Abstract This paper explores one published article that reports research concerning the perception of nurses and physicians communication at night about intensive care patients’ pain, agitation, and delirium. The authors are concerned with the level of accuracy to which interdisciplinary communication occurs in the intensive care unit. Nada Al-Qadheeb et al’s objective is to determine the perceptions of nurses and physicians communication in the intensive care unit at night, as communication between ICU caregivers can often times be complicated by the varying nature of illnesses, frequent assessments, frequent interruptions, and invasive procedures that occur in the ICU. “Ineffective nurse-physician communication in the ICU during the day can compromise patients’ safety, increase length of stay, and boost health care costs” (Al-Qadheeb et al, 2013). The article discusses the “perception” of communication between nurses and physicians at night while maintaining high-quality care to the critically ill patient. Evaluation of such perceptions has not been previously performed. The results of the study “highlights the importance of further qualitative and quantitative investigations on nocturnal ICU communication” (Al-Qadheeb et al, 2013). Further studies on this subject may help to improve nighttime communication between ICU clinicians and continue to impact interventions on outcomes that could improve patient safety, as well as quality of care. Keywords: Perception, communication, nighttime, intensive care unit Ineffective Communication on Night Shift in the Intensive Care Unit Methods and Results The survey was conducted at Tuft’s medical Center in Boston, Massachusetts. The medical Center is a 320-bed academic facility with 2 medical intensive care units (MICU’s). Prior to initiation of the surveys and investigation, approval was received by the appropriate institutional review boards. Prior to this investigation, no survey instrument could be found that focused on communication between ICU nurses and physician’s at night that could be adapted for use in the study. Al-Qadheeb et al reviewed articles and existing literature on communication in the ICU, particularly articles related to pain, agitation, and delirium in the critically ill patient in order to develop a new survey instrument. “The survey was designed to include questions about the recent nighttime experiences of each respondent with members of the other profession, the knowledge of each respondent about patients’ pain, agitation, and delirium, responses to vignettes, and attitudes toward both the respondent’s own actions and the actions of the other group” (Al-Qadheeb et al, 2013). Two surveys (instruments) were used in this study. The first survey was created for the physicians participating in the study. The second survey was created for the nurses participating in the study. “For the purpose of the survey, the nighttime period was defined at the time between 7pm and 7am, and a page was defined as each time an ICU nurse (or nurses designate) sent either the ICU telephone number or a descriptive text page to the ICU on-call physician” (Al-Qadheeb et al, 2013). Recall bias can be caused by differences in the accuracy of “recollections” by study participants regarding events from the past. In an attempt to avoid recall bias, the participants were asked only about the most recent night shift they had worked. “The surveys were administered to house staff physicians who had completed 1 or more MICU rotations in the past year at the medical center and to critical care nurses who currently worked 50% or more of their shifts at night in 1 of the 2 study MICU’s” (Al-Qadheeb et al, 2013). All participants were anonymous. There were no incentives and compensation was not provided to the respondents of the survey. The surveys were divided into 4 sections for both the critical care nurses and the physicians, respectively. Survey questions were constructed into these four categories: “demographics, number of communications and preferred communication delivery methods, communication urgency, accuracy, and delivery, and acceptance of recommendations” (Al-Qadheeb et al, 2013). Concerning questions on frequency, “5 different responses were provided on the basis of standard survey methods” (Al-Qadheeb et al, 2013). The responses and their representative percentages were measured as: “never or almost never, 10%: seldom, 30%; sometimes, 50%; often, 70%; and always or almost always, 90%” (Al-Qadheeb et al, 2013). 45 critical care nurses and 75 physicians were initially sent the surveys. “Of these, 30 nurses (67%) and 56 physicians (75%) responded. Most nurses (73%) had worked at night in a MICU for more than 5 years, and most physicians (68%) had completed 3 or more 4-week MICU rotations during which they were on-call at night for 8-10 hours per rotation” (Al-Qadheeb et al, 2013). “Among the ICU nurse-physician interactions thought to occur during a typical night (via pager or face-to-face), the proportion pertaining to pain, agitation, and delirium was similar between nurses (35%) and physicians (31%)” (Al-Qadheeb et al, 2013). “Nurses (63%) and physicians (55%) each perceived that more communication related to pain, agitation, and delirium were initiated via text message than face-to-face” (Al-Qadheeb et al, 2013). If a physician was receiving a page from a bedside nurse concerning pain, agitation, or delirium the physician seemed to prefer a short message describing the situation, rather than the ICU telephone number. Both the nurses (80%) and physicians (70%) agreed that nurses use good judgment when paging a physician at night about issues with pain, agitation, and delirium. However, the perception and urgency of the page sent to the physician differed between nurse and physician. 71% of nurses believed that their page accurately portrayed the clinical situation. Whereas, 48% of physicians accurately perceived the urgency and accuracy of the message received. Physicians were asked, “whether nurses make changes in medications for pain, agitation, or delirium before contacting the on-call physician” (Al-Qadheeb et al, 2013). It was shocking to read that physicians (41%) strongly believed that this practice occurs. Physicians were also more likely to perceive that the nurses were seeking an order from the physician for something the nurse had already done (32%). These results suggest the physicians consider the judgment of the critical care nurse but do not “perceiving” the accuracy and urgency of the messages being communicated. Discussions and Conclusions “The perception between nurses and physicians about the communications at night regarding pain, agitation, and delirium were numerous and should be studied further” (Al-Qadheeb et al, 2013). There are many influencing factors that can weaken communication between a critical care nurse and the physician. Any miscommunication between care givers can adversely affect a patient’s safety and outcome. “During the first evaluation of the perceptions and practices of ICU nurses and physicians about the communication they have with each other at night, in the context of pain, agitation, and delirium, raises a number of concerns” (Al-Qadheeb et al, 2013). Initial results indicated that nurses and physicians communicate frequently at night concerning pain, agitation, and delirium. However, “the quality of the communication is often perceived as low” (Al-Qadheeb et al, 2013). Both the MICU nurses who send a page and the on-call physician who receives the page think that nurses use good judgment when paging the physician about issues related to pain, agitation, and delirium. On the contrary, nurses and physicians will “often assign a different level of urgency to the same clinical situation” (Al-Qadheeb et al, 2013). Al-Qadheeb et al provide the example, “far more nurses than physicians attribute a high degree of urgency to a patient who is agitated despite the administration of 1 as needed sedative dose. The on-call physician perhaps assumes that the nurse will administer 1 or more additional doses before the nurse pages the physician about this issue, even though an order for the nurse to administer additional doses before the nurse calls the physician may not exist” (Al-Qadheeb et al, 2013). The study determined that there are many barriers to effective nurse-physician communication, especially at night. Reliance on an institutional text paging system when the on call system is away from the MICU is a concern for the communication between clinicians and triage of problems. “Physicians clearly placed a premium on receiving a descriptive text page from nurses about a problem related to a patient’s pain, agitation, and delirium and were frustrated when a text page contained nothing more than the ICU telephone number” (Al-Qadheeb et al, 2013). From the nurse’s perspective, “delivery of the ICU telephone number may have simply reflected the inability of a nurse to leave the bedside of the nurse’s patient if the patient’s condition was unstable (i.e. acute agitation) or the situation was too complex to be communicated to the on-call physician in a text page that allows just a few words” (Al-Qadheeb et al, 2013). “The findings that nurses often perceive that physicians appreciate neither the urgency nor the complexity of the situation that a nurse is trying to communicate via text page, also highlights the inefficiency in nurse-physician communication that results from using text messages to page an on-call physician at night” (Al-Qadheeb et al, 2013). The study found that of the pages sent by the nurse to an on-call physician “to come directly to the MICU to manage an issue related to acute pain, agitation, and delirium, the physician did not realize in 1 of 4 pages that the nurse was requesting the physician’s presence at the patient’s bedside” (Al-Qadheeb et al, 2013). The multiple limitations of the text paging system further hinder communication between nurses and physicians at night. All data was self-reported, no validation or verification of accuracy was completed. The authors believe that, based on their clinical experience, “respondents may have inferred that additional circumstances existed in one or more of the patient scenarios presented” (Al-Qadheeb et al, 2013). All of the nurses and physicians who participated in the study work in the same MICU, at the same academic center, and thus may not represent the perception of nurses and physicians who work in other ICU’s or other hospitals where communication technology and protocols for treating pain, agitation, and delirium may be different. All of these limitations provided further evidence that additional investigation is required in regard to the perception of nurses and physicians of their communication at night about intensive care patients’ pain, agitation, and delirium. Al-Qadheeb et al conclude the outcome of the study, which builds on the importance of teamwork in the ICU, determined that further investigation should lead to a protocolization of communication between nurses and on-call physicians at nighttime. “Technological advances should facilitate the ability of a bedside nurse to provide an on-call physician (who is not present in the ICU) with the pertinent information in real time that will facilitate better quality decision making and decrease communication” (Al-Qadheeb et al, 2013). The study determined that further qualitative and quantitative studies are important to improve nighttime communication between ICU nurses and physicians to ultimately improve patient safety and outcomes.

References Al-Qadheeb, N., Hoffmeister, J., Roberts, R., Shanahan, K., Garpestad, E., & Devlin, J. (2013) Perceptions of Nurses and Physicians of Their Communication at Night About Intensive Care Patients' Pain, Agitation, and Delirium. American Journal of Critical Care, Vol. 22, E49-E61. Retrieved September 2, 2014 from https://www.ajcc.aacnjournals.org/ajcc2013565