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I.
Clinical environment (system)
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Work overload |
“I think in intern years you are literally asked to do impossible things. It is not possible to meet everyone’s expectations, so you are always disappointing people. That is part of why it is so frustrating. Your workload is literally not possible. So you start choosing in which ways you take shortcuts.” |
| High acuity setting/ time pressure |
“Time is the biggest challenge. Taking the time to come up with cogent questions or dialogue and having the time to clear up any questions. Usually it is: I need this, I need this, I need this.” |
| Rapid changing healthcare teams |
“It so hard to attain familiarity with this enormous staff at every different location, on every different shift and then people are switching all the time. It makes it really disconnecting” |
| Electronic order entry |
“A lot of times it’s pretty easy, especially when it’s busy, to run out of the room an write your orders and never talk to the nurse.”
“The only times that I got in trouble, was when I was just throwing in orders and they were not done because I never communicated them to anyone as to why we were doing them.”
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II.
Interpersonal
relationships
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Mutual respect |
“A lot of the times where discussions have gone wrong, is where you didn’t care about the person’s name, you don’t care about how busy they are, or what they have to do, or you devalue or invalidate their opinion because you feel like you’re better trained just as a function of like ten year or the letters you have behind your name.”
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Hierarchy
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“I do think especially as a med student, and as a new resident, there tends to be a negative hierarchy, where your opinions are not respected in an appropriate way.”
“Something I was very aware of was how others really interacted with regards to their understanding of their position on the totem pole.”
“There’s some built-in antagonism between nursing and physicians, which is based on their roles and I don’t think we’ll ever be able to dissipate.”
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| Unfamiliarity |
“We’re not familiar with any of the training that either our PCA’s or nurses, or respiratory therapists go through”
“I still have problems where I don’t recognize what other peoples’ workflows are, and usually that’s when I still have conflicts when I am not appreciating what someone else’s priorities or attention is at that moment and I interject something sort of without realizing that I’m doing.”
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| Feeling part of team |
“Seeing the care team as a team, especially with the nurses, by going back and updating them on the plan so that they feel that they are updated and not just getting the computer orders.” |
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III.
Personal
factors
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Self confidence |
“I am not confident enough in myself yet that I feel comfortable a lot of times approaching anyone, but especially anyone more senior than I am.” |
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Fear
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“I think everyone has an intense fear of looking stupid or looking dumb. And that really prevents a lot of the communication” |
| (Uncontrolled) personal emotions |
“She was frustrated, and I was frustrated, and I was just like: “Aargh”, “What do you do?!” I snapped at her, and then I left, but then I thought: “That’s terrible.”
“I think that the biggest place I saw yelling was in the operation room from the attending surgeon to the scrub nurses, I noticed that the nurses would actually hide things from that surgeon.”
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| Conflict management skills |
“Always connect the conversation that you have to the patient, so you combine interests.”
“I think trying to find some sort of common point in discussion. I try to step back and try to realign the conversation to something everyone can agree upon doing.”
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IV.
Training
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Lack of formal training |
“We don’t have any obviously prior training in this area at all. I think that’s one of the reasons that we should. We are essentially trialed by fire since the day we start, especially as an intern.” |
| Lack of formal feedback/ debrief sessions |
“I think we tend to talk about our communication with nurses, without actually ever including them in the conversation.”
“Right now, there isn’t much feedback. There is no formalized feedback.”
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| Lack of role models |
“The lack of training left you looking to role models, and unfortunately most of the role models that we have are usually people who are the loudest, most assertive and maybe more aggressive end up in getting their job done. And then, in the hospital that sort of disruptive behavior is acceptable as long as the task is accomplished.” |
| Learning by trial |
“Almost all of my communication skills that I learned in residency, I have learned from doing things wrong first, and then later I learned how to do it the right way” |