard it time after time, and it becomes an issue that can affect patient care as well. (Nurse 20)
Being active in communication The interviewed nurses also saw being active in communication as important. They felt that nurses should be active and motivated in getting the essential patient care information and not expect all to simply be given to them. According to the nurses, sometimes some information can be left unsaid, and in these situations their own activity to search for the missing information is important. Also in patient 302
transfer situations, nurses saw it is essential that they are active in communication and when needed that they should take the initiative to get the needed information. In patient transfer situations, nurses for example saw that they should be active contacting the ward the patient was transferring from if they needed some information for the arrangements of the transfer prior to the actual event. They also noted that it was important for nurses to have the courage to contact different professionals to ensure they had all the information they needed. This they described as important way to act, which should be emphasized so everyone would be powered to act this way. The interviewed nurses had the experience that when the communication culture of the ward emphasizes taking the initiative in communicating, it enhances patient safety. It could be that some issue is not mentioned, but a person should not have the attitude that I won’t find out myself; you have to tell me. It is more flexible: you find it out for yourself if everything isn’t said out loud. (Nurse 26)
Discussion Communication is one of the core functions and competencies of psychiatric care globally and is important for patient safety. Many errors in health care are connected with poor communication (Fallowfield 2010), and it has been noted that psychiatric care needs to develop effective communication processes (Simpson 2007). However, there is still little knowledge from the nursing staff’s point of view in inpatient psychiatric care or about which are the main issues affecting communication in these settings and if those are different to other nursing settings. This study aimed to provide more knowledge of the communication elements in psychiatric inpatient care that support patient safety from the viewpoint of the nursing staff. Similar elements have been noted in other nursing settings (e.g. Gilje et al. 2007, Tran & Johnson 2010, Bump et al. 2011). Firstly, in this study, fluent information transfer was an issue frequently mentioned by the nurses. Nurses highlighted several elements connected to it, mainly practical issues such as the importance of accurate documentation, and its use, which enables nurses to provide safe care, as planned, without delays. However, it was noted that documentation had flaws, such as missing information, which have also been noted in previous studies (Tran & Johnson 2010, Bump et al. 2011, Beaumont & Russell 2012). Nurses seemed to accept these flaws. There was a similar situation with information transfer between multidisciplinary staff and problems with it. Different professions may view communication differently (Nathanson et al. 2011, © 2015 John Wiley & Sons Ltd
Communication supporting patient safety
White 2012), which was an issue nurses accepted. Fluent information transfer was mainly described from one ward’s perspective and not as an organizational issue. Handover situations, noted as important in previous studies (Tran & Johnson 2010, Nagpal et al. 2012), were mentioned, but not as much as the communication that happens inside one’s own ward. Secondly, nurses saw an open communication culture as important for patient safety. It was seen as important that patient care, or any work-related issue, could be discussed freely, and that everyone, regardless of their profession, would be heard equally. Nurses saw open communication as their strong area and described the communication cultures in their wards as mainly open. In a couple of cases, nurses described there being an atmosphere of fear in their ward, which prevented open discussion. It has been noted previously that a dysfunctional communication culture can compromise patient safety (Nathanson et al. 2011, Garon 2012). When asked to describe open communication, however, nurses related how the discussions they have mainly take place within their own profession. Simpson (2007) has previously noted that good communication can be rhetorical, which might be the case here, as nurses generally described communication issues in a nursingcentred way. Some also recognized this as one of the problems in communication. Nurses saw that it is hard to create a shared understanding of situations when there are barriers between the professions, caused either by the customs of the ward or by individuals. While one of the core competencies in psychiatric care is seen to be communication, it is worth noting that the nurses pointed out that it did not work flawlessly. Current professional education might not provide opportunities to learn multidisciplinary communication. The third issue the nurses raised was their own role in communication. Only a few of the nurses brought this up, but they discussed it at length and on several occasions, describing how responsible and motivated staff are active in finding the information they need to provide safe care and not let barriers such as haste prevent this. Nurses emphasized how they can individually work towards effective communication, even if there are problems with it in the ward. Work culture that stresses individual initiative in communication was seen to make one’s own role easier, but in the end nurses saw that one’s own choice is a key issue. Nurses thought that they do not need to settle for the information they are provided by the staff members, but can also actively search for more in order to provide quality care for the patients. The issues nurses raised formed three main elements, which are important for communication separately, but should also be noted as a whole. Fluent information trans© 2015 John Wiley & Sons Ltd
fer, for example, is also affected by the communication activity of the staff and the communication culture of the ward. Communication was, however, an issue that was not actively discussed in the wards. Nurses reported many similar problems in communication, but only a few said that they had taken action. They had created checklists for handover situations, which have previously been noted to improve handover communication (Street et al. 2011). None said that the daily work routine had been developed systematically, so there would be the possibility of, for example, documenting appropriately and discussing in multidisciplinary teams, or enhancing the communication flow between different wards. Communication barriers may be an issue that the nurses are used to and seen more as a normal part of the work. A busy time on the ward, for example, was seen as an acceptable excuse not to communicate effectively, and it had not been considered whether work processes could be developed so that haste would decrease, allowing better communication.
Limitations A limitation of the study is that our findings are based on two hospitals within the same health care district in one country. It is possible that the descriptions provided by the nurses were of working in the way that is expected of them. However, similar findings have been made in previous literature in other nursing fields. Psychiatric care has similar elements globally, and results can be relevant for other countries also. Because the interviewer had previously worked in the field of psychiatric inpatient care, it could be that the nurses interviewed left some things unsaid because they expected the interviewer to know about them already. To avoid this, the interviewees were asked to elaborate on their answers if they seemed to indicate that the interviewer knew what they were talking about.
Conclusions The conclusions can be made from four perspectives. At an individual, level it is important to recognize, and have a positive attitude towards, the central role of communication in patient safety. At unit level, it is important to aim multidisciplinary development of communication and patient safety towards a shared understanding, with the use of multidisciplinary staff training. Leadership plays an important role in making this possible, and creating an atmosphere where communication and patient safety are seen as important. At the organizational level, processes concerning communication, for example, written documentation, reporting and handover, should be developed across unit boundaries. In the process organizations, 303
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policies and patient safety research, the aim should be wider than medical care and avoiding errors. The communication aspect should also be noted and developed in these globally.
where the boundaries of different specialities are not explicit, the need for development of evidence-based communication between disciplines and units increseas in the future. At the strategic level, in addition to health care
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Communication elements supporting patient safety in psychiatric inpatient care A . K A N E R VA 1 R N M H S P h D - c a n d i d a t e , T. K I V I N E N 2 J . L A M M I N TA K A N E N 3 Ph D
Ph D
&
1
Clinical Nursing Specialist, 2Head of Research and Development on Nursing, Central Finland Health Care District, Jyväskylä, and 3Professor, Department of Health and Social Management, University of Eastern Finland, Kuopio, Finland
Keywords: communication,
Accessible summary
interpersonal skills, qualitative methodology, quality of care
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Correspondence: A. Kanerva Central Finland Health Care District Keskussairaalantie 19 40620 Jyväskylä Finland E-mail: [email protected]
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Accepted for publication: 9 October 2014 doi: 10.1111/jpm.12187
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Communication is important for safe and quality health care. The study provides needed insight on the communication elements that support patient safety from the psychiatric care view. Fluent information transfer between the health care professionals and care units is important for care planning and maintaining practices. Information should be documented and implemented accordingly. Communication should happen in an open communication culture that enables discussion, the opportunity to have debriefing discussions and the entire staff can feel they are heard. For effective communication, it is also important that staff are active themselves in information collecting about the essential information needed in patient care. In mental health nursing, it is important to pay attention to all elements of communication and to develop processes concerning communication in multidisciplinary teams and across unit boundaries.
Abstract The study aims to describe which communication elements support patient safety in psychiatric inpatient care from the viewpoint of the nursing staff. Communication is an essential part of care and one of the core competencies of the psychiatric care. It enables safe and quality patient care. Errors in health care are often connected with poor communication. The study brings needed insight from the psychiatric care view to the topic. The data were gathered from semi-structured interviews in which 26 nurses were asked to describe the elements that constitute patient safety in psychiatric inpatient care. The data were analysed inductively from the viewpoint of communication. The descriptions connected with communication formed a main category of communication elements that support patient safety; this main category was made up of three subcategories: fluent information transfer, open communication culture and being active in information collecting. Fluent information transfer consists of the practical implementation of communication; open communication culture is connected with the cultural issues of communication; and being active in information collecting is related to a nurse’s personal working style, which affects communication. It is important to pay attention to all the three areas and use this knowledge in developing patient safety practices and strategies where communication aspect and culture are noted and developed. In mental health nursing, it is important to develop processes concerning communication in multidisciplinary teams and across unit boundaries.
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Communication supporting patient safety
Introduction Patient safety has been emphasized in national and international health policies over the last decade (World Health Organization 2004, 2010, Legido-Quigley et al. 2008, Ministry of Social Affairs and Health 2009). Strategies for enhancing patient safety have been formulated and implemented in order to provide good quality care, and the body of research has increased substantially in recent years. However, in the field of psychiatric nursing care, patient safety is a less studied topic (Kanerva et al. 2013). Most studies are done in general hospital settings, in different fields of somatic care, where different topics connected to communication are introduced. Studies from psychiatric nursing care are needed to see if there are specific communication issues to be noted in this field. In providing safe care staff professional competencies need to be constantly developed (Gilje et al. 2007, Priest et al. 2008, Blegen & Severinsson 2011, Cleary et al. 2011, Wauben et al. 2011, White 2012). For patient safety, an important competency is communication (Calleja et al. 2010, Fallowfield 2010, Fernandez et al. 2010). It is also one of the core competencies in psychiatric care and plays an important role in structuring care and in establishing therapeutic relationships (Gilje et al. 2007, Timmons 2010). Communication is the transfer of information and forming a shared understanding between people (Gillespie et al. 2010). It is practised on several levels (Curtis et al. 2011) and should be clear and collaborative (McCaffrey et al. 2011). As multidisciplinary staff may view communication issues differently (Nathanson et al. 2011, White 2012), regular collaboration is needed to ensure effective communication (Simpson 2007). This can be enhanced, for example, through such practices as multidisciplinary discussion forums, which offer a safe forum for the multidisciplinary staff to share their views (Lown & Manning 2010). Open dialogue, verbal and written, is important (Gilje et al. 2007), but there is research showing that the time staff spend in open verbal dialogue has decreased and that more time is spent on patient records (Westbrook et al. 2011). Errors in patient records have also been noted: incomplete charts, documentation omitted, unsigned forms, incomplete checklists and missing patient contact details (Tran & Johnson 2010). Clear guidance for anticipated patient events may also be missing, and records are not always updated at handover (Bump et al. 2011). Communication at clinical handover is important for safe care, but it does not always happen adequately (Tran & Johnson 2010): it may be incomplete or fragmented, or there may be information overload. Opinions may be sought, but are not always followed up on (Nagpal et al. 2012). Barriers to effective communication at handover © 2015 John Wiley & Sons Ltd
include an inability to access accurate information, interruptions and idle chatting during handover. It can be improved by standard communication protocols (Street et al. 2011). In addition to breakdowns in multidisciplinary communication, there are also breakdowns in nurse-to-nurse communication (Tran & Johnson 2010): not recording observations, not passing on previous observations, not providing clinical history and not communicating concerns effectively (Beaumont & Russell 2012). As nurses are often the first to notice changes in patient status, they need to have a strong focus on communication and continuing the flow of information (Deacon & Fairhurst 2008, Chang et al. 2011). Staff–patient communication is influenced by shared language, the right timing and, for example, opportunities given for communication (Fakhr-Movahedi et al. 2011). The current health care, where care encounters are short, and which have adopted a production-line approach to it, can affect to communication towards patients and alienate them if the staff does not identify the opportunities for communication and compassion (Crawford & Brown 2011, Crawford et al. 2013). The role of staff in relation to patients is to ensure that communication is appropriate to the patient’s understanding and values, and enables patients to empower themselves (Blegen & Severinsson 2011). Communication between staff and patients can be enhanced with practices such as bedside handovers, thereby including patients as partners and active participants in communication (Maxson et al. 2012). Encouraging two-way communication between the staff and patients has been also noted in patient safety initiatives (e.g. National Patient Safety Agency 2004). Communication is essential for patient safety, but it has been noted that effective communication is often assumed, and training and evaluation in this area have been lacking (World Alliance for Patient Safety 2008). Psychiatric care has also been seen to have a rhetoric of good communication and needs to develop processes which enable effective communication (Simpson 2007). Dysfunctional communication cultures can compromise patient safety (Nathanson et al. 2011, Garon 2012). When communication improves, staff are also more aware of patient safety problems (Auerbach et al. 2012). Through learning new communication protocols, more attention is paid to skills related to communication (Fernandez et al. 2010).
Aim The aim of this study is to describe communication elements in inpatient psychiatric care that support patient safety from the nursing staff’s point of view. 299
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Methods The data for this study were gathered in semi-structured interviews in September and October 2011. Interviewees were selected from two psychiatric hospitals in Finland, which provide specialized psychiatric care for adult patients with any psychiatric diagnosis. In Finland, municipalities have the responsibility to organize the mental health services. They include outpatient, inpatient and rehabilitative services. One weekday was selected randomly, and nurses working the morning shift that day were asked to participate. A total of 34 nurses (27% of the total nursing staff) were contacted by e-mail and asked whether they would be willing to take part in the study. Out of the 34 nurses who were contacted, 26 agreed to take part in the study and those 26 were interviewed. Their ages ranged from 23 to 60; their mean age was 39. They had 1–30 years’ work experience, with a mean work experience of 11 years. Ten of the nurses were men and 16 women. At an earlier stage of the study, we performed a literature review on the concept of ‘patient safety’, and this guided our formulation of the questions. The literature review identified organizational culture as a basis for patient safety: within this culture, the roles of the organization’s management, staff and patients are formed in interaction with each other (Kanerva et al. 2013). In the interviews, the nurses were asked to describe patient safety in general, and how they see management’s role, the staff’s role and the patient’s role in patient safety in inpatient psychiatric care. The previously done literature review was not discussed with the interviewed nurses. In this paper, the focus is on the communication elements interviewees described as part of patient safety. Data gathered through semi-structured interviews provided the opportunity to compare the information provided by the participants, but also allowed the interviewer to vary the wording of the questions or their order in the interviews. The material thus gathered was systematic and comprehensive, but the interviews could be quite informal (Eriksson & Kovalainen 2008). The interviews were digitally tape recorded and lasted approximately 51 min each. The interviews were transcribed verbatim and the data analysed inductively from the perspective of communication. The process included coding, creating categories and abstraction (Elo & Kyngäs 2007). The written material was read through, and a word or sentence was chosen as a unit of analysis. Coding was done by underlining the expressions corresponding to the research theme. At the categorizing stage, similarities and differences were sought, and data were categorized according to the similarities in groups. Expressions with the same meaning 300
formed categories that were named using contentcharacteristic words.
Ethics Ethical approval for the study was obtained from the Central Finland Health Care District Ethical Committee. The interviewees were informed about the research and its purpose in the contact e-mail and again before starting the interview, and that their participation was voluntary and they had the right to withdraw at any time. Interviewees were able to ask more about the research before signing an informed consent form. With informed consent, interviewees can decide whether or not to participate (Eriksson & Kovalainen 2008). To protect the privacy of the interviewees, no identifiable information is presented here.
Results The literature review highlighted fluent information transfer inside the ward and between wards as part of the communication dimension of patient safety. In the interviews, the nurses discussed these aspects in more detail. The issues the nurses described formed a main category of communication that supports patient safety in psychiatric inpatient care, and it comprises three subcategories: fluent information transfer, open communication culture and being active in communication (Fig. 1). Fluent information
Fluent information transfer - Documentation of essential information for care planning - Reading and implementation of essential care documentation - Active nurse-to-nurse transfer of information about patients - Active information transfer between multidisciplinary staff - Active transfer of information about changes in ward practices - Active information transfer between wards
Open communication culture
Communication that supports patient safety in psychiatric inpatient care
- Openness of communication - Opportunities for open debriefing discussions - All staff members feeling that they are heard
Being active in communication
Figure 1 Communication that supports patient safety in psychiatric inpatient care.
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Communication supporting patient safety
transfer comprises the implementation elements of communication; open communication culture consists of communication culture issues; and being active in communication is part of a personal working style.
Fluent information transfer Fluent information transfer is made up of six subcategories: documentation of essential information for care planning, reading and implementation of essential care documentation, active nurse-to-nurse transfer of information about the patients, active information transfer between professional groups, active transfer of information about the changes in ward practices and active information transfer between wards. The nurses described it as important for the patient safety that the essential care planning information is documented appropriately. They said that the up-to-date documentation makes care planning easier and safer. Confusion and inaccurate documentation can lead to problems such as incorrect medicine dosages and thus cause harm to the patient. Documentation can sometimes be quite vague: you can do a lot of interpretation, even when it is clear in principle, but mistakes can be made if the instructions look a bit funny. (Nurse 10)
The nurses also said that the reading and implementation of essential care documentation was important, but they saw that the documentation was not always read or used appropriately in care planning, and one of the reasons for this could be their hectic work schedule. The nurses also saw that sometimes information was not used appropriately and guided care planning in the wrong direction. Sometimes it feels like parts of good documentation disappear somewhere along the way. Someone was responsible for documenting the information and considered the situation, but certain things might have gone unnoticed. (Nurse 5)
Active nurse-to-nurse transfer of information about patients was described as another important issue in communication. Reporting was seen as a way to ensure this, together with an active discussion of observations about the patients and the activities performed with them. In some wards, information transfer between nurses had been improved by simplifying it so that the information would be communicated as straightforwardly and clearly as possible. During the reports you can see a kind of continuity that then brings safety to the patients, that all issues are taken care of and information about what has happened © 2015 John Wiley & Sons Ltd
is transferred, and that’s the way, I think, patient safety is best handled. (Nurse 1)
Furthermore, the nurses said that active information transfer between multidisciplinary staff was important. When information was not communicated, the nurses felt that this made it more difficult to implement the care plan and keep the patient informed. The nurses were afraid that they might pass on inaccurate information, and they felt it was also problematic to discuss adverse events when not all the multidisciplinary staff were present, as this meant that issues could not be discussed thoroughly. I don’t know about other professional groups, but sometimes it feels as if the communication is quite nursingcentred. (Nurse 13)
In the nurses’ experience, the active transfer of information about changes in ward practices was also vital so that everyone working in the ward could follow them. There had been situations when some of the staff did not know about such changes or, when changes were made frequently, did not know what the current practice was. These situations had led to confusion and sometimes caused needless frustration for patients. It is a big problem that you might not get information until after it has been in effect for a week. – And when the changes happen often, we often laugh about what the rules are for today. Think about it, about how it sounds to a patient when you say something as if it were a fact and then hear that it has been changed. (Nurse 24)
In addition, the nurses considered active information transfer between wards to be important, so that the care facility the patient was being transferred to would receive the latest information on the patient’s situation. The nurses saw that the distance between the wards had a negative effect on the transfer of information. Also because of shift work, the nurse accompanying patient did not always have all the essential information. Often, time was seen to be a threat, as the accompanying nurse did not have time to stay and share relevant information. Some of the wards had developed structured ways of handling these situations to ensure that the information was transferred along with the patient. Situations where there is a distance, and if there is a nurse accompanying the patient, there are these situations where one can imagine us getting enough information. The ideal would be to sit around the same table. (Nurse 19)
Open communication culture Culture of open communication was described as important for patient safety and formed three subcategories: openness of communication, the opportunity to have open 301
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debriefing discussions and the entire staff felt they were heard. Openness of communication was described as important by the nurses: everything connected with patient care and ward practices should be discussed openly and immediately. Nurses described a culture of blame could threaten patient safety and make open discussion challenging. With adequate openness, we are honest and brave actors. This is the challenge, I think. As there is still this mentality that it’s necessary to find out who made the mistake: that sucks. (Nurse 25)
The opportunity to have open debriefing discussions was something the nurses felt was important so they could openly discuss their experiences, as well as possible causes of harm. Some of the wards had had weekly debriefing sessions, and at some this was the practice only when the situation was more serious (patient seclusion, restraint or resuscitation). The nurses felt that debriefing sessions were important and hold them in a more informal way among their other work duties. These discussions usually took place only among nurses: the rest of the multidisciplinary staff were rarely present. We used to have this kind of venting hour every week led by a psychologist, and then the people who were at work took part, and you could talk about the past week and what it had been like. If there had been some difficult situations, violence especially, then they were discussed there. (Nurse 4)
The nurses described it as important that all staff members felt that they were heard. They saw it as necessary for good care that all staff are equal and everyone’s opinion was heard on patient care and other ward issues. Nurses felt not being heard could cause them frustration and could lead to situations in which staff did not talk to each other: this could have a negative effect on patient care. It frustrates you to see that most of the team shares a view of what good care is like but then we can’t reach a consensus and feel that our own message is not heard. It leads to situations where we just don’t talk anymore. Disregard it time after time, and it becomes an issue that can affect patient care as well. (Nurse 20)
Being active in communication The interviewed nurses also saw being active in communication as important. They felt that nurses should be active and motivated in getting the essential patient care information and not expect all to simply be given to them. According to the nurses, sometimes some information can be left unsaid, and in these situations their own activity to search for the missing information is important. Also in patient 302
transfer situations, nurses saw it is essential that they are active in communication and when needed that they should take the initiative to get the needed information. In patient transfer situations, nurses for example saw that they should be active contacting the ward the patient was transferring from if they needed some information for the arrangements of the transfer prior to the actual event. They also noted that it was important for nurses to have the courage to contact different professionals to ensure they had all the information they needed. This they described as important way to act, which should be emphasized so everyone would be powered to act this way. The interviewed nurses had the experience that when the communication culture of the ward emphasizes taking the initiative in communicating, it enhances patient safety. It could be that some issue is not mentioned, but a person should not have the attitude that I won’t find out myself; you have to tell me. It is more flexible: you find it out for yourself if everything isn’t said out loud. (Nurse 26)
Discussion Communication is one of the core functions and competencies of psychiatric care globally and is important for patient safety. Many errors in health care are connected with poor communication (Fallowfield 2010), and it has been noted that psychiatric care needs to develop effective communication processes (Simpson 2007). However, there is still little knowledge from the nursing staff’s point of view in inpatient psychiatric care or about which are the main issues affecting communication in these settings and if those are different to other nursing settings. This study aimed to provide more knowledge of the communication elements in psychiatric inpatient care that support patient safety from the viewpoint of the nursing staff. Similar elements have been noted in other nursing settings (e.g. Gilje et al. 2007, Tran & Johnson 2010, Bump et al. 2011). Firstly, in this study, fluent information transfer was an issue frequently mentioned by the nurses. Nurses highlighted several elements connected to it, mainly practical issues such as the importance of accurate documentation, and its use, which enables nurses to provide safe care, as planned, without delays. However, it was noted that documentation had flaws, such as missing information, which have also been noted in previous studies (Tran & Johnson 2010, Bump et al. 2011, Beaumont & Russell 2012). Nurses seemed to accept these flaws. There was a similar situation with information transfer between multidisciplinary staff and problems with it. Different professions may view communication differently (Nathanson et al. 2011, © 2015 John Wiley & Sons Ltd
Communication supporting patient safety
White 2012), which was an issue nurses accepted. Fluent information transfer was mainly described from one ward’s perspective and not as an organizational issue. Handover situations, noted as important in previous studies (Tran & Johnson 2010, Nagpal et al. 2012), were mentioned, but not as much as the communication that happens inside one’s own ward. Secondly, nurses saw an open communication culture as important for patient safety. It was seen as important that patient care, or any work-related issue, could be discussed freely, and that everyone, regardless of their profession, would be heard equally. Nurses saw open communication as their strong area and described the communication cultures in their wards as mainly open. In a couple of cases, nurses described there being an atmosphere of fear in their ward, which prevented open discussion. It has been noted previously that a dysfunctional communication culture can compromise patient safety (Nathanson et al. 2011, Garon 2012). When asked to describe open communication, however, nurses related how the discussions they have mainly take place within their own profession. Simpson (2007) has previously noted that good communication can be rhetorical, which might be the case here, as nurses generally described communication issues in a nursingcentred way. Some also recognized this as one of the problems in communication. Nurses saw that it is hard to create a shared understanding of situations when there are barriers between the professions, caused either by the customs of the ward or by individuals. While one of the core competencies in psychiatric care is seen to be communication, it is worth noting that the nurses pointed out that it did not work flawlessly. Current professional education might not provide opportunities to learn multidisciplinary communication. The third issue the nurses raised was their own role in communication. Only a few of the nurses brought this up, but they discussed it at length and on several occasions, describing how responsible and motivated staff are active in finding the information they need to provide safe care and not let barriers such as haste prevent this. Nurses emphasized how they can individually work towards effective communication, even if there are problems with it in the ward. Work culture that stresses individual initiative in communication was seen to make one’s own role easier, but in the end nurses saw that one’s own choice is a key issue. Nurses thought that they do not need to settle for the information they are provided by the staff members, but can also actively search for more in order to provide quality care for the patients. The issues nurses raised formed three main elements, which are important for communication separately, but should also be noted as a whole. Fluent information trans© 2015 John Wiley & Sons Ltd
fer, for example, is also affected by the communication activity of the staff and the communication culture of the ward. Communication was, however, an issue that was not actively discussed in the wards. Nurses reported many similar problems in communication, but only a few said that they had taken action. They had created checklists for handover situations, which have previously been noted to improve handover communication (Street et al. 2011). None said that the daily work routine had been developed systematically, so there would be the possibility of, for example, documenting appropriately and discussing in multidisciplinary teams, or enhancing the communication flow between different wards. Communication barriers may be an issue that the nurses are used to and seen more as a normal part of the work. A busy time on the ward, for example, was seen as an acceptable excuse not to communicate effectively, and it had not been considered whether work processes could be developed so that haste would decrease, allowing better communication.
Limitations A limitation of the study is that our findings are based on two hospitals within the same health care district in one country. It is possible that the descriptions provided by the nurses were of working in the way that is expected of them. However, similar findings have been made in previous literature in other nursing fields. Psychiatric care has similar elements globally, and results can be relevant for other countries also. Because the interviewer had previously worked in the field of psychiatric inpatient care, it could be that the nurses interviewed left some things unsaid because they expected the interviewer to know about them already. To avoid this, the interviewees were asked to elaborate on their answers if they seemed to indicate that the interviewer knew what they were talking about.
Conclusions The conclusions can be made from four perspectives. At an individual, level it is important to recognize, and have a positive attitude towards, the central role of communication in patient safety. At unit level, it is important to aim multidisciplinary development of communication and patient safety towards a shared understanding, with the use of multidisciplinary staff training. Leadership plays an important role in making this possible, and creating an atmosphere where communication and patient safety are seen as important. At the organizational level, processes concerning communication, for example, written documentation, reporting and handover, should be developed across unit boundaries. In the process organizations, 303
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policies and patient safety research, the aim should be wider than medical care and avoiding errors. The communication aspect should also be noted and developed in these globally.
where the boundaries of different specialities are not explicit, the need for development of evidence-based communication between disciplines and units increseas in the future. At the strategic level, in addition to health care
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