Nurse communication supports collaboration and care coordination

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Collaboration underpins comprehensive palliative care and continuity of care. And good communication underpins collaboration.

Nurses can facilitate communication within the care team through:

  • their ongoing assessment and communication of the current and anticipated needs of the person, their family and carers
  • alerting relevant team members to significant change in a person's condition
  • their understanding of the roles, responsibilities, and expertise of other team members
  • their understanding of who (internal and external to the team) is involved in a person’s care
  • clear, respectful communication (verbal and written)
  • coordination of scheduled communication among team members (e.g. meetings)
  • support from leaders or managers.

Nurses can play a role in pulling together the various providers and ensuring that their points of view are heard, misunderstandings are prevented or resolved, and a comprehensive plan of care is created that reflects input from all. With experience and seniority a nurses' contribution towards this is likely to grow.

There are programs specifically developed to guide inter-disciplinary team collaboration and communication including:

Case conferences are also known as family meetings. These meetings usually bring together the health care team to discuss issues relating to clinical care and coordination of care. The person with life-limiting illness and their family may also be invited to ensure that the focus is on their needs and care preferences.

Case conferences can be of greatest value when:

  • they are structured and led by a skilled chair
  • all members have the opportunity to contribute
  • using agreed and common language
  • actions and responsibilities are clearly articulated
  • discussions are documented.

Begin by asking what guidance and protocols your organisation already has in place. Tools such as ISBAR (Situation–Background–Assessment–Recommendation) model can help to guide discussions by:

  • identifying or introducing the person, self, and team
  • describing the situation - the person’s name, location, any cause for concern
  • giving a one-line summary of the background
  • providing an assessment of what is occurring
  • offering a recommendation or seeking advice based on that assessment.

As a person’s needs and priorities shift, nurses often communicate these to other members of the care team (internal and external to the same organisation).

It is often the registered nurse who will decide when to contact the person’s GP. They may also need to liaise with palliative care specialists.

Some approaches to facilitating conversation and involvement of an external care provider such as GP, other health professional or service include:

  • Telehealth appointments
  • Providing information on Medicare Benefits Schedule (MBS) remuneration for General Practitioners and Specialists see: Remuneration for palliative care services
  • Clearly stating the reason for your call and explaining recent changes and their impact on the person (e.g. symptoms, mobility, alertness, distress, function). To make the assessment and decision easier for the doctor/specialists include a brief description of:
    • the person’s vital signs
    • the person’s status
    • current nursing care and what has changed
    • how they can help (e.g. an assessment, a prescription, a referral).

Effective communication is essential when all or part of a person’s care is transferred between locations, clinicians, or different levels of care within the same location. This includes:

  • a change in care staff (for example, shift change)
  • when a person is transferred to another care service or organisation (for example from hospital to an aged care home, another hospital, or hospice)
  • when a person is moved within an organisation (for example to a different ward or for tests)
  • when a person is discharged to home.

The context of the handover determines whether the handover is communicated verbally or in writing.

Tools that can be used to facilitate communication during clinical handover include:

  • ISBAR (Identify, Situation, Background, Assessment, Recommendation)
  • SBAR (Situation, Background, Assessment, Recommendation)
  • SHARED (Situation, History, Assessment, Risk, Expectation, Documentation)
  • I PASS the BATON (106kb pdf) (Introduction, Patient, Assessment, Situation, Safety concerns, Background, Actions, Timing, Ownership, Next)

What is included in a handover summary will depend on the context and reason for handover. For a person with palliative care needs, handover information is likely to include physical, social, psychological, and spiritual aspects of care. Handover notes might include preferred place of death, phase of illness, and functional ability (AKPS). In deciding where handover takes place, consideration should be given to what information has already been provided to the patient and their level of fatigue.

A handover, where appropriate, will include:

  • the person’s identity
  • the person’s status (diagnosis, clinical assessment with any recent alerts, and clinical condition – stable, improving, deteriorating)
  • recent concerns (physical, psychosocial, spiritual) of the person, family or carer
  • medications
  • emerging new critical information (recent changes, investigation results, information outstanding or needing follow-up)
  • agreed care plan and priorities of care
  • people responsible for the person’s care (e.g. GP, specialist, nurse practitioner)

See Documentation for more on the list of minimum requirements for safe care for complex patients.

Interdisciplinary or multidisciplinary team meetings (MDT) aim to enhance collaboration within the MDT (medical, nursing, allied health and spiritual care). The composition of the team often varies. Meetings can include patient case discussions, decision-making, education and research. They may help a MDT coordinate care for people with complex needs, or discuss matters that are currently unclear or unresolved.

These meetings are usually facilitated by a nominated chair (105kb pdf) whose role is to:

  • ensure all participants are introduced
  • keep meetings to the agenda
  • initiate discussions
  • facilitate the full range of input into discussions
  • summarise the discussion and invite any further input before moving to the next case
  • negotiate resolution of conflict if necessary
  • promote mutual professional respect among all team members.

This information was drawn from the following resources:

  1. Australian Commission on Safety and Quality in Health Care (ACSQHC). Communicating with patients and colleagues [Internet]. 2022 [cited 2022 Sep 23].
  2. Australian Commission on Safety and Quality in Health Care (ACSQHC). Communication at clinical handover [Internet]. 2022 [cited 2022 Sep 23].
  3. Borgstrom E, Cohn S, Driessen A, Martin J, Yardley S. Multidisciplinary team meetings in palliative care: an ethnographic study. BMJ Support Palliat Care. 2021 Sep 30:bmjspcare-2021-003267. doi: 10.1136/bmjspcare-2021-003267. Epub ahead of print.
  4. Thomas JDL, Moment A, Abrahm J, Fitzgerald K. Communication between professionals Internet]. In: Cherny N, Fallon M, Kaasa S, Portenoy RK, Currow DC, editors. Oxford Textbook of Palliative Medicine. 5th ed. Oxford: Oxford University Press; 2015.
  5. Messam K, Pettifer A. Understanding best practice within nurse intershift handover: what suits palliative care? Int J Palliat Nurs. 2009 Apr;15(4):190-6. doi: 10.12968/ijpn.2009.15.4.41968.
  6. Nancarrow SA, Booth A, Ariss S, Smith T, Enderby P, Roots A. Ten principles of good interdisciplinary team work. Hum Resour Health. 2013 May 10;11:19. doi: 10.1186/1478-4491-11-19.

Page created 26 September 2022