Data indicate that many healthcare-associated infections (HAIs) result from the use of medical devices, such as indwelling vascular and urinary catheters, accounting for about 25% of all HAIs. The effectiveness of interventions to reduce unnecessary catheter use often varies, depending on how well interventions are integrated into busy clinicians’ workflows and communication practices. For a study published in the American Journal of Critical Care, we and our colleagues sought to characterize communication-related barriers between physicians and nurses and to understand how these barriers could impact appropriate catheter use, removal, or both.
This analysis was part of a larger ongoing study designed to develop and test technology aiming to improve awareness of catheters and prompt communication between clinicians about those devices. We conducted interviews and focus groups with nurses, physicians, and advanced practice professionals to understand their perspectives on barriers to communication about appropriate device use. Our study was conducted on a single, 20-bed, progressive care unit of an academic medical center where both medical and surgical teams admit patients for care. We found three categories of barriers to communication, which were all contextual in nature: organizational, cognitive, and social complexity. Organizational complexity was reflected in workflow misalignment between clinicians, because multiple physician specialty teams from medicine and surgery admitted patients to this unit (as an “open” unit situation common to most hospital units nationwide), and thus were able to interact only irregularly and at unpredictable times with the unit-based nurses. The dependence on pager use contributed to cognitive complexity for both physicians and nurses. Nurses paged physicians for updates on the plan of care when they did not communicate during rounds. Physicians had to exert cognitive effort to determine whether to return a page and when, given multiple competing priorities, and nurses had to also exert cognitive effort to determine next steps when a physician did not respond to a page with expected timeliness. Social complexity was evident in the occasionally challenging interpersonal relationships that affected communication and inability of nurses to overcome hierarchical differences when they disagreed with physicians.
Our study highlights the contextual nature of communication and suggests that interventions to improve communication among clinicians may need to mitigate barriers that add to organizational, cognitive, and social complexity.