Background

There is a large and developing body of literature indicating that there is an increasing need for improved communication skills among health care professionals.1-5 Ineffective communication has been attributed as one of the most common causes of hospital related incidents, which is currently estimated to be around $A2 billion per year.6-11 Inadequate quality or lack of communication between nurses and physicians has been found to be accountable for approximately 37% of errors in intensive care units.12-15

Emergency department (ED) professionals are extremely busy due to the high volume of patients that are treated each day. Studies of ED consultants show that communication consumes the highest percentage of their time (42% of each hour), with about 88% of this time spent in communication with other ED professionals.16-19 Yet there are few available training programs that address communication, interpersonal and influencing skills among health professionals.20-23

Communication skills training has been shown to improve ED doctors' communication skills with a flow-on effect being an increase in patient satisfaction and a reduction of complaints against ED doctors.14,17,20,24 A number of studies found that efficient communication and effective interpersonal interactions are vital capabilities in most workplaces, and particularly in demanding and high risk work environments, such as EDs.13,25,26

Emergency departments are consistently described as high-risk environments for patients and clinicians because of the demand on clinicians to work together as a cohesive group at a fast pace.6,16,20,27,28 Without good communication and cooperation amongst members of an ED team, team members are at risk of lacking vital information.6,29,30 The flow-on effect will be that the ED work environment, as well as the parent organization, may suffer, leading to poor quality of care and a greater propensity for errors.13,20,31

Poor communication and coordination have been identified as research priorities for improving patient safety in developed countries.6,12,14,16 This has resulted in an increasing amount of research focused on health professionals' communication in the hospital setting. This research has predominantly been descriptive, with communication issues being identified and described.16,17,20

There appears to be a paucity of intervention research that addresses these communication problems through developing and implementing educational interventions designed to improve health professionals' communication skills. There are two types of educational interventions targeted at improving health professionals' communication skills. First, there are specific communication training programs.7,32 These training programs often focus on improving a particular communicative event, such as handover. For example, staff may be trained in the use of a structured communication protocol to improve the adequacy of the information communicated during the communicative event.5,7 Second, there are teamwork training programs that include communication training. Crew Resource Management (CRM) and TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety), both of which originated in aviation and defence, are two teamwork training programs that appear to have been the most widely implemented in EDs.33-37

Crew Resource Management or Cockpit Resource Management is a set of training procedures that are used in high risk environments where the impact of human error can have devastating effects. Cookpit Resource Management focuses on interpersonal communication, leadership and decision making in the cockpit. TeamSTEPPS are a comprehensive set of teamwork based tools, aimed at optimizing patient outcomes by improving communication and teamwork skills. The training curriculum, therefore, aims to successfully integrate teamwork principles into the health care context. More recently, there have been training programs that have combined CRM or TeamSTEPPS instruction within simulation-based training.14,20,34,35,38,39

The objective of this review is to explore the effectiveness of educational interventions that have been used to improve ED health professionals' communication skills in relation to a more cohesive environment for staff and improved patient care. A preliminary search of literature including the JBI Database of Systematic Reviews and Implementation Reports, the Cochrane Database of Systematic Reviews and MEDLINE Complete indicated there are no other reviews completed or underway on this topic.

Inclusion criteria

Types of participants

This review will consider studies that include all health professionals or clinical support administrative staff in emergency departments in Western countries, including the United States, United Kingdom and Australasia, for example, administrative staff (register patient information when they arrive at the ED), nurses (provide and co-ordinate patients' care during their stay in the ED), doctors (assess patients' condition and start treatment for their illness), emergency physicians (senior specialist doctors who supervise the overall medical care in the ED), allied health staff (cover a broad range of trained workers and may be asked to help with patient care. These include physiotherapists, occupational therapists, social workers, pharmacists, radiologists and mental health workers).

Types of intervention(s)

This review will consider studies that evaluate any structured communication or educational intervention designed to improve communication among health professionals applicable to the ED setting. Examples of interventions are written, verbal, combined written and verbal ones being delivered to individuals, groups or whole teams of staff. These may be programs that have been designed locally for in-house implementation or established programs that have been brought in and delivered. As such, they may be didactically taught, incorporate simulation or be experiential. Comparator interventions, such as TeamSTEPPS, CRM, VA Medical Tram Training (VA MTT), will be identified and reported in this review.

Outcomes

The primary outcome for the educational interventions to be reviewed will be improved quality of patient care. Improved quality in this context will include measures of enhanced patient safety such as a reduction in adverse event rates or patient complaints. Staff are integral to patient outcomes, therefore any study of educational interventions that result in improved staff performance will also be included. Secondary outcome measures include, but are not limited to, behavior change (after participating in the intervention program), attitudes and confidence (gained through the intervention program), and knowledge and skills (received through the intervention program).

Types of studies

The quantitative component of the review will consider both experimental and epidemiological study designs including randomized controlled trials, non-randomized controlled trials, quasi-experimental, before and after studies, prospective and retrospective cohort studies, case control studies and analytical cross sectional studies for inclusion.

Search strategy

The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe an article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Third, the reference lists of all identified reports and articles will be searched for additional studies. Studies published in English only will be considered for inclusion in this review. In order to obtain the most current and evidence based studies, a decision was made to include contemporary studies published between 2009 to present.

The databases to be searched include:

Agency for Healthcare Research and Quality (AHRQ)

CINAHL

EMBASE

MEDLINE Complete (EBSCO platform)

Nursing & Allied Health Collection

Psychology and Behavioral Sciences Collection

PsycINFO

The search for unpublished studies will include:

Center for the History of Psychology, Special Interest Collection

DNP (Doctor of Nursing Practice)

EIGE, Resource and Documentation Centre

Grey Literature in the Health Sciences

Google Scholar

OpenGrey

ProQuest Dissertations

Initial keywords to be used will be: medical staff; nurs*; physicians; allied health personnel; communicat*; educat*; combined with other terms; and cooperative behavior; emergenc*

Assessment of methodological quality

Quantitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.

Data extraction

Quantitative data will be extracted from papers included in the review using the standardized data extraction tool from JBI-MAStARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Authors of primary studies will not be contacted for missing information or to clarify unclear data because it is unlikely the reported quantitative data will require this level of scrutiny. Two principal reviewers will perform each stage of seek and confer if there are any disagreements. A third reviewer will mediate any persistent disagreement.

Data synthesis

Quantitative papers, where possible, will be pooled in statistical meta-analysis using JBI-MAStARI. All results will be subjected to double data entry. Effect sizes will be expressed as odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-square test and also explored using subgroup analyses based on the different quantitative study designs included in this review. Where statistical pooling is not possible the findings will be presented in narrative form, including tables and figures to aid in data presentation where appropriate.

Appendix I: Appraisal instruments

MAStARI appraisal instrument

Appendix II: Data extraction instruments

MAStARI data extraction instrument

References