Communication
2.4 Communicating with Health Care Team Members
Professional communication with other members of the health care team is an important component of every nurse’s job. See Figure 2.8[1] for an image illustrating communication between health care team members. Common types of professional interactions include reports to health care team members, handoff reports, and transfer reports.
Reports to Health Care Team Members
Nurses routinely report information to other health care team members, as well as urgently contact health care providers to report changes in patient status.
Standardized methods of communication have been developed to ensure that information is exchanged between health care team members in a structured, concise, and accurate manner to ensure safe patient care. One common format used by health care team members to exchange patient information is ISBARR, a mnemonic for the components of Introduction, Situation, Background, Assessment, Request/Recommendations, and Repeat back.
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- Introduction: Introduce your name, role, and the agency from which you are calling.
- Situation: Provide the patient’s name and location, why you are calling, recent vital signs, and the status of the patient.
- Background: Provide pertinent background information about the patient such as admitting medical diagnoses, code status, recent relevant lab or diagnostic results, and allergies.
- Assessment: Share abnormal assessment findings and your evaluation of the current patient situation.
- Request/Recommendations: State what you would like the provider to do, such as reassess the patient, order a lab/diagnostic test, prescribe/change medication, etc.
- Repeat back: If you are receiving new orders from a provider, repeat them to confirm accuracy. Be sure to document communication with the provider in the patient’s chart.
Read an example of an ISBARR report in the following box. A hyperlink is provided to a printable ISBARR reference card.
Sample ISBARR Report From a Nurse to a Health Care Provider
I: “Hello Dr. Smith, this is Jane White, RN from the Med Surg unit.”
S: “I am calling to tell you about Ms. White in Room 210, who is experiencing an increase in pain, as well as redness at her incision site. Her recent vital signs were BP 160/95, heart rate 90, respiratory rate 22, O2 sat 96%, and temperature 38 degrees Celsius. She is stable but her pain is worsening.”
B: “Ms. White is a 65-year-old female, admitted yesterday post hip surgical replacement. She has been rating her pain at 3 or 4 out of 10 since surgery with her scheduled medication, but now she is rating the pain as a 7, with no relief from her scheduled medication of Vicodin 5/325 mg administered an hour ago. She is scheduled for physical therapy later this morning and is stating she won’t be able to participate because of the pain this morning.”
A: “I just assessed the surgical site and her dressing was clean, dry, and intact, but there is 4 cm redness surrounding the incision, and it is warm and tender to the touch. There is moderate serosanguinous drainage. Otherwise, her lungs are clear and her heart rate is regular.”
R: “I am calling to request an order for a CBC and increased dose of pain medication.”
R: “I am repeating back the order to confirm that you are ordering a STAT CBC and an increase of her Vicodin to 10/325 mg.”
View or print an ISBARR reference card
.
Handoff Reports
Handoff reports are defined by The Joint Commission as “a transfer and acceptance of patient care responsibility achieved through effective communication. It is a real-time process of passing patient specific information from one caregiver to another, or from one team of caregivers to another, for the purpose of ensuring the continuity and safety of the patient’s care.”[2] In 2017, The Joint Commission issued a sentinel alert about inadequate handoff communication that has resulted in patient harm such as wrong-site surgeries, delays in treatment, falls, and medication errors. Strategies for improving handoff communication have been implemented at agencies across the country.
Although many types of nursing shift-to-shift handoff reports have been used over the years, evidence strongly supports that bedside handoff reports increase patient safety, as well as patient and nurse satisfaction, by effectively communicating current, accurate patient information in real time.[3] See Figure 2.9[4] for an image illustrating two nurses participating in a handoff report. Bedside reports typically occur in hospitals and include the patient, along with the off-going and the oncoming nurses in a face-to-face handoff report conducted at the patient’s bedside. HIPAA rules must be kept in mind if visitors are present or the room is not a private room. Family members may be included with the patient’s permission. See a sample checklist for a bedside handoff report from the Agency for Healthcare Research and Quality in Figure 2.10.[5] Although a bedside handoff report is similar to an ISBARR report, it contains additional information to ensure continuity of care across nursing shifts. For example, the “assessment” portion of the bedside handoff report includes detailed pertinent data the oncoming nurse needs to know, such as current head-to-toe assessment findings to establish a baseline; information about equipment such as IVs, catheters, and drainage tubes; and recent changes in medications, lab results, diagnostic tests, and treatments.
View Sample Information to Include in a Shift Report.
View a video on creating shift reports.[6]
Transfer Reports
Transfer reports are provided by nurses when transferring a patient to another unit or to another agency. Transfer reports contain similar information as bedside handoff reports, but are even more detailed when the patient is being transferred to another agency. Checklists are often provided by agencies to ensure accurate, complete information is shared.
- "1322557028-huge.jpg" by LightField Studios is used under license from Shutterstock.com ↵
- The Joint Commission. (n.d.). Sentinel event alert 58: Inadequate hand-off reports. https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel-event-alert-newsletters/sentinel-event-alert-58-inadequate-hand-off-communication/ ↵
- Dorvil, B. (2018). The secrets to successful nurse bedside shift report implementation and sustainability. Nursing Management, 49(6), 20-25. https://doi.org/10.1097/01.NUMA.0000533770.12758.44 ↵
- "618721604-huge" by Rido is used under license from Shutterstock.com. ↵
- "Strat3_Tool_2_Nurse_Chklst_508.pdf" by AHRQ is licensed under CC0 ↵
- RegisteredNurseRN. (2015, May 23). Nursing shift report sheet templates | How to give a nursing shift report. [Video]. YouTube. All rights reserved. Video used with permission. https://youtu.be/X76iKFQhPNw ↵
Asking a patient to rate the severity of their pain on a scale from 0 to 10, with “0” being no pain and “10” being the worst pain imaginable is a common question used to screen patients for pain. However, according to The Joint Commission requirements described earlier, this question can be used to initially screen a patient for pain, but a thorough pain assessment is required. Additionally, the patient's comfort-function goal must be assessed. The comfort-function goal provides the basis for the patient's individualized pain treatment plan and is used to evaluate the effectiveness of interventions.
PQRSTU, OLDCARTES, and COLDSPA
The “PQRSTU," “OLDCARTES,” or "COLDSPA" mnemonics are helpful in remembering a standardized set of questions used to gather additional data about a patient’s pain. See Figure 11.4[1] for the questions associated with a “PQRSTU” assessment framework. While interviewing a patient about pain, use open-ended questions to allow the patient to elaborate on information that further improves your understanding of their concerns. If their answers do not seem to align, continue to ask focused questions to clarify information. For example, if a patient states that “the pain is tolerable” but also rates the pain as a “7” on a 0-10 pain scale, these answers do not align, and the nurse should continue to use follow-up questions using the PQRSTU framework. Upon further questioning the patient explains they rate the pain as a “7” in their knee when participating in physical therapy exercises, but currently feels the pain is tolerable while resting in bed. This additional information assists the nurse to customize interventions for effective treatment with reduced potential for overmedication with associated side effects.
Sample questions when using the PQRSTU assessment are included in Table 11.3a.
Table 11.3a. Sample PQRSTU Focused Questions for Pain
| PQRSTU | Questions Related to Pain |
|---|---|
| Provocation/Palliation
|
What makes your pain worse?
What makes your pain feel better? |
| Quality
|
What does the pain feel like?
Note: You can provide suggestions for pain characteristics such as “aching,” “stabbing,” or “burning.” |
| Region
|
Where exactly do you feel the pain? Does it move around or radiate elsewhere?
Note: Instruct the patient to point to the pain location. |
| Severity
|
How would you rate your pain on a scale of 0 to 10, with “0” being no pain and “10” being the worst pain you’ve ever experienced? |
| Timing/Treatment
|
When did the pain start?
What were you doing when the pain started? Is the pain constant or does it come and go? If the pain is intermittent, when does it occur? How long does the pain last? Have you taken anything to help relieve the pain? |
| Understanding
|
What do you think is causing the pain? |
An alternative mnemonic to use when assessing pain is “OLDCARTES.”
- Onset: When did the pain start? How long does it last?
- Location: Where is the pain?
- Duration: How long has the pain been going on? How long does an episode last?
- Characteristics: What does the pain feel like? Can the pain be described in terms such as stabbing, gnawing, sharp, dull, aching, piercing, or crushing?
- Aggravating factors: What brings on the pain? What makes the pain worse? Are there triggers such as movement, body position, activity, eating, or the environment?
- Radiating: Does the pain travel to another area or the body, or does it stay in one place?
- Treatment: What has been done to make the pain better and has it been helpful? Examples include medication, position change, rest, and application of hot or cold.
- Effect: What is the effect of the pain on participating in your daily life activities?
- Severity: Rate your pain from 0 to 10.
A third mnemonic used is "COLDSPA."
- C: Character
- O: Onset
- L: Location
- D: Duration
- S: Severity
- P: Pattern
- A: Associated Factors
No matter which mnemonic is used to guide the assessment questions, the goal is to obtain comprehensive assessment data that allows the nurse to create a customized nursing care plan that effectively addresses the patient’s need for comfort.
Pain Scales
In addition to using the PQRSTU or OLDCARTES methods of investigating a patient’s chief complaint, there are several standardized pain rating scales used in nursing practice.
FACES Scale
The FACES scale is a visual tool for assessing pain with children and others who cannot quantify the severity of their pain on a scale of 0 to 10. See Figure 11.5[2] for the FACES Pain Rating Scale. To use this scale, use the following evidence-based instructions. Explain to the patient that each face represents a person who has no pain (hurt), some pain, or a lot of pain. “Face 0 doesn’t hurt at all. Face 2 hurts just a little. Face 4 hurts a little more. Face 6 hurts even more. Face 8 hurts a whole lot. Face 10 hurts as much as you can imagine, although you don’t have to be crying to have this worst pain.” Ask the person to choose the face that best represents the pain they are feeling.[3]
FLACC Scale
The FLACC scale (i.e., the Face, Legs, Activity, Cry, Consolability scale) is a measurement used to assess pain for children between the ages of 2 months and 7 years or individuals who are unable to verbally communicate their pain. The scale has five criteria, which are each assigned a score of 0, 1, or 2. The scale is scored in a range of 0–10 with “0” representing no pain.[4] See Table 11.3b for the FLACC scale.
Table 11.3b The FLACC Scale[5]
| Criteria | Score 0 | Score 1 | Score 2 |
|---|---|---|---|
| Face | No particular expression or smile | Occasional grimace or frown, withdrawn, or uninterested | Frequent to constant quivering chin; clenched jaw |
| Legs | Normal position or relaxed | Uneasy, restless, or tense | Kicking or legs drawn up |
| Activity | Lying quietly, normal position, and moves easily | Squirming, shifting, back and forth, or tense | Arched, rigid, or jerking |
| Cry | No cry (awake or asleep) | Moans or whimpers or occasional complaint | Crying steadily, screams or sobs, or frequent complaints |
| Consolability | Content and relaxed | Reassured by occasional touching, hugging, or being talked to; distractible | Difficult to console or comfort |
COMFORT Behavioral Scale
The COMFORT Behavioral Scale is a behavioral-observation tool validated for use in children of all ages who are receiving mechanical ventilation. Eight physiological and behavioral indicators are scored on a scale of 1 to 5 to assess pain and sedation.[6]
Pain Assessment in Advanced Dementia (PAINAD) Scale
The Pain Assessment in Advanced Dementia (PAINAD) Scale is a simple, valid, and reliable instrument for assessing pain in noncommunicative patients with advanced dementia. See Table 11.3c for the items included on the scale. Each item is scored from 0-2, When totaled, the score can range from 0 (no pain) to 10 (severe pain).
Table 11.3c The PAINAD Scale[7]
| Item | 0 | 1 | 2 |
| Breathing independent of vocalization | Normal | Occasional labored breathing. Short period of hyperventilation. | Noisy labored breathing. Long period of hyperventilation. Cheyne-Stokes respirations. |
| Negative vocalization | None | Occasional moan or groan. Low-level speech with a negative or disapproving quality. | Repeated troubled calling out. Loud moaning or groaning. Crying. |
| Facial Expression | Smiling or inexpressive | Sad. Frightened. Frown. | Facial grimacing. |
| Body language | Relaxed | Tense. Distressed pacing. Fidgeting. | Rigid. Fists clenched. Knees pulled up. Pulling or pushing away. Striking out. |
| Consolability | No need to console | Distracted or reassured by voice or touch. | Unable to console, distract, or reassure. |
Comfort-Function Goals
Comfort-function goals encourage the patient to establish their level of comfort needed to achieve functional goals based on their current health status. For example, one patient may be comfortable ambulating after surgery and their pain level is 3 on a 0-to-10 pain intensity rating scale, whereas another patient desires a pain level of 0 on a 0-to-10 scale in order to feel comfortable ambulating. To properly establish a patient's comfort-function goal, nurses must first describe the essential activities of recovery and explain the link between pain control and positive outcomes.[9]
If a patient's pain score exceeds their comfort-function goal, nurses must implement an intervention and follow up within 1 hour to ensure that the intervention was successful. Using the previous example, if a patient had established a comfort-function goal of 3 to ambulate and the current pain rating was 6, the nurse would provide appropriate interventions, such as medication, application of cold packs, or relaxation measures. Documentation of the comfort-function goal, pain level, interventions, and follow-up are key to effective, individualized pain management.[10]
