MTH 115 Statistics Project Paper DUE Wednesday, Jul.docx

MTH 115 Statistics Project / Paper
DUE: Wednesday, July 22, 2015 - the last day of class
Each paper should consist of these parts:
Part I: Introduction
This section should include some perspective about the problem
you are trying to analyze; in other words, you should
review the literature concerning your subject. The library or the
web will be a good source of information. This research
should provide the rationale for your study; it is a very
important part of your paper / project.
Part II: Statement of the Problem
This section should contain a clear and concise description of
the problem that you are trying to solve. This should be
short, not to exceed one paragraph.
Part III: Statement of the Hypotheses
This section should contain a listing of the hypotheses (null and
alternate) for each test you are conducting.
Part IV: Methodology
This section needs to include a detailed explanation of the
manner in which you selected your sample(s). Make sure the
reader knows whether or not this sample was randomly selected.
If it was randomly selected, make sure the process of
selection is well documented. This section should include a
statement of the possible weaknesses of our study based on
your inability to collect a random sample. Describe your

sample(s) in detail. Be sure to tell the reader the makeup in
terms of gender, ethnicity, socioeconomic status, etc.
The section should also include a description of how you
obtained your data from your sample(s). If you used a
questionnaire that you developed, include it in this part of the
project. Give reasons for including specific questions. If
you used a questionnaire developed by someone else, you
should provide background information on the questionnaire
including its author and purpose. Include a copy of the
questionnaire in this section. Any and all descriptions of how
you
conducted your study should be placed inside this section.
Part V: Analysis of the data
If you are doing some preliminary descriptive statistics on your
sample(s) be sure to include this information here. You
may wish to include charts, frequency tables, means and
standard deviations. Explain, in great detail, how you
conducted
your test(s) and how you analyzed your data and results. All
statistical results should be provided. You may want to
include a printout of the results (if you used Excel) in this
section.
Part VI: Conclusions and Implications
This section should include the conclusions that you made after
analyzing your data. Be sure you do not make grandiose
statements about your population in general if your sample was
not representative of the entire population. You might
add your own opinion about any other study that you might
think appropriate to follow your own.
Part VII: Bibliography
This section should contain references to at least 4 sources of
information.

Grading Rubric Name: _______________________
Section Possible
points
Comments Your
points
Part I:
Introduction
20
I will be looking for the background and rationale for your
study. Be sure to give
credit to the sources you are using for the stuff you are saying.
Part II:
Statement of
the Problems
10
I am looking for a concise statement of what your study is
about. This should
naturally flow out of the end of your Introduction. By the time

I have read your
Introduction and your Statement of the Problem section I should
totally understand
what it is you are planning to do. The rest of the paper would
just be devoted to
explaining how you did what you were planning and analyzing
your results.
Part III:
Statement of
Hypotheses
5
It really is best if these are written in both symbols and words.
It makes it a little
easier for your reader to understand them.
Part IV:
Methodology
30
I am looking for a clear explanation of how you went about
setting up the test you
are conducting. I would like to have a good explanation and
description of your
sample. Is your sample a random sample? Exactly how was it

gathered? If it
would enhance your study to know the number of males and
females who comprise
your sample, then provide that. If it would enhance your study
to know the ages of
the people in your sample then provide that. If it would enhance
your study to know
the ethnicity of the people in your study, then provide that.
(Things like these last
three ideas are easily shown in tables and histograms.) If you
have divided your
people into two groups, then it is extremely important that we
know how that was
done. Basically, by the time someone has completed this
section, the reader will
know exactly how this study was conducted. The reader will
understand your
definitions, and just overall, why you did what you did. Be sure
your reader
understands all of the weaknesses of your study. Be sure to
speak to the
assumptions of the test you are conducting and make sure your
reader knows as to
whether or not they were met.
Part V:
Analysis of the
Data
25
I am looking for you to conduct whatever test you have chosen

to do. I am looking
for you to make sure your reader knows why you made the
decision you made.
Part VI:
Conclusions
and
Implications
20
This is where you get to make the conclusion from your study.
Be sure to give your
interpretation as to why things ended up why they did. You are
welcome to put in
all sorts of personal opinions here. Add in your ideas about any
future studies that
might be done based upon the results of this study.
Part VII:
Bibliography
5
Correct,
grammar,

spelling, etc
throughout
10
Final
Presentation
75
Total 200
The SBAR Communication Technique
Teaching Nursing Students Professional Communication Skills
Cynthia M. Thomas, EdD, RNC, CDONA
Evelyn Bertram, MS, RN
Doreen Johnson, MA, RN
The Joint Commission and Institute for Healthcare Improvement
have mandated healthcare organizations to improve

professional communication. Nursing students lack experience
in communicating with physicians. As a result, recent
graduates may not be prepared to meet the demands of
professional communication to ensure patient safety. The
authors
discuss the SBAR (situation, background, assessment,
recommendations) communication technique implemented
during a
2-day simulation exercise that provided an organized logical
sequence and improved communication and prepared graduates
for transition to clinical practice.
E
ffective communication between nurses and physi-
cians is extremely important to patient safety.
Nurses are often overwhelmed by the complexity
of patient care, increasing technology, emerging standards
of care, and enforcement from regulatory agencies. Over-
stimulation may result in poor communication between
healthcare team members. The Joint Commission reports
that communication errors contribute to the majority of
sentinel events reported.1 Another report indicates medical
errors to be the eighth leading cause of death in America.2
The Joint Commission and the Institute for Healthcare Im-
provement recommend the SBAR (situation, background,
assessment, recommendations) communication technique
to improve communication and reduce medical errors.3
Nursing Students and Recent
Graduate Nurses
Nursing students are traditionally prevented from receiving
physician orders. As a result, recent graduates lack ex-
perience with interprofessional communication skills and
are fearful of making mistakes. Omission of vital patient

information including the patient’s age, sex, race, and
medical history is common when transferring information
from one professional to another.4 Students and recent
graduates are still developing vital communication skills,
such as listening, assimilating, interpreting, gathering, and
sharing information.5 However, healthcare organizational
staff have an expectation that new graduates perform these
communication skills safely and effectively, at the same time
recognizing that these skills are most often learned ‘‘on the
job.’’
5
In addition, Anderson
6
reported that nurses and
physicians experienced increased frustration with poor
professional communication.
Faculty are challenged to find innovative strategies to
improve communication skills among nursing students
preparing them for safe practice as graduate nurses. The
SBAR communication technique is a simple, brief, yet
effective structured approach to transfer critical information.7
As management/leadership faculty, we successfully imple-
mented the SBAR approach with a variety of strategies,
improving both clinical practice preparation and communi-
cation competency of our senior nursing students.
SBAR—defined
The Joint Commission (1) describes the SBAR communi-
cation technique as the:
Situation: what is the situation; why are you calling the

physician?
Background: what is the background information?
Assessment: what is your assessment of the problem?
Recommendation: how should the problem be corrected?
SBAR was developed by the military, adapted by
the aviation industry, and adopted for use at Kaiser
Permanente of Colorado.8 SBAR can be applied to almost all
forms of communication between healthcare professionals
and thus provides a standard framework to transfer important
information. SBAR helps nursing students and recent graduate
nurses organize their thoughts prior to calling physicians,
during handoff to another nurse, and when transferring
patients to other organizations or levels of care.9 Experienced
nurses can also benefit from the SBAR technique to save time,
reduce frustration, and improve overall communication.
How Does SBAR Work?
SBAR works by communicating what is happening at the
present time (S = situation), providing a structure for
176 Volume 34 & Number 4 & July/August 2009 Nurse
Educator
Nurse EducatorNurse Educator
Nurse Educator
Vol. 34, No. 4, pp. 176-180
Copyright ! 2009 Wolters Kluwer Health |
Lippincott Williams & Wilkins
Authors’ Affiliations: Assistant Professor (Dr Thomas), School
of

Nursing, Ball State University, Muncie, Indiana; Clinical
Director of ICU
(Ms Bertram), Community Hospital, Anderson, Indiana; Chief
Nursing
Officer (Mrs Johnson), Ball Memorial Hospital, Muncie,
Indiana.
Corresponding Author: Dr Thomas, Ball State University,
School of
Nursing, 2000 University Ave, Muncie IN 47306
([email protected]).
9Copyright @ 200 Lippincott Williams & Wilkins.
Unauthorized reproduction of this article is prohibited.
background information (B = background), formulating
the completed health assessment (A = assessment), and
offering possible solutions (R = recommendations).10 The
SBAR format provides a brief, organized, predictable flow
for information improving critical thinking and communi-
cation skills.7
Barriers to Effective Communication
Multiple factors translate to poor, ineffective communication.
Healthcare organizations are complex and have high noise
levels due to the multitude of equipment and the continual
hum of people. Researchers at The John Hopkins University
found that high noise levels in hospitals increased the stress
level for the employees and increased the risk for errors
because information was not heard correctly.
11
Vijay
12

discov-
ered that elevated noise levels contribute to employees’ stress
levels or may lead to depression and irritability in addition to
increased medical errors related to the inability to concentrate.
Noise was also found to interrupt a patients’ healing process
while negatively impacting the patient’s hospital experience.13
Nurses and physicians are educated differently and
communicate differently. In general, nurses are taught to be
descriptive in their thought and spoken language. Physi-
cians, on the other hand, are concise in thought and speak
in shorter sentences and become impatient waiting for the
point of the nurse’s call.8,14 Not surprising, cultural differ-
ences, a diverse workforce, educational levels, stress, fear,
and fatigue all contribute to communication failure and dif-
ferences.5 Rosenstein and O’ Daniel15 reported that nurses
often expressed fear when calling physicians and frequently
postponed calls, resulting in delayed patient care. Experi-
enced nurses can recall feelings of fear and intimidation
calling a physician for the first time. Inexperienced nurses
may suffer from brain fog, forget to bring their notes, and
respond inconsistently to physician questions.
Evaluation of Skills Prior to SBAR
Implementation
Faculty developed a 2-day simulation role-play experience
and evaluated the communication, decision making, prob-
lem solving, organizing, time managing, and critical-thinking
skills of senior nursing students to assess students’ communi-
cation skills prior to their first management/leadership clinical
experience. The first day consisted of reading and transcribing
physician orders, reviewing incident reports, and evaluating
actual narrative nursing notes. Students also participated in
crisis management role-play and a group-scheduling exercise.
Particular attention was given to physician orders and

communication skills. Students were given the opportunity
to interpret actual physician orders written specifically for the
simulation exercise. The orders were obtained from volunteer
physicians, physician assistants, and nurse practitioners. Many
orders had errors either in dosing or improper abbreviation
use and were difficult to read. Faculty evaluated the students’
ability to find and report the errors. Students’ communication
skills were evaluated for clarity, scope or depth, organization
of thoughts, and the ability to be concise and accurate when
providing information to others during role-play.
On the second day, students assumed the charge nurse
role. Emphasis was placed on effective communication
between faculty/physicians and other healthcare team mem-
bers during the simulation role-play. Students were given
specific practice scenarios, which required critical thinking,
problem solving, decision making, and communication skills.
Faculty assumed different roles, such as physicians, case
managers, family members, and other nurses. Faculty also
controlled the time and direction of the role-play. Students
were required to call faculty/physicians to receive orders or
to give a patient status report. This was accomplished by
placing the students in mild to moderate stressful situations
requiring multitasking, decision making, and problem solv-
ing to replicate a realistic hospital environment.
Faculty discovered students lacked appropriate knowl-
edge of a logical, sequential communication process. We saw
their fear through their facial expressions, delayed speech,
and sweating when calls were placed to the physician. These
same behaviors increased during the actual faculty/physician
conversations. Students had difficulty organizing their
thoughts, forgetting to state their identity, and forgetting to
identify the patient or from where they were calling. Almost
all students forgot to bring the patient’s medical record with

them to the telephone. They lacked appropriate knowledge
of the patient’s present condition and history and never
offered recommendations to support the reason for their call.
When the faculty/physician asked questions regarding
the patient’s present condition or previous laboratory values,
most students were unable to answer the questions effec-
tively. Students’ responses included, ‘‘I don’t know, or I’ll
have to ask another nurse.’’ The most common statement
made by students to the faculty/physician was ‘‘I’ll have to
call you back.’’ Many students demonstrated a flight of ideas
and lacked an organized structure to their communication.
Students were given immediate constructive feedback from
faculty regarding their performance.
Once students began their hospital clinical experience,
clinical faculty noticed that the experienced nurse paired with
the student would automatically telephone the physician with
the report or for a new order, then relayed the information to
the student. This behavior did not change when physicians
were physically present on the unit. Faculty then noted the
student stood silent while the experienced nurse gave the
physician report. Faculty realized students were being denied
this important piece of the communication process. The lack
of participation in the communication process decreased the
opportunity for the student to improve the necessary skill.
Clinical managers serving as student preceptors during
the management/leadership clinical rotations also expressed
to clinical faculty the inability of students and recent
graduates to effectively and safely communicate. Managers
believed that poor communication led to increased medical
errors and decreased quality of patient care. Because nursing
students traditionally are not allowed to accept physician
orders, it was apparent that we had to develop innovative
teaching strategies to improve effective communication skills

prior to graduation.
SBAR Application
Based on our observations of student performance during
the previous semester’s 2-day simulation role-play exercise
without the SBAR communication technique being used and
manager/preceptor feedback from the student’s hospital
Nurse Educator Volume 34 & Number 4 & July/August 2009
177
clinical rotation, it was apparent that we needed to address
the student’s lack of professional communication skills. The
following semester we implemented, at the school’s practice
laboratory, the SBAR communication technique as part of the
course lecture and simulation exercises to prepare students
for use in the clinical area. A half-hour lecture was given on
the use of the SBAR communication technique at the
beginning of the first simulation day. Each student was given
an SBAR reference guide to use during the remainder of the
simulation exercises and for use during the clinical experi-
ence. The SBAR format was to be used for all communication
between student/nurse and faculty/physician role-play.
Faculty initially prompted students if they struggled during
the simulation role-play exercise. As the students worked
through various simulation exercises using SBAR, faculty
noted increased confidence, decreased fear, and improved
thought organization. As the day progressed, students
learned from each other’s mistakes and successes.
Faculty then reinforced the SBAR technique in the

classroom through case study role-play and during hospital
clinical experience. To implement the SBAR technique in the
classroom, students were given a case study and paired to
role-play physicians and nurses. SBAR was also threaded
throughout specific management/leadership topics such as
safety, quality management, time management, and critical
thought, which demonstrated how a failure to communica-
tion had an impact on quality of care. The clinical faculty
reinforced the use of SBAR while making clinical rounds with
students and preceptors. Preceptors were encouraged to
allow students to give the handoff report and discuss patient’s
plan of care with physicians using the SBAR technique.
Role-Play Application Case Study
Figure 1 illustrates the case study used by the students to
apply the SBAR communication principles in the class-
room. Students read the case study, and pairs of student
groups role-played the nurse and physician. Faculty
moved around the classroom, listened to student’s inter-
actions, and provided feedback.
Students were instructed to answer the following
questions using the SBAR communication technique: what
information does the physician need regarding the cur-
rent situation (S = situation)? What was Mrs Burton’s back-
ground or medical history (B = background)? What
information will the physician need from the health assess-
ment (A = assessment)? And what are the appropriate
recommendations (R = recommendation)?
Review of Appropriate Case
Study Response
While the students were engaged in the classroom role-play,
we listened to the responses students gave to each other to
ensure they included the appropriate SBAR response criteria.

Following the role-play exercise, the students received an
appropriate SBAR response guide document to serve as a
reference.
Figure 1. Role-play scenario.
Educator
Appropriate SBAR Response Guide
S = Situation:
Dr Hall, this is Jim Jones, RN, calling from the 4 west
medical floor at Mountain View Hospital. I am calling
about Mrs Burton in room 403. Her condition has
changed, and I wanted to update you with her current
medical status. I just assessed her personally; she is
complaining of a headache, experiencing photosensi-
tivity, and dizziness. The most recent blood pressure is
220/120, pulse 120, and her respiratory rate is 24. There
has been a steady increase in her vital signs since her
admission. The vital signs were BP160/90, P 98, and
R16 on admission to the floor; BP 180/100, P 102, and
R 18 at 10:15 last night around 10 PM, and at 7:30 this
AM they were 186/110, P 100, and R 22. She is also
diaphoretic and holding her head between her hands.
She is also complaining of being dizzy.
B = background:
Apparently, last month, she had an episode of hyper-

tension noted at a health fair. She was unable to tell me
what her blood pressure was at the time, but the nurse
who took it told her it was quite elevated. She had been
instructed to notify her physician, but she failed
to follow through. She was admitted last night around
10 PM through the ED for an unexplained fall at home
the day before. She does not take any medication.
A = assessment:
I am concerned about the combination of the blood
pressure episode last month at the health fair; the steady
increase in her vital signs since admission, the current
headache, complainant of being dizzy, and now being
diaphoretic along with the photosensitivity may all in-
dicate hypertension with the potential for a future CVA.
R = recommendation:
Would you consider ordering an antihypertensive medi-
cation at this time and establishing a target blood pressure
as future call orders? As a standard nursing measure, I will
be checking Mrs Burton’s vital signs every 2 hours for the
next 24 hours. Based on her future medical state, we can
determine how closely to monitor her after the next 24-hour
period. Would you like for me to call you with an update on
her progress after the next assessment in 2 hours?
Conclusion. As the semester progressed, we witnessed
improved communication, increased confidence, and orga-
nized information as students became more familiar with
using the SBAR communication technique. We recognize that
when students graduate, they may become overwhelmed
with their new role responsibilities and may forget important
steps in the professional communication process. Figure 2

illustrates important considerations prior to making calls to
physicians and was given as an additional reference docu-
ment to help students with professional communication after
graduation. We did not formally evaluate the communica-
tion skills of this group of students prior to or after the SBAR
technique was implemented; however, a formal evaluation
will be conducted for future students.
The implementation of the SBAR communication tech-
nique during the 2-day simulation exercise, reinforced in the
classroom with a case study role-play and during the
students’ hospital clinical experience, provided an organized
logical sequence to improve the communication skills of
Figure 2. Important considerations before calling physicians.
Nurse Educator Volume 34 & Number 4 & July/August 2009
179
senior nursing students. The SBAR technique encourages
students to organize information quickly and concisely,
which then allows physicians to make clinical judgments
based on the concrete information that the nurses provide.
The SBAR technique assisted students to better organize
critical information. Both faculty and clinical staff saw that
students had improved confidence and critical thoughts and
made better decisions. In addition, the students’ ability to
identify and solve problems continued to improve over time
as they used the SBAR communication technique. Based on
our experience, the SBAR communication technique gives
students a tool with the potential to improve their transition

from academia to clinical practice.
Reference
1. The Joint Commission. Hand-off communications: standar-
dized approach. The Joint Commission. 2008. Available at
http://www.jointcomission.org/AccreditationAmbulatoryCare/
Standards/09_FAQs/NPSG/Communication/NPSG.02.05.01/.
Accessed December 28, 2008.
2. Goeckner B, Gladu M, Bradley J, Bibb SC, Hicks RW.
Differ-
ences in perioperative medication errors with regard to orga-
nization characteristics. AORN J. 2006;83(2):351-368.
3. Institute for Healthcare Improvement. Web and action: using
SBAR to
improve communication. 2006. Available at
http://www.ihi.org/ihi/
fbmms/Sh()wForum^spx?ForumID:97. Accessed November 11,
2008.
4. Ascano-Martin F. Shift report and SBAR: strategies for
clinical
post conference. Nurse Educ. 2008;33(5):190.
5. Manning ML. Improving clinical communication through
structured conversation. Nurs Econ. 2006;24(5):268-271.
6. Anderson DE. Bridging the professional chasm: tools for col-
laborative communication. Med Surg Matters. 2008;17(1):8-9.
7. Powell SK. Editorial: SBAR—it’s not just another
communica-
tion tool. Perspect Case Manag. 2007;12(4):195-196.

8. Pope BB, Rodzen L, Spross G. Raising the SBAR: how better
communication improves patient outcomes. Nursing. 2008;
38(3):41.
9. Safer Healthcare. SBAR—a communication technique for
today’s healthcare professional. 2008. Available at http://
www.saferhealthcare.com/index2.php?option=com_content&
task=view&id=33&pop=1&page=0&itemid=84&print=1.
Accessed November 11, 2008.
10. Rodgers KL. Using the SBAR communication technique to
improve nurse-physician phone communication: a pilot study.
AAACN Viewpoint. 2007;29(2):7-10.
11. Hospital noise stresses patients and staff. ASHA Leader.
2006;11(3):5.
12. Vijay SA. Reduce and optimize hospital noise with six
sigma tools.
Six Sigma.com. 2007. Available at http://healthcare.isixsigma.
com/library/content/c071205a.asp. Accessed December 26,
2008.
13. Overman-Dube JA, Barth MM, Cmiel CA, et al.
Environmental
noise sources and interventions to minimize them: a tale of 2
hospitals. J Nurs Care Qual. 2008;23(3):216.
14. Leonard M, Graham S, Bonacum D. The human factor. The
critical importance of effective teamwork and communication in
providing safe care. Qual Saf Health Care. 2004;(13):185-190.
15. Rosenstein AH, O’Daniel M. Disruptive behavior & clinical
outcomes: perceptions of nurses and physicians. Am J Nurs.
2005;105(1):54-64.

New Guidelines for Management of ST-Elevation Myocardial
Infarction (STEMI)
The American Heart Association (AHA) and the American
College of Cardiology (ACC) have recently
released updated recommendations for patients presenting with
ST-elevation myocardial Infarction. The need
for fast action is the primary message of these revised
recommendations since permanent heart damage is
known to occur if blood flow is not restored within twenty
minutes of the onset of symptoms.
The new guidelines provide four specific decision making
criteria to determine if thrombolytics or stents
should be used with patients presenting with STEMI: 1) the time
that has passed since the onset of symptoms;
2) the risk of death; 3) the risk of intracranial hemorrhage with
thrombolytic use and; 3) how much time
is needed to get the patient to a cardiac catheterization lab for
stent insertion.
The guidelines also recommend the daily use of aspirin and beta
blockers. ACE inhibitors are strongly
recommended. If intolerance to ACE inhibitors is a concern,
angiotensin receptor blockers are recommended.
Statin drugs are advised on discharge for those with low-density
lipoprotein levels (LDL) greater than or equal to
100 mg/dl. Sidney Smith, Co-Chair of the Task Force noted that
this guideline is more aggressive than the original
‘‘Adult treatment III goal recommended by the National
Cholesterol Education Panel’’. Smith continues to note
that aggressively lowering the LDL improves the patient
outcomes in large clinical trials of statin drugs.
Nurses inemergency rooms or inother immediate care facilities

need to be aware of these guidelines. Providing the
correct assessment data can make a critical difference in time of
treatment, appropriateness of treatment, the
extent of myocardial damage, and even survival. Full guidelines
are available at http://circ.ahajournals.org/cgi/
content/full/112/12/e154.
Source: American Heart Association. March 26, 2009.
Emergency Medicine Cardiac Research and Education
Group (EMCERG). Available at
http://www.emcreg.org/news_events/news/articledetails.html?R
ecID=89.
Accessed March 26, 2009.
Educator
Perceptions of Effective and Ineffective
Nurse–Physician Communication in Hospitalsnuf_182 206..216
F. Patrick Robinson, PhD, RN, Geraldine Gorman, PhD, RN,
Lynda W. Slimmer, PhD, RN, and
Rachel Yudkowsky, MD, MHPE
PROBLEM. Nurse–physician communication affects
patient safety. Such communication has been well
studied using a variety of survey and
observational methods; however, missing from the
literature is an investigation of what constitutes
effective and ineffective interprofessional

communication from the perspective of the
professionals involved. The purpose of this study
was to explore nurse and physician perceptions of
effective and ineffective communication between
the two professions.
METHODS. Using focus group methodology, we
asked nurses and physicians with at least 5 years’
acute care hospital experience to reflect on effective
and ineffective interprofessional communication
and to provide examples. Three focus groups were
held with 6 participants each (total sample 18).
Sessions were audio recorded and transcribed
verbatim. Transcripts were coded into categories of
effective and ineffective communication.
FINDINGS. The following themes were found. For
effective communication: clarity and precision of
message that relies on verification, collaborative
problem solving, calm and supportive demeanor
under stress, maintenance of mutual respect, and
authentic understanding of the unique role. For
ineffective communication: making someone less
than, dependence on electronic systems, and
linguistic and cultural barriers.
CONCLUSION. These themes may be useful in
designing learning activities to promote effective
interprofessional communication.
Search terms: Interprofessional care,
nurse–physician communication, safety
F. Patrick Robinson, PhD, RN, is Campus Dean,
Chamberlain College of Nursing, Chicago, IL. Geraldine
Gorman, PhD, RN, is Clinical Assistant Professor,
Department of Health Systems Science, College of
Nursing, University of Illinois at Chicago, Chicago, IL.
Lynda W. Slimmer, PhD, RN, is Clinical Associate
Professor, Department of Biobehavioral Health Science,

College of Nursing, University of Illinois at Chicago,
Chicago, IL. Rachel Yudkowsky, MD, MHPE, is Associate
Professor, Department of Medical Education, College of
Medicine, University of Illinois at Chicago, Chicago, IL.
Introduction
Very little nursing or medical education addresses
interprofessional communication, yet nurses and phy-
sicians are expected to deliver safe, high-quality
health care as member of a team. Such care, particu-
larly in hospitals, depends greatly on the ability of
health professionals to communicate effectively and
efficiently with each other (The Joint Commission,
2009; Lingard et al., 2006). The preeminence of com-
munication is supported by data showing an associa-
tion between poor communication and medical errors
(Alvarez & Coiera, 2006; Gandhi, 2005; Gawande,
Zinner, Studdert, & Brennan, 2003; Sutcliffe, Lewton,
& Rosenthal, 2004) that result in significant patient
mortality (Consumers Union, 2009; Kohn, Corrigan,
& Donaldson, 2000). In fact, the Joint Commission
reports that sentinel events can consistently be traced
back to problems with communication (The Joint
Commission, 2008).
Nurse–physician communication is particularly
important, given the interdependence of the two pro-
fessions and the primary role they play in safe, quality
patient care. The well-entrenched hierarchical author-
ity structure and sexism (even though women make
up over one-third of the physician workforce) compli-
cate nurse–physician communication. Unfortunately,
disruptive communication occurs with alarming fre-
quency in both nurses and physicians, and both sets of

AN INDEPENDENT VOICE FOR NURSING
206 © 2010 Wiley Periodicals, Inc.
professionals agree that such ways of communicating
decrease patient safety (Rosenstein & O’Daniel, 2008).
The well-entrenched hierarchical authority
structure and sexism (even though women
make up over one-third of the physician
workforce) complicate nurse–physician
communication.
The extant literature is full of reports detailing the
deleterious effects of poor interprofessional communi-
cation (mostly between nurses and physicians)
(Bokhour, 2006; Burd et al., 2002; Dechairo-Marino,
Jordan-Marsh, Traiger, & Saulo, 2001; Simpson, James,
& Knox, 2006) and suggesting mechanisms to enhance
interprofessional communication (Lyndon, 2006;
McCallin, 2003; McKeon, Oswaks, & Cunningham,
2006). However, much of the research related to inter-
professional communication, and patient safety has
been narrow in scope and related to highly specific
contexts (hand-offs, types of charting, rounds) (Varpio,
Hall, Lingard, & Schryer, 2008). Although this has
aided our understanding of how and when communi-
cation fails, what is missing from the literature is an
investigation of what constitutes effective and ineffec-
tive interprofessional communication from the per-

spective of the professionals involved. Analyzing such
perspectives may illuminate types of communication
or communication strategies that could be taught and
utilized to enhance interprofessional communication
for increased patient safety. The purpose of this study
was to explore nurse and physician perceptions of
effective and ineffective communication between the
two professions.
Methods
Focus group methodology was used. This qualita-
tive research technique is useful in obtaining data
about feelings and opinions of small groups of par-
ticipants about a given problem, experience, or other
phenomenon (Basche, 1987). Focus groups are
designed to obtain participants’ perceptions regarding
a defined area of interest in a permissive, nonthreat-
ening environment (Krueger, 1994). The group inter-
action stimulates discussion that provides data and
insights that do not occur with other data collection
techniques (McDaniel & Bach, 1994). The study was
approved by the university institutional review
board.
Setting and Sample
The study was conducted at a large, urban univer-
sity health science center in the United States. Partici-
pant inclusion criteria were registered nurses or
physicians who had practiced in their clinical disci-
pline for a minimum of 5 years in a hospital setting.
This time-in-practice requirement was to ensure that
participants had been exposed to a variety of commu-
nication styles and experienced significant successes
and failures with various techniques. The assumption

here is that at least 5 years of experience provided the
insight needed to determine effective and ineffective
interprofessional communication practices.
Three different focus group sessions were con-
ducted. Each group consisted of six participants. One
session included only nurses, another only physi-
cians, and a third was mixed. The makeup of the
groups was based on the assumption that nurses and
physicians may have different ideas about what con-
stitutes effective and ineffective interprofessional
communication. As such, the single-discipline groups
may offer insight into such phenomena because
respondents may not feel the need for “political cor-
rectness” in front of their colleagues from the other
discipline. Also, the combined group may reflect
Nursing Forum Volume 45, No. 3, July-September 2010 207
“negotiated” ideas that result from the group
dynamic of individuals from different professional
perspectives. In sum, the different group composi-
tions were meant to add to the richness and diversity
of the data in order to gather the most comprehensive
information regarding effective and ineffective inter-
professional communication.
Procedure
We recruited participants for the focus groups
through the university mass email distribution that
reaches hundreds of practicing nurses and physi-
cians. The email explained the purpose of the focus
group and directed interested participants to contact

a member of the investigative team. Individuals
who met the eligibility criterion were invited to
participate, and recruitment ceased after nine
nurses and nine physicians accepted the invitation to
participate.
Via email, prefocus group questionnaires were dis-
tributed to all participants to collect demographic and
other descriptive information on the sample. In addi-
tion, the focus group guide that would be used during
the actual focus group session was distributed so that
participants could give forethought to the two sce-
narios. See Table 1 for the focus group guide.
Each of the three focus group sessions lasted 60 min
and was facilitated by a different member of the inves-
tigative team (two doctorally prepared nurses and one
physician) who were members of the university
faculty. Facilitators were trained to follow a specific
protocol that included introductory remarks, presenta-
tion of the two scenarios, and verification of informa-
tion provided. While using different facilitators for
each group introduced variance into the design, it also
had the potential to enrich the data by bringing a dif-
ferent style and perspective to each group. Sessions
were audio recorded for transcription to text. For par-
ticipants’ convenience, all sessions took place at the
noon hour in a hospital conference room, and lunch
was served. Each participant received a $50 gift card to
the university bookstore to compensate for their time
and effort.
At the start of each focus group session, the facilita-
tor gave a brief overview of the objectives and instruc-
tions regarding the process of the session. The

facilitator proceeded to ask the open-ended questions
previously distributed to participants. Clarification of
responses was sought, and additional information was
Table 1. Focus Group Guide
Instructions We are asking that you reflect on your
clinical experiences when participating. Our
plan is that everyone will get an
opportunity to speak. Our desire is to keep
the proceedings flexible and informal. You
should feel free to comment on others’
answers by agreeing, disagreeing,
elaborating, providing additional examples,
providing counter examples, etc.
Scenario 1 Think of an actual clinical situation in which
interprofessional communication (verbal
and nonverbal) was key to the outcome of
the situation. For example, situations that
were on the edge of going well or poorly
and communication tipped the outcome in a
negative or positive direction. Briefly
describe the situation. In what ways was
communication critical to the outcome?
Provide explicit examples. Provide as much
detail of the types of communication or
approaches to communication that work
well or are problematic.
Scenario 2 Think of two health professional colleagues
(from your profession or another), one an
exceptionally good interprofessional
communicator and the other a poor
interprofessional communicator. Do not
name or identify these persons. What does

each do consistently that makes him or her
exceptionally good or poor at
interprofessional communication? Provide
explicit examples.
Focus group guide was distributed to participants prior to the
focus group session for reflection and used by the group
facilitator
to conduct the session.
Nurse–Physician Communication
208 Nursing Forum Volume 45, No. 3, July-September 2010
requested as deemed necessary by the facilitator. The
facilitator remained neutral and nonjudgmental
throughout the session. The facilitator ended the ses-
sions by summarizing the highlights of discussion and
seeking verification from the participants (McDaniel &
Bach, 1994).
Data Analysis
Audio recordings of the focus groups were tran-
scribed verbatim. Two members of the investigative
team (both of whom were present at all focus group
sessions) read and reread the transcripts and devel-
oped individual preliminary thematic categories of
effective and ineffective interprofessional communica-
tion. The two investigators developed a list of thematic
categories along with supporting quotes for each
theme. In order to be included, evidence of the theme
had to occur across all focus groups and both investi-
gators had to agree on the theme and its supporting

evidence. The themes were reviewed and discussed at
an investigator team meeting (four investigators)
where themes were further refined and clarified.
Results
The characteristics of the sample are displayed in
Table 2. Given that scheduling conflicts existed for
many interested participants, multiple invitations to
participate were declined.
Five themes were identified that characterized effec-
tive communication in the hospital setting, and three
themes were identified that characterized ineffective
communication. The themes are summarized in
Table 3.
Themes
Effective Communication
Clarity and precision of message that relies on
verification. The most common theme expressed by
participants was a need for straightforward unam-
biguous communication. For example, “I think you
have got to be . . . clear, and time is of the essence”
and “I think being clear and concise tells me what
you want the first time.” Effective communication
was enhanced when participants were confident that
what was being heard or said was accurate. Accuracy
seemed to rely on verification and confirmation. For
example, “ . . . the nurse or physician sort of reiterates
the important points in the care plan especially
in . . . ICU . . .” Also,

Table 2. Participant Characteristics
Profession Characteristic
Nursing Gender 9 females
Mean (SD) age 46.72 (9.29) years
Mean (SD) years in
practice
20.82 (10.47) years
Medicine Gender 1 female, 8 males
Mean (SD) age 39.88 (13.92) years
Mean (SD) years in
practice
13 (11.7) years
The total sample size was 18 with characteristics as indicated.
Table 3. Effective and Ineffective Interprofessional
Communication Themes
Effective
communication
Clarity and precision of message that
relies on verification
Collaborative problem solving
Calm and supportive demeanor
under stress
Maintenance of mutual respect
Authentic understanding of the

unique role
Ineffective
communication
Making someone less than (derision)
Dependence on electronic systems
Linguistic and cultural barriers
Results of thematic analysis of interprofessional focus groups.
The most common theme expressed by
participants was a need for straightforward
unambiguous communication.
We usually try to discharge in the morning but with
this particular patient we did not end up . . . putting
in a [discharge] order until late afternoon because her
tests were pending. But I was not sure if . . . the resi-
dent was communicating with the rest of the ancil-
lary healthcare staff and head nurse, so I actually
called in the afternoon, I had a gut feeling, and I
called and I said hey, so is the patient going home?
. . . Yeah, yeah, yeah. The patient is going home. Fine.
I did not follow up any more than that. I just assumed
that it would happen. It turns out that the patient
actually never went home and what happened was
the nurse apparently did not know the patient was
going home. The nursing staff did not know. They
thought we had cancelled the discharge. I called the

nursing supervisor and asked what do you think
happened? What was the reason? I got a lot of dis-
cussion that occurred over what might have been
such a simple thing as confirming with the nurses the
patient is going home, not having to have the patient
sleeping in a hotel hospital for the night. It ended up
putting a lot of people into kind of a foul mood over
the whole thing.
Collaborative problem solving. Participants felt that
effective communication included coming together to
problem solve as a team. For example,
There is so much information that they are provid-
ing and this is really helping and it became a new
way of being and so beneficial and helped on both
sides. Instead of seeing it as “us versus them.” It was
the “we as a team.”
Also, “ . . . teamwork is probably one of the greatest
means of cutting down on mistakes and having a posi-
tive attitude.” This was accomplished by efforts to
make sure that all were “on the same page” and that
understanding was the same for all. For example, “We
now have the same baseline so that . . . we are not
grading things differently.” “So I think if we are on the
same page . . . ineffective communication will be mini-
mized.” “ . . . having the nurse or physician . . . under-
stand the plan and be on the same page.” Also,
A nurse calls and says X has a fever and he does not
have a Tylenol order and in fact what [she] does not
need is a Tylenol order. What you need is a discus-
sion examining why he has the fever. . . . What she
can identify that is wrong is the fever and what she is
really saying is that he has changed, something is

different. Let us look at this guy together but what
you get is I need a Tylenol order and if the doctor then
responds to that by saying . . . here is your Tylenol
order then everybody has missed the whole thing.
Participants highly valued members of the other
profession seeking them out for advice. There was con-
sensus that patients benefited when both professions
sought each other out for routine and complex deci-
sion making. For example,
. . . the best kinds of communications were the
nurses who would sit down and say to me, “I want
you to explain to me why you wrote these orders.”
I remember very clearly somebody saying to me,
“wait a minute, you have not been on this floor
before. I do not know you.”
I think that what contributes to good communica-
tion is when a nurse says to me, “I do not like what
I am seeing or I am seeing this. What do you think is
happening? Why do you think this is going on?”
If the resident asks questions . . . they talk to us.
They ask for our guidance. What do you think? They
respect our opinion . . .
Calm and supportive demeanor under stress. A calm
and supportive demeanor emerged as an integral part
of effective communication for participants. This

seemed particularly important in high-stress and
emergency situations. Many participants mentioned
the need for calm communication that included atten-
tion to a collegial tone and normal volume. For
example, “And it looked like we knew we were not
going to be able to have a positive outcome in this
situation but the doctor was calm.” “I think some-
times even with the tone you know if there are cul-
tural differences the urgency of a situation may be
misunderstood.”
Participants also expressed that effective communi-
cation included showing support and appreciation.
For example, “It is important to let the other staff know
that they have indeed done what was expected of them
and provide positive reinforcement.”
Maintenance of mutual respect. Effective communi-
cation was considered respectful. Respect for one
another was tied to the establishment of a relationship.
For example, “I think a good relationship between the
communicator and the receiver.” “Good communica-
tion would be enhanced by that nurse having a good
relationship with the physician.”
The theme also included the idea that trust was
important to effective communication. Patients were
served best when the members of the profession could
rely on each other. For example,
When I was an intern I got taken aside by my attend-
ing . . . who said the nurses are afraid of you. How
can they be afraid of me? Well you are sarcastic. Well
that is my personality and he said something which
is true and very important which is they are not here
for your personality. They have to be able to talk to

you about what they are seeing. If they are afraid
that you are going to snap at them they will not be
willing to tell you if they are not sure about some-
thing. The point of communication is that they will
talk to you. It is not so that you can express your
sense of humor and that was probably the most
important thing anybody told me in supervision
through my whole life.
We find because we know the same kids . . . if one of
us says to the other . . . “does not this kid remind
you of X?” and then we can figure out what it is that
is bringing that to our minds and we usually come
to the right place.
Authentic understanding of the unique professional
role. An authentic understanding of what each profes-
sional uniquely provides in terms of patient care was
seen as an important factor in effective communication.
Nurses were particularly vocal about how lack of
understanding of their unique professional role led to
communication difficulties. For example, “I think one
of the problems is that most doctors have no idea what
nurses actually do and they think that what they are
doing is carrying out orders and treatments and giving
medications.” “I think that where I find the poorest
communication is with physicians that don’t under-
stand the role of the nurse.” “I think a lot of it is lack of
insight into our role.”
An authentic understanding of what each
professional uniquely provides in terms of
patient care was seen as an important

factor in effective communication. Nurses
were particularly vocal about how lack of
understanding of their unique professional
role led to communication difficulties.
However, physicians also recognized that either
they or their colleagues did not understand the full
scope of professional nursing practice. They acknowl-
edged that recognizing unique roles and clarifying who
is doing what and why contributes to effective commu-
nication. For example, “The other thing that I have seen
a positive outcome in is recognizing each other’s
strengths and what you bring to the table.” “These are
the things that I am going to be doing and this is my role
and this is what you are supposed to do.”
Ineffective Communication
Making someone less than (derision). Participants
clearly expressed that derision contributed to ineffec-
tive communication. Often this included humiliating
colleagues and making them feel incompetent. For
example, “I looked at the baby and obviously I did not
know anything and I did not do anything and the next
morning she said to me that the baby died because you
did not call your senior soon enough.” “He said in the
presence of the patient, ‘It is amazing on this floor; the
nurses don’t know what they are doing.’ ”

These tactics resulted in making members of one
profession feel less than their colleagues in the other
profession. Bullying and intimidation were also com-
monly used tactics. For example, “It came across as
panic and bullying and ‘do this’ and ‘do that’ instead of
a team and let’s get together in one room. . . . [and say]
This is what is going on.” “When he came back on the
unit, he was very upset with her and told her that she
can’t be paging him all the time for something that is
not important.”
Dependence on electronic systems. Many times, par-
ticipants credited communication problems with a
dependence on electronic information systems that are
supposed to support efficiency and enhance safety.
One nurse commented,
. . . electronic medical record[s] . . . put physicians
in this sort of fantasy. I had expected things to
happen because it was . . . in the computer, but it
goes a long way to have verbal communication and
also follow up on the things that had happened.
Specific examples of reliance on electronic informa-
tion systems were identified. A physician said,
I ordered it for earlier and did not tell the nurse I
just sort of put it in the computer and assumed it
would get done . . . but I did not tell the nurse; I
assumed that it would print up and she would get
it . . . and about four or five hours later she asked
me . . . “you wanted blood?”
Participants felt that electronic communication, in

many instances, had taken the place of face-to-face
dialogue. There was consensus that this was trouble-
some because it resulted in incomplete or fragmented
communication that often failed to reach the sender in
a timely manner. For example, “Computers do their
part, e-mails, phone calls, but actually having people
in the room in real time processing all of this is
invaluable.”
Linguistic and cultural barriers. A final ineffective
communication theme concerned miscommunication
attributed to differences in language. Multiple partici-
pants mentioned poor communication with individu-
als for whom English was not their first language. In
these instances, it appears as though the intended
message was not received. For example,
I have noticed . . . there is a language barrier . . .
their first language is not English and so communi-
cation . . . has been an issue at times . . . if there is a
way . . . to make sure they are able to communicate
in English with their physicians that would help
even the same the other way around as well.
Or “ . . . in the past . . . it is physicians or nurses
having a language barrier.” “ . . . that patient had a
bad outcome based on that . . . the nurse did not
understand what the question was . . . English was not
her first language.”

Participants also pointed out that differences in
culture contributed to ineffective communication. For
example, “ . . . language barrier not only with words
though. I think sometimes even with the tone . . . if
there are cultural differences the urgency of a situation
may be misunderstood so in that sense it is also . . . a
barrier.” Or
. . . more than half of our nurses are Asian and I
know we are generalized as submissive and subser-
vient and then we also have a doctor group that is
very diverse, too. They come from the Middle East
and India. Sometimes I wonder with all the cultural
diversity that is going on, a lack of training and lack
of communication skills and you put that all
together in a very stressful place like this, some-
times I wonder if that has a lot of bearing with how
we deal with each other and that we are not under-
standing each other, not just work-wise and role-
wise, but from where we came from and how we
were raised. . . . The things that I see, sometimes, I
stop and I say, “I wonder if he would have said that
to her or to me if I were Caucasian.”
Discussion
This study explored perceptions of effective and
ineffective interprofessional communication in hospi-
tals from the perspective of practicing nurses and phy-
sicians. The majority of the extant literature on
interprofessional communication is descriptive in
nature and uses observational or survey methodology
(Alvarez & Coiera, 2006). This study adds to the
growing knowledge base related to interprofessional
communication by using a qualitative focus group

methodology whereby professionals offered rich
descriptions of personal experiences with communica-
tion successes and problems.
Many of the themes validated previously sup-
ported evidence. The need for clear, precise commu-
nication that includes feedback mechanisms has been
identified as contributing to safety in the military
(Alonso et al., 2006) and the aviation industry (Helm-
reich, 2000). Likewise, recent guidelines for enhanc-
ing teamwork in health care recommend supporting
precise and accurate communication through a
closed-loop communication protocol, which means
ensuring that information sent was received and
interpreted correctly (Salas, Wilson, Murphy, King, &
Salisbury, 2008).
Additionally, collaborative problem solving was
seen as effective communication. This supports the
vast amount of evidence that suggests interprofes-
sional teamwork is an essential component of safe,
quality care (Salas et al., 2008). In fact, the collective
knowledge and situation awareness of members of an
interprofessional team exemplified through shared
problem solving is necessary for patient safety (Cook,
Salas, Cannon-Bowers, & Stout, 2000; Salas et al.).
Our data suggest that such teamwork is highly
prized by both nurses and physicians. Members of
each profession expressed how patients benefited
when team members came together to compare patient
data and problem solve. This idea is supported by
earlier work that suggests a link between nurse–
physician collaboration and positive patient outcomes
(Zwarenstein & Reeves, 2006).

Establishment of a relationship was seen as almost a
precursor to effective communication. That is, partici-
pants had to feel comfortable with each other in order
to communicate effectively. Relationships that were
based on respect and trust were seen as the ones that
most promoted quality care. In this respect, our partici-
pants felt that the ability to communicate effectively
grew over time, noting that members of one profession
had to “prove” themselves to members of the other
and “earn” their respect. One method to develop
deeper interprofessional relationships may be to
implement more frequent and comprehensive inter-
disciplinary rounds whereby nurses and physicians
really get to know each other and their respective
perspectives (Chapman, 2009).
Nurses expressed frustration that physicians did not
understand the independent nature of their practice or
the scope of their practice. Nurses expressed their dis-
appointment in being purveyors of tasks rather than
professionals. This complicates communication in
many ways. It would be difficult for communication to
be perceived as respectful if it was not based on an
authentic understanding of what one brings to the situ-
ation. In addition, true collaboration would not be pos-
sible if physicians did not understand what nurses
could contribute to problem solving or clinical decision
making. This profession-centric thinking is a construed
and preferred view of the world that is most likely
developed and reinforced through health profession
education (Pecukonis, Doyle, & Bliss, 2008). Given that

we educate health professions in silos, it is not surpris-
ing that they graduate and enter practice not under-
standing each other’s unique perspectives and unable
to communicate effectively with each other. Develop-
ing and implementing high-quality interprofessional
education pre- and post-licensure may enhance each
profession’s understanding of the other.
In terms of ineffective communication, our data
support the deleterious effect of derision on commu-
nication. Almost all participants could recall a time
when they felt humiliated at the hands of a member of
the other profession. This finding supports previous
research that indicated that the majority of nurses and
physicians have experienced or witnessed such disrup-
tive behavior in members of both professions (Grenny,
2009; Rosenstein & O’Daniel, 2008). The type of disrup-
tive behavior typified by derisive communication has
been associated with errors, compromises in safety and
quality, and patient mortality (Rosenstein & O’Daniel).
Some evidence supports that electronic communi-
cation mechanisms such as computerized order entry
may enhance quality care and patient safety; however,
such evidence is far from conclusive, with some data
supporting our participants’ perception that errors
may occur as a result of electronic communication
(Eslami, de Keizer, & Abu-Hanna, 2008; Wolfstadt
et al., 2008; Yu et al., 2009). Participants indicated that
reliance on electronic communication was problem-
atic. Most often, the problems occurred because the
messages were not received. Participants felt that com-
munication would be improved if electronic commu-
nication, especially that which is urgent, is followed
up with verbal contact. Such a tactic is in line with the

need for communication to be clear with mechanisms
for verification.
We collected our data in a large urban medical
center with a high percentage of nurses and physicians
from countries outside the United States (Philippines,
China, Middle Eastern countries, etc.). In every group,
participants spoke about not being able to understand
colleagues because of poor language skills or difficult
accents. Furthermore, participants pointed to adverse
patient outcomes because they were not understood,
which they attributed to lack of language skill on
behalf of the receiver. Others attributed communica-
tion problems not as much to language barriers but
rather to cultural barriers, including attributing par-
ticular stereotypical traits to others based on ethnicity.
While much work has been done related to the effect of
language and culture on the provider–patient relation-
ship, we found no research that investigated these
phenomena in the context of interprofessional
relationships.
Limitations
The study presents several limitations. While
viewing the questionnaire prior to the focus group
session enabled forethought and reflection, it may also
have yielded scripted and socially desirable responses.
Even though the use of multiple facilitators could have
added to the richness of the data, it could also decrease
reliability across groups. The sample size was small
and most likely not representative of most institutions.
Conclusion
The results of this qualitative study are not meant to

be generalized beyond the particular sample and
setting. However, awareness of the themes could be
a good starting point for encouraging nurses and
physicians to reflect on their own contributions to
effective and ineffective communication. Additionally,
given that interprofessional education is a key strategy
to improve quality care and patient safety, the themes
could be used to design learning activities for nursing
and medical students, including discussions, simu-
lations, and role playing. Future research should
attempt to verify these themes and evaluate strate-
gies to increase effective interprofessional commu-
nication and decrease ineffective interprofessional
communication.
Author contact: [email protected], with a copy to the
Editor: [email protected]
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