Nursing Issue: Volume 52(2), February 2022, p 56-59 Copyright: Copyright

Nursing Issue: Volume 52(2), February 2022, p 56-59 Copyright: Copyright (C) 2022 Wolters Kluwer Health, Inc. All rights reserved. Publication Type: [Department: INSPIRING CHANGE] DOI: 10.1097/01.NURSE.0000806180.71822.99 ISSN: 0360-4039 Accession: 00152193-202202000-00016 Hide Cover [Department: INSPIRING CHANGE]« Previous Article Table of Contents Next Article » Improving perceptions of communication, collaboration, and teamwork using structured nurse-surgeon bedside rounds Harris, Adrienne MSN, RN, ONC; Lane, Rosemary BSN, RN-BC; Higgins, Melinda PhD Author Information At Emory Johns Creek Hospital in Johns Creek, Ga., Adrienne Harris is the director of the surgical unit and Rosemary Lane is a unit charge nurse. Melinda Higgins is a biostatistician in the Office of Nursing Research at Emory University’s School of Nursing. The authors have disclosed no financial relationships related to this article. Despite ongoing efforts to reduce the number of adverse events in healthcare, sentinel events continue to occur. In 2020, an estimated 794 events were reported to the Joint Commission, 76 of which were related to treatment delays.1 Communication plays a contributory role in adverse safety events.2 Ineffective handoff communication between healthcare professionals can be harmful as information can be untimely, inaccurate, misinterpreted, and/or incomplete.3 In hospital settings including busy surgical units, the high frequency of handoffs coupled with potentially unstructured casual communication can confound the issue.3 Communication issues can also occur between healthcare professionals and patients.4 Electronic health records that are not updated, accurate, or readily accessible can also result in communication problems as nurse and healthcare provider (HCP) notes are not usually maintained in the same areas.5 Separating patient information can negatively impact communication since technology can distract from patient care.5 For example, if information is unavailable during patient rounding, HCPs may utilize alternative sources to gather information such as communicating with other members of the nursing team. At our mixed surgical unit, for example, HCPs would consult the nursing leadership or patients. These methods of communication circumvent an essential aspect of the interdisciplinary team: the clinical nurse. To address this communication gap, the adoption of interdisciplinary or interprofessional bedside rounds has been shown to improve communication in many medical units. This article discusses the impact of interdisciplinary bedside rounds in a mixed surgical unit, particularly on the communication, collaboration, and teamwork among nurses and surgeons. Back to Top Literature Review Interdisciplinary bedside rounds are reported to improve patient safety and quality of patient care.6 A review of the literature supports studies conducted in ICUs and medical units with a primary focus on medical management and hospital medicine. Using various methods and tools, prior studies have evaluated patient care outcomes and job satisfaction. Urisman and colleagues explored nurse and surgeon attitudes toward interprofessional collaboration with structured interdisciplinary rounds in an ICU.7 They evaluated the impact on quality outcomes, specifically concentrating on patient falls and self-extubation, and found a positive impact on collaboration based on reports from physicians and nurses.7 While this study suggested an improvement in quality outcomes, the results were not statistically significant.7 Henkin and colleagues implemented interprofessional bedside rounds with four general medicine services, residents, and nurses on an inpatient medical unit.8 They evaluated the effects on teamwork and the number of physician pages.8 Henkin and colleagues found an increase in perceptions of teamwork as measured using the Safety Attitudes Questionnaire among nurses and residents.8 While volume outcomes were measured and showed an overall reduction post-round implementation, the results were not statistically significant.8 Next, Pritts and Hiller studied the communication and collaboration among nurses and hospital physicians utilizing the validated Collaborative Practice Scales, pre- and post-rounding implementation.9 In addition, nurse satisfaction was evaluated via the National Database of Nursing Quality Indicators. Patient satisfaction with teamwork was evaluated using the Press Ganey survey on the hospital unit.9 While Pritts and Hiller found no favorable impact on physician perception, the nurses responded with a higher perception of collaboration postimplementation and higher satisfaction scores.9 Higher Press Ganey results supported patients’ perceptions of teamwork among the staff during the implementation period.9 Ashcraft and colleagues identified gaps in interprofessional clinical rounds in their systematic review that focused on an integrated care delivery system with proven ways to strengthen interprofessional rounds.4 They identified three strategies of functioning interprofessional rounds and improved communication: (1) the use of daily worksheets or portable workstations with medical record access, (2) having a standardized rounding process, and (3) developing a participatory team.4 Back to Top Methods This descriptive, exploratory study evaluated the impact of nurse and surgeon bedside rounds on nurse, surgeon, and mid-level (PA or NP) perceptions of communication, collaboration, and teamwork utilizing a pre- and posttest controlled study design. Perceptions were assessed using a validated scale, the Nurse-Physician Collaboration Scale (NPCS). The scale is divided into three subscales-sharing of information, joint participation, and cooperation-directly comparable to the areas studied.10 The dependent variable for the study was bedside rounds via a structured process. The study was approved by the University Investigational Review Board, and participants were recruited from a 36-bed mixed unit that had patients with orthopedic, colorectal, bariatric, general-surgical, and spinal diagnoses. Bedside rounds were conducted throughout the day between 0600 and 2000 with the surgical team, and a nurse, and led by a nurse round’s leader. The surgical team was represented by either the surgeon, mid-level provider, or both. The nurse utilized a structured bedside rounding tool as a discussion guide to address necessary patient information. A Patient Assignment Sheet (PAS) containing information from the nurse, patient, and surgeon team was completed daily by the rounds leader to provide structure and preparedness. The PAS was used to directly observe and track the process. Back to Top Results Forty-one NPCS presurveys were collected, and 19 (46%) voluntarily completed the postsurvey. Participant ages ranged from 22 to 64, averaging 41 years old (SD 11.2). The majority were White (39.0%) or Asian (26.8%). Most were RNs (70.7%) with either an associate (17.1%) or baccalaureate (48.8%) degree with 12 years or fewer years of practice experience (58.6%). Most participants worked day shift (58.5%). The NPCS is a 5-point Likert scale. For each question, a rating from 1 to 5 was provided as follows: (1) Always, (2) Usually, (3) Sometimes, (4) Rarely, and (5) Never.10 Lower scores are better, indicating more collaboration, sharing, and joint participation. There are 27 questions divided into three subscales: 12 items for “joint participation in the cure/care decision-making process”; 9 items for the “sharing of patient information”; and 6 items for “cooperativeness.”10 Average scores were computed for each subscale. Overall, the average scores of all three subscales improved (decreased) from pre- to posttest indicating higher levels of joint participation (decreased from 2.47 [0.88] pre- to 1.96 [0.84] posttest, P = .053), sharing of patient information (decreased from 2.62 [0.89] pre- to 1.75 [0.56] posttest, P = .002) and cooperation (decreased from 2.81 [1.13] pre- to 2.21 [0.96] posttest, P = .110). The most substantial improvement was observed in the sharing of information, followed by joint participation and cooperation, respectively. Back to Top Analysis Data were summarized using descriptive statistics, including means and standard deviations for normally distributed variables, medians and IQR (interquartile range) for nonnormally distributed or skewed data, and frequencies and percents reported for categorical variables. Paired t-tests were performed to compare the pre-to-post test differences in the NPCS. Change scores were computed, and correlations were checked with demographics to see what, if any, characteristics predicted larger changes pre-to-post. The level of significance for all tests was set at alpha = 0.05. Since the data were collected anonymously, the pre- to posttest responses could not be linked. Therefore, cross-sectional data analysis was performed. Independent group tests were performed. Given the ordinal scales and small sample size, nonparametric Mann-Whitney tests were performed. IBM SPSS v.26 was used for all analyses. Some participants, both pre- and posttest, did not complete the survey. To adjust for a minor number of skipped items (less than 8% of the participants), within-person mean substitution was used on up to 17% (1 to 2 items) or fewer of the items within each subscale: 2 skipped items out of the 12 for the “joint” subscale, 1 out of the 9 items for the “sharing” subscale, and 1 out of the 6 items for the “cooperativeness” subscale. Back to Top Discussion This study explored the perceptions of communication, collaboration, and teamwork among nurses and the surgical team before and after the implementation of bedside rounds in a 36-bed mixed surgical unit. Rounding throughout the day with surgeons of various specialties posed a challenge to the nurse-surgeon bedside rounds process. Surgeon inpatient rounding patterns are typically based on their specific office hours, lunch breaks, and OR schedules, presenting barriers to intervention and unpredictable process variability. The most notable obstacles included multiple surgeons rounding at the same time and rounds conducted during nursing shift change. Having multiple surgeons doing rounds at the same time strained the rounds process as nurses at times were unavailable to make the rounds with all surgeons for patients assigned. To mitigate these process challenges, the rounds leader in this study focused efforts to the PAS and patients were coupled to nurses as much as possible. In addition, charge nurses and clinical nurses learned the surgical team rounding patterns, allowing for greater preparedness. Rounds that occurred between 0700 and 0730 created the greatest process barrier as it conflicted with the nurse bedside shift report schedule. Some surgeons and midlevel providers round multiple times throughout the day, increasing opportunities for intervention. Components of the structured bedside rounds intervention were selected to address concerns from surgeons regarding the lack of information available to formulate effective treatment plans and promote patient readiness for discharge. The nurses also expressed concern to the patient or surgeon regarding inadequate knowledge about care plans. Prior to the study, surgeons and nurses would often call the nurse leader as the primary intermediary for communication on patient care needs and the plan of care. While the study results showed an overall improvement in each area, the greatest impact was seen in information sharing. This finding aligns with the fundamental intent to bridge the communication gap between interdisciplinary teams. Before this study’s rounding implementation, the nurse and surgeon practices often resulted in mutual frustrations and poor satisfaction. The study results reveal favorable post-implementation feedback from the nurses and surgeons. The nurses reported having a greater sense of awareness with care plans as received directly from the surgeon or surgeon team. The subscale of joint participation showed an improvement from pre- to posttest, suggesting a favorable impact on the perceptions of collaboration. The results can be significant to patient care and safety as clinical nurses are an integral part of the healthcare team and effective decision-making. Nurses interact with interprofessional team members, patients, and families throughout the day to coordinate, deliver, and monitor care at the bedside. In contrast, physician partners have rounding time that may only equate to 30-45 minutes on any given day.11 At the bedside, communication and collaboration among the team are essential to ensure the delivery of streamlined, safe, and patient-centered care. Back to Top Limitations Though the study showed a positive impact on perceptions of communication, collaboration, and teamwork with the implementation of structured bedside rounds, notable limitations exist. A significant limitation of the study was the small sample size, which makes it challenging to generalize the study findings. Moreover, the number of participants who completed the posttest was less than half of the number who completed the pretest, (19 versus 41 participants, respectively). The loss in posttest responses can be due to a decline in postintervention participation from night-shift nurses; some night-shift nurses may have elected to not participate in the posttest as most observations occurred throughout the day after 0730. The pre- versus posttest sample size and the participant anonymity posed challenges in the comparative analysis. Back to Top Implications For Nursing Practice Interdisciplinary rounds are largely associated with medical units and ICUs. However, nurse and surgeon teams in mixed surgical units can benefit from these collaborative bedside rounds. The opportunities for enhanced communication and collaboration through direct information sharing may strengthen patient safety and improve patient outcomes in surgical units. While communication was the predominant force for change, further research is warranted to evaluate measurable patient outcomes such as timeliness of discharge, length of stay, readmission rates, adverse events, and patient satisfaction question: In-Text Quotation and Citation:

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