MUCH HAS BEEN MADE of the problems that patients have not only identifying hospitalists by name but reporting accurate information on individual doctors on patient satisfaction surveys. But how well do nurses know the physicians they work with, and what impact does knowing which physician to contact have on nursing satisfaction?
That’s a particularly thorny issue on hospitalist teaching services, where interns and residents rotate every month. Hospitalist Cheryl O’Malley, MD, the internal medicine residency program director at Banner Good Samaritan Medical Center in Phoenix, Ariz., and chief resident Margaret Paulson, DO, observed a phenomenon that Dr. O’Malley says was borne out in the scant evidence she found in a literature search on nurse-physician communication: A lot of the time that nurses spend “communicating” with physicians is really wasted time just figuring out who to call.
“A significant portion of the phone calls that nurses made were just to find out how to reach the right physician,” Dr. O’Malley says. “The time wasn’t spent on the task at hand, but finding the right answering service and pager number.”
To get the academic hospitalist team and nurses on the same page, Dr. O’Malley and a team of residents decided to make some additions to an information sheet that nurses already use for patients.
The paper sheets, which are kept in patient charts, include the names, pager numbers and after-hours contact information for members of the care team, including attendings, residents and interns. To help nurses identify individual doctors much more quickly, Dr. O’Malley’s team decided to add the photos of the interns and residents on that month’s care team, as well as their signatures.
(Because the attendings spend more time at one hospital and have more long-term relationships with nurses, the sheet does not include attendings’ photos. It does, however, include their name and signature.)
Last fall, when Dr. O’Malley surveyed nurses two months after they started using sheets with photos and signatures, she wasn’t surprised that most said they could much more quickly identify which doctor to contact with questions or concerns. She was surprised, however, to learn that adding photos and signatures significantly improved nurses’ perception of doctor appreciation and cooperation.
Matching a face to a name
Considering that she works in a 670-bed academic center with three other hospitalist groups, Dr. O’Malley says that it’s no wonder that nurses can’t keep residents’ names straight. There are nearly 100 medicine and med-peds residents, as well as preliminary residents who go back and forth between two hospitals.
Dr. O’Malley has long suspected that nurses would appreciate physician photos to help put a face to a name. That suspicion was confirmed when the hospitalists moved to reduce the confusion that patients were feeling from having so many doctors cycle through their rooms.
“We started having physicians on our teaching service give patients photo business cards, and quite a few nurses who saw them expressed interest in having something similar,” she says. But because the business cards gave patients a different number to contact, the cards weren’t right for nurses. “We already had a sheet that instructed the nurses on how to reach the cross-cover pager after hours, so we decided to modify it.”
Adding photos makes intuitive sense, she adds, given how many times physicians are contacted by nurses for a patient they’re not covering, or the number of times that nurses might be trying to reach a resident, only to realize that he or she has been sitting in front of them at the nurses’ station for a while. But why did Dr. O’Malley and her team decide to include signatures as well?
“With paper orders, the physicians’ signatures were at times hard to read, and they would forget to print their name,” she explains. “The nurses were left with the question of whose name the order should be entered under.”
Now, with a record of each physician’s signature, nurses can much more readily match up signatures from the information sheets with those on orders and not be left hanging.
According to survey responses, the vast majority of nurses agreed that including physician photos and signatures on the information sheet helped them identify physicians more quickly and improved their communications. But why would giving nurses access to additional identifiers cause them to rate physician cooperation more highly?
“My guess would be that it may be very lonely taking care of a patient and not knowing the right person to call with a question or concern,” Dr. O’Malley says. “You may have a much stronger sense of teamwork with those physicians by just knowing who you’re working with.”
Being able to readily match a physician’s name with a face may also lead to more informal communication.
“Sometimes you may not want to bother someone with a phone call,” says Dr. O’Malley, “but if you know who you’re looking for and that physician comes to the floor, that’s another opportunity for a conversation that you might not have otherwise had.”
Plus, providing information that nurses can use if they need you is a “nice gesture to nursing staff” she says, that reinforces the fact that you’re available.
Moving to a new format
The sheets need to be updated every month because the interns rotate on the first of the month and the residents switch on the fifth. The information sheets also need to be dated so nurses can be sure the information is up to date.
Dr. O’Malley admits that the study, which was presented as a poster at this year’s Society of Hospital Medicine meeting, had some important limitations. But the additional information, which has now become the standard within the academic hospitalist service, is “something simple that seems to work well,” she says.
That appreciation was reinforced last month when Banner Good Samaritan switched to computer physician- order entry from paper orders. Nurses immediately complained that the paper information forms with the photos and signatures were no longer available to them.
“That interest implies that the process is worth recreating in a new format,” says Dr. O’Malley, who adds that both nurses and physicians are exploring ways to add physician photos to the electronic record. And while CPOE will make some components of the information form unnecessary, it does introduce new challenges.
“When we enter orders in remotely,” she says, “that further minimizes the time that physicians and nurses spend communicating directly.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.