Health Care Delivery
Commentary
Team Communication: It’s About Patient Safety
By Susan B. Childress, RN, MN, OCN
Huntsman Cancer Hospital, University of Utah Health Care, Salt Lake City, UT
“The single biggest problem in communication is the illusion
that it has taken place.”
—George Bernard Shaw
The article by Weaver et al1 in this issue of Journal of Oncol-
ogy Practice provides an important reminder to oncologists who
lead interprofessional teams that opportunities to improve team
communication remain. Studies in a variety of settings have
concluded that communication affects the quality of patient
care, team satisfaction, and nursing turnover rates.2 The discon-
nect in perception of communication between physicians and
their nursing colleagues is significant and well documented in
the literature,3-6 so much so that it is surprising that studies are
still taking place. As Weaver et al describe, strong team collab-
oration supports patient safety on many levels. The challenge
for researchers in this field is to replicate the results of interven-
tions already implemented at a few institutions in a multicenter
study. Other potential research could examine questions re-
lated to the types and breadth of communication. In the past
10 years, tools such as texting, Vocera, and electronic med-
ical records (EMRs) have added to the complexity of team
communication.
Fifteen years ago, the Institute of Medicine challenged pro-
viders to embrace the need to radically improve how patient
care is delivered by “hard wiring” safety into our culture.7 Ini-
tiatives such as checklists, rapid response teams, medication
reconciliation, and hand-off procedures all contribute to im-
proving patient safety outcomes.8 An example of a national
effort is the Agency for Healthcare Research and Quality pro-
gram, “On the Cusp: Stop BSI Project,” which was able to show
a 44% decrease in central line blood stream infections.8 Yet we
continue to witness communication breakdowns that adversely
affect patient outcomes. Most recently, the highly publicized
Ebola outbreak brought to light a gap in communication when
a nurse asked all the right questions and documented the an-
swers in the EMR, yet a patient who should have been flagged as
potentially infected was allowed to leave the emergency room
before the Ebola risk was noted.9 Most nurses and physicians
would not be surprised by this event; electronic records are not
always supportive of interdisciplinary communication.
As Weaver et al1 point out, the impact of poor interprofes-
sional team communication on an oncology inpatient unit and
the resulting quality outcomes are less understood. Although
research in the specialty of inpatient oncology is still needed,
studies in a wide range of “dynamic domain” specialties such as
operating rooms, intensive care and trauma units, and emergency
departments have produced a body of literature that identifies
some specific barriers to effective communication.4-6,10,11 Thomas
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et al6 described barriers related to suboptimal conflict resolution
and interpersonal communications skills. Other findings go on
to identify status, authority, responsibilities, gender, training,
and nurse/physician cultures as factors that influence effective
communication.5,6,12 Colleagues in these dynamic domains
have led the way in studying communication barriers and im-
plementing changes to improve patient safety. These studies
report that miscommunication is frequently among the causes
of error and often the leading cause.4,10 Intensive care unit data6
reveal that nurses find it difficult to speak up, disagreements are
not appropriately resolved, and nursing input is not well re-
ceived. Both Awad et al4 and Makary et al5 confirmed a differ-
ence in communication ratings between nurses and surgeons in
the operating room, with physicians believing communication
was not flawed. Janss et al12 reviewed communication research
and its impact on teamwork from the domain of social and orga-
nizational psychology. Their conclusions were that power and con-
flict influenced individual communication styles, and they
recommended training interventions to help teams improve col-
laboration.
In the oncology setting, unique challenges underscore the
need for strong communication among team members, includ-
ing intricate diagnostic procedures, patient populations with
multiple comorbidities, and complex and potentially dangerous
treatments. Oncology patients continually transition from in-
patient to outpatient status. Multiple hand-offs for surgery,
procedures, radiation, and outpatient infusion create multiple
opportunities for miscommunication. Most oncology profes-
sionals would agree that this setting could also be appropriately
categorized as a “dynamic domain.”11
In an attempt to reduce the number of communication-
based errors, health care has looked to other industries such as
aviation for solutions. After air crashes, investigators frequently
found communication errors between airline staff to be the root
of the problem. Training and system changes implemented
specifically to improve communication have significantly re-
duced near misses and crashes.2 These changes involved intro-
duction of checklists and redundant safety technology, thereby
reducing the possibility and influence of human error.13 With
this knowledge, health care interventions to improve commu-
nication among teams have included preoperative briefings,
hand-off improvements such as SBARQ tools, check-off lists,
and medication reconciliation procedures.4,8 The SBARQ tool
has been shown to significantly improve satisfaction with nurse-
physician communication.14 The use of surgical checklists re-
sulted in reducing major surgical complications by 36% in the
preoperative setting.15 Medication errors were decreased by
• jop.ascopubs.org 23
93% with the implementation of a medication reconciliation
process.16
Although patient safety is a priority, many other reasons to
embrace a culture of improved communication in the health
care system exist. Previous studies have demonstrated that good
communication is associated with improved job satisfaction,
less time missed from work due to illness, less nursing turnover,
and less fatigue, thereby also providing a financial motivation to
improve communication.10,17
Nursing research provides another perspective by identi-
fying a variety of solutions to improve nurse satisfaction
through better communication. A 2003 study by Kramer and
Schmalenberg18 identified three factors present when nurses
felt they had a collegial relationship with their physicians: (1)
nursing staff perception of their role as “equal but different” and
articulation of how their knowledge was unique and worth
communicating; (2) an institutional culture that values, ex-
pects, and rewards collegial relationships between nurses and
physicians; and (3) expectations that nurses maintain clinical
competence in their specialty, along with assistance in doing so,
which promotes confident communication. Lindeke and Sieck-
ert19 recommend a focus on understanding the perspective of
others, avoiding “compassion fatigue,” and learning how to
manage conflict. Bunnell et al20 demonstrated successful imple-
mentation of role definition and team training in a program
called the “Two-Challenge Rule.” This rule requires team
members to state their observations at least twice to ensure that
their interests are being addressed. Their work in an ambulatory
oncology setting showed improved communication; task coor-
dination; and perception of efficiency, quality, and safety, as
well as higher levels of patient satisfaction.
Historically, physician accountability in university settings
has focused on clinical management, research, and house staff
education. Many organizations are challenging this culture by
expecting medical directors to be more engaged in the manage-
ment of their inpatient units, specifically in the areas of quality,
patient experience, and financial strength. This change of ac-
References
1. Weaver AC, Callaghan M, Cooper AL, et al: Assessing interprofessional team-
work in inpatient medical oncology units. J Oncol Pract [epub ahead of print on
October 28, 2014]
2. Leape LL, Berwick DM, Bates DW: What practices will most improve safety?
Evidence-based medicine meets patient safety. JAMA 288:501-507, 2002
3. Nelson GA, King ML, Brodine S: Nurse-physician collaboration on medical-
surgical units. Medsurg Nurs 17:35-40, 2008
4. Awad SS, Fagan SP, Bellows C, et al: Bridging the communication gap in the
operating room with medical team training. Am J Surg 190:770-774, 2005
5. Makary MA, Sexton JB, Freischlag JA, et al: Operating room teamwork among
physicians and nurses: Teamwork in the eye of the beholder. J Am Coll Surg
202:746-752, 2006
6. Thomas EJ, Sexton JB, Helmreich RL: Discrepant attitudes about teamwork
among critical care nurses and physicians. Crit Care Med 31:956-959, 2003
7. Institute of Medicine: To err is human: Building a safer healthcare system.
https://www.iom.edu/~/media/Files/Report%20Files/1999/To-Err-is-Human/
To%20Err%20is%20Human%201999%20%20report%20brief.pdf
8. Agency for Healthcare Research and Quality: Eliminating CLABSI: A National
Patient Safety Imperative. www.ahrq.gov/professionals/quality-patient-safety/
cusp/onthecusprpt/index.html
24 JOURNAL OF ONCOLOGY PRACTICE • V O L . 11, I S S U E 1
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Copyright © 2017 American Society of Clinical Oncology. All rights reserved.
countability has encouraged stronger collaboration with nurse
managers and other key team members. When positive team-
work is modeled by the unit administrative leaders, the poten-
tial for improved patient outcomes increases at many levels.
Kim et al21 described the unit-based interprofessional leader-
ship models in six hospitals and how the development and
implementation of these models may be viewed as options for
other inpatient departments.
In conclusion, effective communication in the health care
system is important to prevent errors and improve job satisfac-
tion. Physicians and nurses continue to disagree in their percep-
tion of the quality of their communication. Potential solutions
are identified throughout the literature. It is time for hospital
administrators, physician and nurse leaders, and our medical
and nursing education institutions to enact permanent changes
in team dynamics that support improved communication.
Acknowledgment
I thank Pim Gal, MD, for his insight and logistical support; Diane Fouts
for her outstanding editorial skills; and John Sweetenham, MD, for his
leadership, nurse-physician communication skills, and role modeling.
Author’s Disclosures of Potential Conflicts of Interest
Disclosures provided by the authors are available with this article at
jop.ascopubs.org.
Corresponding author: Susan B. Childress RN, MN, OCN, Director of
Nursing Services, Huntsman Cancer Hospital, University of Utah Health
Care, 1950 Circle of Hope, Salt Lake City, UT 84112; e-mail: susan.
childress@hci.utah.edu.
Susan B. Childress is currently the Director of Oncology Nursing Ser-
vices at Huntsman Cancer Institute at the University of Utah. Prior to
Huntsman Cancer Institute, Ms. Childress worked for many years at the
Salt Lake City Veterans Affairs Medical Center, managing the medicine/
oncology inpatient unit and infusion services. She has published papers
on ethics at the end of life, palliative care, pain management, clinical
staff education and orientation, and quality improvement.
DOI: 10.1200/JOP.2014.002477
9. Khazan O: The Ebola patient was sent home because of bad software. http://
www.theatlantic.com/technology/archive/2014/10/the-ebola-patient-was-sent-
home-because-of-an-electronic-health-record-problem/381087/
10. Manojlovich M: Linking the practice environment to nurses’ job satisfaction
through nurse-physician communication. J Nurs Scholarship 37:367-373, 2005
11. Manser T: Teamwork and patient safety in dynamic domains of healthcare: A
review of the literature. Acta Anaesth Scand 53:143-151, 2009
12. Janss R, Rispens S, Segers M, et al: What is happening under the surface?
Power, conflict and the performance of medical teams. Med Educ 46:838-849,
2012
13. Haynes AB, Weiser TG, Berry WR, et al: A surgical safety checklist to reduce
morbidity and mortality in a global population. N Engl J Med 360:491-499, 2009
14. Beckett CD, Kipnis G: Collaborative communication: Integrating SBAR to
improve quality/patient safety outcomes. J Healthc Qual 31:19-28, 2009
15. de Vries EN, Prins HA, Crolla RM, et al: Effect of a comprehensive surgical
safety system on patient outcomes. N Engl J Med 363:1928-1937, 2010
16. Agrawal A, Wu WY: Reducing medication errors and improving systems
reliability using an electronic medication reconciliation system. Jt Comm J Qual
Patient Saf 35:106-114, 2009
17. Larrabee JH, Janney MA, Ostrow CL, et al: Predicting registered nurse job
satisfaction and intent to leave. J Nurs Admin 33:271-83, 2003
Copyright © 2015 by American Society of Clinical Oncology
18. Kramer M, Schmalenberg C: Securing “good” nurse/physician relationships.
Nurs Manage 34:34-38, 2003
19. Lindeke LL, Sieckert AM: Nurse-physician workplace collaboration. Online J
Issues Nurs 10:5, 2005
20. Bunnell CA, Gross AH, Weingart SN, et al: High performance teamwork
training and systems redesign in outpatient oncology. BMJ Qual Saf 22:405-413,
2013
21. Kim CS, King E, Stein J, et al: Unit-based interprofessional leadership models
in six US hospitals. J Hosp Med 9:545-550, 2014

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AUTHOR’S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST
Team Communication: It’s About Patient Safety
The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships
are self-held unless noted. I ⫽ Immediate Family Member, Inst ⫽ My Institution. Relationships may not relate to the subject matter of this manuscript.
For more information about ASCO’s conflict of interest policy, please refer to www.asco.org/rwc or jop.ascopubs.org/site/misc/ifc.xhtml.

Susan B. Childress
No relationship to disclose

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