In this issue of JNN, Siegler and colleagues report their findings of a prospective, mixed-methods pilot study of a Scheduled Provider Alert-Response Communication System (SPARCS) between nurses and residents at a tertiary care center. This article is an excellent example of development and testing of an effective communication strategy to reduce nurse-resident frustration and improve quality of care.
Purpose
The purposes of this study were to measure the effect of a communication strategy in reducing interruptive nursing notifications to the resident during scheduled educational conferences and overnight shifts and to describe subjective improvement of nursing and resident awareness regarding clinical concerns for hospitalized patients.
Significance
Effective communication strategies between nurses and residents can impact the patient care outcomes. Nonemergent nursing notification during work rounds, teaching conferences, and overnight call shifts can result in frustration for both nurses and the residents. The purpose and design of this investigation was developed by a multidisciplinary task force using a validated A3 problem-solvingapproach where a formal problem statement concerning interruptive nurse-provider communications led to the development of a specific series of interventions aimed to address the root cause of the problem.
Methods
This was a mixed-methods study using both quantitative and qualitative measurements. The trial was conducted during the middle of resident academic year to avoid skewing of results and had a 3-month preintervention period and a 3-month postintervention period. Nurses and residents participated in both aspects of SPARCS intervention, which included mandatory evening rounds and new standardized communication strategy for emergent, urgent, and nonurgent nursing notifications. Preintervention and postintervention surveys were conducted among nurses (n = 60 preintervention survey, n = 51 postintervention survey) and residents (n = 26 preintervention survey, n = 24 postintervention survey) who had worked a minimum of 3 overnight shifts during either preintervention or postintervention periods. Outcome measures that were quantified were as follows: (1) safety, number of adverse events reported; (2) utility, number of pages urgent and nonurgent during the prespecified periods; and (3) satisfaction, quantified residents' sleep duration per shift and survey response.
The Intervention
During the preintervention period, all nurse notifications regardless of urgency were communicated immediately to the resident. Protocols regarding urgency of notification were reinforced by the charge nurse during the "nursing huddle" at change of nursing shift, and any concerns regarding urgency of notifications were reviewed. During the postintervention period, "nonurgent" notifications were entered in a logbook to be reviewed by the covering resident twice during the daytime shift and twice during the evening shift. The "urgent" notifications during scheduled teaching conferences were entered by the unit nurse into the logbook and reviewed by the covering resident twice during the day. During the night, the urgent notifications were logged and communicated to the covering resident in "batches" by the charge nurse at 2-hour intervals. For "emergent" notifications, the unit nurse could directly telephone the covering resident to communicate the concern, both during the day and the evening. If the urgency of the concern was unclear to the unit nurse, it was up to his/her discretion whether to first notify the charge nurse for triaging of the notification or to bypass the charge nurse to immediately notify the covering resident.
Results
A total of 728 patients (n = 360 preintervention and n = 360 postintervention) were admitted during the study, with no significant differences in the patient medical complexity during preintervention and postintervention periods. The same nurses (n = 71) participated during the preintervention and postintervention periods, with 26 residents in the preintervention period and 25 in the postintervention period. Of the 704 resident-recorded notifications, 50% did not require immediate intervention and could be safely deferred until change of shift or after academic conferences. There was a mild-moderate agreement in perceived notification urgency between external validators and unit nurses ([kappa] = 0.43). During the postintervention period, there was an overall decrease in the nurse-reported notifications per patient (P < .01) with an increase in notification per patient for restraint and telemetry order (P < .05). The postintervention survey findings showed favorable responses from nurses and residents regarding safety, utility, and satisfaction measures (P < .05 for most metrics).
Clinical Implication
This intervention has the potential to improve the nursing awareness about patient issues and promote nursing autonomy, in accordance with the 2017 recommendations from the American Association of Neuroscience Nurses. On the basis of the root problem of nurse-resident communications, the SPARCS model may be a helpful intervention in other institutions.