Table 2.

Teamwork and Communication Factors Observed During Shadowing Exercise

Communication Issues Identifieda	Teamwork Issues Identified
Nurses working 4-hour shifts increased the number of handoffs,  and increased the risk that information about the patient would  not be reported.	One resident placed a new central line without supervision, despite  the nurse saying he had to be supervised. This situation is also a  communication issue because the resident did not tell the nurse  he was going to insert the line, so the nurse did not have a new  line ready.
During morning rounds, the resident presented a patient that he  had rounded on hours earlier. When the dayshift nurse [that I  shadowed] came on, the patient had suffered a GI bleed, of  which the resident was not aware. As a result, the nurse had to  update almost the entire review of systems for the patient. The  nurse tried to tell the resident, but he just continued collecting  information on his other patients. She was assertive but he did  not listen.	Nurses who worked 4-hour shifts usually had patients to transfer.  Some of the house officers paged for transfer orders did not  return their pages. This situation affected patient flow for the day.  Because of this, transfer orders not written resulted in the nurse  [I was with] signing off her patient to another nurse, who now  had 3 patients to discharge before his/her new admission.
I was totally blown away at how much responsibility the nurse had.  The nurse I was with kept everyone informed. The surgical team  only stopped by once, but she had to run orders the surgical  team wanted by the ICU team, who was actually taking care of  the patient. The nurse was superb, but anyone could make a  mistake when they are in the middle. When I asked the resident  why he didn’t talk to the team directly, he said it was easier to  leave the information with the nurse.	One resident was difficult to approach and reportedly had been  sarcastic the entire month on the unit. He seemed to have a bad  attitude. I asked the nurse I was shadowing what they did in this  type of situation. She said they ran important information by the  other house officer still there from the day before, or approached  the fellow on the unit for help. This definitely impacted patient  care.
There were many pages that were not answered quickly. “Definitely  a barrier to communication in the ICU and timely patient care.”	The surgeons did not round on their patients in the ICU on a regu-  lar basis. The patients were managed by intensivists and house  officers, who relied heavily on the nurses' assessment skills and  experience.
Multiple shift changes and multiple reports are opportunities to for-  get pertinent patient information.
The nurse and residents were so rushed they simply said things  like, “I am going to be at lunch. Could you watch my patient?  They should not need anything.” This is dangerous knowing what  I know now. You can’t even see into the room next door to you.
When the staff got an admission, the anesthesia resident had just  started giving report, and the new patient was unstable so the  nurse essentially heard nothing and, before you knew it, the  anesthesia resident was gone.

^aDirect quotes from students.