An Example of Clarity in Communication: Study Paper
This example of clarity in communication presents the results of a quality assurance process that gathered feedback on the relevance and importance of the AIMA guiding principles document and letter writing templates. In addition, we have reported more broadly on the views and opinions of Australasian HCP in relation to IPC that includes communication between conventional and T&CM HCP. Our findings suggest there is a consensus that IPC and formal communication tools such as the AIMA letter writing resources play an important role in contributing to effective IPC that fosters patient-centered care and safety.
The importance of facilitating effective IPC using formal instruments has been reported in earlier studies and several initiatives and frameworks have been developed and evaluated that aim to circumvent the negative impact of poor IPC on patient care and outcomes. However, this is the first study to explore communication needs and gaps between a broader spectrum of HCP (medical, allied health and complementary medicine practitioners) that Australians engage as part of their health care. This study aimed to identify and address this gap by evaluating the AIMA guiding principles document and letter writing resources that aim to foster IPC between all HCP involved in a person’s healthcare. The meta-themes, clarity of communication, continuity of care and professional practice, embody an overall view that all HCP must play an active role in cooperating and engaging in formal communication to ensure the delivery of patient-centered, quality healthcare.
Clarity of Communication
Effective and open IPC involves clear, concise and comprehensive documentation of patient information to ensure coordinated and appropriate healthcare. While informal methods of IPC including face-to-face interactions or telephone calls are reportedly favored by HCP whether such communication is documented in patients’ records is largely unknown. Formal communication resources within the professional practice such as referral or discharge letters and reports remains one of the most frequently used between conventional healthcare providers. The recommendation by AIMA to only use technical words in letters of correspondence that are understood by other HCP seemed to be well received by the study participants. In keeping with other research, participants highlighted that the use of different ‘medico’ language and the terminology impacts the clarity of communication. Interdisciplinary differences in professional knowledge and roles were noted to further influence what information is communicated and how it is received, understood and incorporated in patient care, along with its perceived importance. The ‘cultural-language-disciplinary’ barriers between conventional and T&CM HCP were often given a reason for implementing strategies that support IPC.
Education and training that focus on clarity of communication, have been shown to promote effective and easily understood information during patient handover. The importance of ‘cross-cultural/cross-disciplinary’ training and support that promotes clear, standardized and technically accurate letters of correspondence is supported by our results and those of others and was viewed as critical to promoting effective IPC. Central to this is an agreed, standardized healthcare-language that promotes a clearer understanding of different approaches used by HCP. Feedback from study participants supports this premise and the development of the AIMA guiding principles and letter writing templates.
Previous studies have shown the implementation of the standardized SBAR (Situation, Background, Assessment and Recommendation) as a verbal communication tool helps bridge communication gaps observed between different HCP. Similarly, the extended ISBAR framework (I: Identify) has been shown to support patient handover and cultivate collaboration between HCP. The AIMA letter writing resources adopted a modified framework version of ISBAR that extended ‘A’ to include ‘actions’ and ‘R’ to include ‘requests’. Whilst the working group was keen to use the evidence-based tool, the modifications helped apply the acronym to letter writing. Collectively bringing the elements of the ISBAR framework and a common healthcare-language into the AIMA guiding principles and templates seeks to bridge ‘cultural/disciplinary’ barriers to effective IPC.
Continuity of Care
Effective IPC plays an essential role in providing continuity of care that is patient centered. To this end, the study results affirmed the importance of minimizing miscommunication between HCP when they realize and optimize the skills and expertise of other HCP involved in a patient’s care. Whilst the open-ended comments mostly focused on effective IPC as a way to promote patient-centered care, it is noteworthy that patient-centered care that actively involves the patient as an integral part of the transmission of their medical/health information also improves continuity of care. Further, patients who have a detailed understanding of the treatments they are receiving from their HCP, have a reduced risk of harm associated with poor communication.
The transition of a patient’s care from one HCP to another requires the transmission of relevant, accurate and easily understood information about the patient’s clinical history and current treatments. The results of our study suggest that HCP could see the relevance of the structured approach recommended in AIMA letter writing resources for promoting continuity of care across a range of HCP and reducing miscommunication. Indeed, the SBAR communication framework also plays a role in the continuity of care. Shahid et al examined the utilization of the SBAR communication tool in multiple clinical settings, reporting a favorable impact on reducing hospital readmissions and unexpected mortality. The results of our study also suggest that HCP could see the relevance of the guiding principles and the structure of the templates to clinical practice and effective continuity of care across a range of HCP.
While there are a number of dynamics to consider in regards to IPC within multidisciplinary care, Mills et al, suggests that both an understanding and respect for the roles of HCP are essential to effective continuity of patient care. Similarly, other studies have identified having clarity about other HCP roles enables each HCP expertise and skills to be used in a timely and appropriate way to optimize patient care and outcomes.
Professional Practice
The professional practice environment and associated day-to-day logistics were identified by HCP in this study as having a negative impact on IPC. This finding is not new and has repeatedly been reported in the IPC literature. The limited time to dedicate to letter writing was raised as a barrier to effective formal communication. Furthermore, an association has been made between the time spent writing letters and the quality of a patient’s medical records. As medical records transition to electronic health systems, the implementation of these templates using an automated system was considered within the development of the templates. Electronic health systems have been proposed to increase the likelihood of comprehensive documentation by HCP. This view is supported in our results suggesting a more concise resource implemented within the electronic health system or program would be suited to the limited time HCP have to devote to IPC.
Our findings further confirm ongoing concerns about the legalities of conventional HCP referring to T&CM HCP and align with earlier reports. In line with other research, a lack of clarity about professional roles and responsibilities were considered an impediment to formal IPC by medical doctors. Balancing medical practitioners’ duty of care for patients, that includes appropriate referrals to promote continuity of care is challenged by the associated medico-legal uncertainties when referring to T&CM HCP. Based on the results of this study, these medico-legal uncertainties around IPC are yet to be completely resolved. Formal communication strategies that advance practice and build trust between HCP could, therefore, benefit from a stronger regulatory framework of T&CM HCP in Australasia.
Medico-legal concerns about IPC between conventional and T&CM HCP is likely related to the complex interplay between understanding, respecting and trusting the role of HCP who are outside the medically dominant healthcare system. This medically dominant paradigm has developed over centuries and in many countries is supported by statutory law, with arguably the patient interests at the center. Medical practitioners have final authority and responsibility for patient care within the field of medicine. Within the context of IPC, it has been argued that to foster effective IPC that is in line with patients’ healthcare choices, conventional medical doctors will need to shift from the culture of their professional silos to optimize multidisciplinary care so patients may benefit from the skills and expertise of a broader team of HCP. Aligned with this study, the professional cultural differences between conventional and T&CM HCP were emphasized, signaling the need for education between and within HCP disciplines. A lack of understanding and respect for each other’s roles will likely reduce appropriate referral between conventional and T&CM HCP. The interplay between respect and trust has been reflected in other studies, highlighting the importance of these two factors in supporting a progressive practice that positively impacts effective IPC.
Study Limitations
While overall the value of IPC and the format and content of the AIMA resources were considered important for improving HCP professional practice, there are limitations that need to be considered. Firstly, combining the quantitative and qualitative data for the analysis may have resulted in double counting as it was not possible to know whether a participant completed both the CPD event questionnaire and online survey. Nevertheless, given the overall consistency of the results both within and between the two samples, any double counting is unlikely to have affected the overall conclusions. The underrepresentation of some HCP in particular pharmacists, nurses and medical specialists being obtained from the study participants, in turn, may limit the generalizability of our findings. Further studies would be helpful to gauge the perspectives of these HCP. Despite an underrepresentation of some HCP, the views obtained from general practitioners and T&CM HCP support the quality and value of the AIMA resource.
Conclusion
HCP from a range of disciplines distinctly value the importance of effective IPC in facilitating coordinated patient-centered care. There are multiple factors impacting effective IPC and the AIMA Guiding Principles for Letter Writing will not solely address all of these. The IPC resource that is the subject of this study was considered to be both a relevant and practical resource. Further studies and intervention strategies such as education focused on IPC that fosters continuity of care, clarity in communication and professional practice IPC standards in addition to advocacy for IPC by professional groups are encouraged.
Practice Implications
The feedback obtained from a range of stakeholders who participated in this study and are involved in patient care have informed changes to the AIMA Guiding Principles for Letter Writing and associated documents. HCP have emphasised the importance of IPC and thus the AIMA resources have potential in bridging the gap of IPC across all HCP, predominantly between conventional and T&CM HCP as confirmed by our sample size of these HCP. Further, the disclosure of other HCP writing to administration/ health managers informs the need to develop letter writing templates also aimed at these professionals. The final document and letter writing templates can be used in the development of IPC education and training as well as CPD for undergraduate and post-graduate health care professionals to foster effective IPC and therefore improve patient care and safety.
