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Characterizing medical and nursing student communication using verbal listening behaviors and closed loops in simulated health care delivery




Rosser, Paul M., author
Makela, Carole, advisor
Barley, Gwyn, committee member
Gloeckner, Gene, committee member
Maynard, Travis, committee member

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Few issues are more unsettling than the persistent threats to patient safety from medical errors; communication failure among providers is among the leading causes for medical errors (The Joint Commission, 2012). Significant reduction of medical errors is constrained by a lack of understanding for the causes of communication failure; the bulk of knowledge about communication failure is known after such failures result in medical errors. The problem addressed in this dissertation is the lack of tools to study provider-provider communication in progress. The study included here aims to demonstrate one means by which provider-provider communication can be successfully characterized. Few studies of provider-provider communication during care delivery have been conducted. Some understanding of information exchanges has been provided from studies by communication and listening scholars in health care and in other fields where precise communication is essential. However researchers lack the ability to recognize the specific components in an information exchange between two or more providers that indicate communication has succeeded or failed. These conditions leave new studies without testable theories and offer no reasonable basis for hypotheses about communication failure. This study employed an exploratory inquiry strategy and leveraged verbal listening behaviors in closed loop communication (CLC) to identify characteristics of communication. Observations were conducted of medical (MD) and nursing (RN) student teams managing Emergency Medicine (EM) simulations. Observers accessed the videotaped EM encounters at the Center for Advancing Professional Excellence (CAPE) at the University of Colorado Denver's Anschutz Medical Campus (UC/AMC). Students' verbal listening behaviors were used to characterize their exchanges of information; CLC provided a framework to identify and position the listening behaviors in exchanges of information. This study had three goals, which were revised based on learning gained from the study. 1. To identify specific steps in provider-provider exchanges of information where communication succeeds and fails--is revised to--To characterize the exchanges of information among the MD and RN student teams during simulated care delivery. 2. To describe the characteristics of communication sufficiently to assess outcomes of communication loops not being closed--is deleted as data gathered did not support this goal and the goal was determined to exceed the scope of the study. 3. To recommend hypotheses to study to inform providers' communication curriculum, professional development, and subsequent research--The exploration and data supported this goal and it was retained. Hypotheses for future studies are detailed. Competencies and decision-making: Hypothesis One. There is a negative correlation between students' demonstration of specific communication competencies and specific clinical decision-making competencies in the same simulation of care delivery. Researchers should consider study participants' level of communication education and/or practice experience when deciding the type and number of competencies to be evaluated in the study. Level of communication skill and competencies: Hypothesis Two. There is no relationship between IP teams whose members are closely matched with respect to their level of acquired communication skill and their ability to demonstrate communication competencies. The data suggests that researchers should minimize disparities among study participants' education and/or practice experience. Nonverbal behaviors: Hypothesis Three. There is no relationship between nonverbal behaviors and the ability to more thoroughly identify the contributing factors for successful and unsuccessful communication. This study and the literature make a case for nonverbal behaviors to supplement, expand, and give clues to underlying issues in the associated verbal behaviors. Hypothesis Four. There is no relationship between increasing acuity of the care delivery encounter and the number of information exchanges that end in closed loops. Provider-provider observational studies demonstrate as acuity of the condition being treated increases participants' listening behaviors increase and, in some cases, communication competency declines. Educators and providers need precise understandings of communication failure to confidently advise changes to curriculum and practice and produce the health professions work force to deliver that care.


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closed loop communication
listening behaviors
medical errors
patient safety


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