Understanding Communication Between Rehabilitation Practitioners and Nurses: Implications for Post-Acute Care Quality

Abstract

Objective:

This study examined post-acute care (PAC) rehabilitation practitioner’s perspectives on communication.

Method:

This is a secondary data analysis of a larger qualitative study, which included PAC rehabilitation provider (n = 99) focus groups that were held in a purposive sample of 13 skilled nursing facilities (SNFs).

Results:

Participants emphasized the importance of bidirectional communication between rehabilitation and nursing. Three themes were identified: (a) communication between rehabilitation practitioners and registered nurses or licensed practical nurses, (b) communication between rehabilitation practitioners and certified nursing assistants, and (c) communication between rehabilitation practitioners and nursing leaders. Two subthemes within each of the three themes were further characterized to understand how information was exchanged: (a) static communication and (b) action-oriented communication.

Conclusion:

Our findings highlight opportunities for better communication in PAC between rehabilitation practitioners and nursing and thus lay a foundation for future efforts to improve care coordination through enhancing interdisciplinary communication.

Background and Objective

Reducing care fragmentation is an important priority for national health care quality initiatives. Fragmentation occurs when services within an episode of care are delivered by multiple competing entities (e.g., practitioners and clinical settings), each with their own priorities (Cebul, Rebitzer, Taylor, & Votruba, 2013). Fragmentation is associated with increased health care costs, lapses in care, and diminished patient outcomes, particularly for frail patients with complex medical needs (Tsai, Orav, & Jha, 2015). As the number of older adults and the prevalence of elders managing chronic disease increases, health systems are called to invest in patient-centered models of care that enhance outcomes through improved coordination.

Care coordination is a conscious organization of patient care activities delivered among multiple participants (e.g., patients and practitioners) to ensure collaborative, safe, and high-quality service delivery (“2016 National Healthcare Quality and Disparities Report,” 2016). To this end, effective communication is essential for assuring that key data are available to all care team members throughout the episode of care and that they have clear, shared expectations of their roles. As a result of said activities, care coordination and patient outcomes can be improved (Lancaster, Kolakowsky-Hayner, Kovacich, & Greer-Williams, 2015; Leland et al., 2017; Tjia et al., 2009; Zwarenstein, Goldman, & Reeves, 2009). Such an approach is essential in post-acute care (PAC), where patients are admitted upon discharge from the hospital to receive short-term rehabilitation services (e.g., occupational and physical therapy) with the goal of a safe return to the community (Stucki, Stier-Jarmer, Grill, & Melvin, 2005). As an increasingly critical component of an episode of care, over 40% of Medicare beneficiaries are discharged from acute hospitals to PAC annually and frequently include high-risk populations such as frail elders (Gage, Morley, Ingber, & Smith, 2011). Yet, care coordination in PAC remains fragmented and patient outcomes suboptimal given a wide range of PAC settings (i.e., long-term care hospitals, inpatient rehabilitation facilities, skilled nursing facilities (SNFs), and home health agencies) and large interdisciplinary teams (Leland, Gozalo, Teno, & Mor, 2012; Mroz, Meadow, Colantuoni, Leff, & Wolff, 2017; Ottenbacher et al., 2014). Specifically, adults with a hip fracture are one such high-risk group whose patients disproportionately experience poor outcomes including increased morbidity, mortality, falls, and an unsuccessful return to the community (Leland et al., 2015; Marks, 2010; Parker & Johansen, 2006).

Recent policy initiatives have targeted improving communication and care coordination in PAC. For example, the Improving Medicare Post-Acute Care Transformation (IMPACT) Act expands efforts to enhance coordination and quality throughout the episode of care (i.e., hospital to PAC to community; “Improving Medicare Post-Acute Care Transformation Act,” 2014). As one of its goals, the IMPACT Act prioritizes the collection of standardized data across PAC settings to quantify care quality across settings and foster improvements in the transfer of health information across the care continuum. Similarly, value-based payment reform intends to link provider payments to their performance on a defined set of quality measures (VanLare & Conway, 2012). Thus, improving communication strategies and information exchange to enhance patient outcomes is a priority for PAC organizations.

However, there is a paucity of evidence examining communication in the PAC rehabilitation context. More specifically, it is unclear how rehabilitation practitioners communicate with other team members in PAC settings. Existing research examining communication among practitioners has focused on hospital and community settings, most frequently describing information exchanges between nurses, physicians, patients, and their caregivers or families (Lancaster et al., 2015; Zwarenstein et al., 2009). Given the exponential growth of short-term rehabilitation services and the aforementioned knowledge gap, there is a need to investigate communication between rehabilitation practitioners and other health care personnel in PAC. To this end, the goal of this secondary qualitative data analysis is to characterize communication during an episode of care from the perspectives of rehabilitation practitioners in PAC. Specifically, we discuss strategies for exchanging information, key topics for communication, and identify members of the interdisciplinary team most frequently involved in rehabilitation communication to build a foundation that promotes enhanced care coordination in PAC.

Research Design and Methods

This article is based on a secondary analysis of data derived from a larger qualitative study that examined best practices for hip fracture rehabilitation from the perspectives of rehabilitation practitioners, which are discussed in detail elsewhere (Kim & Leland, 2016; Leland et al., 2018). In brief, following Institutional Review Board approval, the study team conducted in-depth semistructured focus groups with rehabilitation practitioners employed in participating SNFs. Eligible rehabilitation practitioners included occupational therapists, occupational therapy assistants, physical therapists, and physical therapy assistants with at least 1 year of practice experience. SNFs were located in Los Angeles County, California, and were selected through purposive sampling to demonstrate variations in practice contexts, available resources, and patient characteristics. Once a facility was chosen as an eligible facility, a researcher contacted the facility for participation. When facilities agreed to participate, the administrative staff was given information on the study and focus groups to disseminate to the rehabilitation practitioners. A total of 99 rehabilitation practitioners participated in 13 focus groups in each of the 13 different SNFs. About 50% of the participants were occupational therapy practitioners and 50% were physical therapy practitioners. A total of 30 males and 69 females participated in the focus groups and their ages ranged from 22 to 64 years (mean [M] = 41.44, standard deviation [SD] = 9.16). A majority of the participants were Asian (42%), 2% African American/Black, 41.4% White, and 8.1% other (i.e., participants who selected other or more than one race).

During the focus groups, participants were asked to share their perspectives and experiences regarding high-quality hip fracture rehabilitation. An interview guide was provided to a trained qualitative researcher to elicit their perspectives on treating patients with a hip fracture and what constitutes as high-quality rehabilitation for this population.

Data Analysis

In this initial study, rehabilitation practitioners identified communication with other PAC practitioners as a highly ranked best practice for hip fracture rehabilitation (Leland et al., 2018). More specifically, rehabilitation practitioners emphasized nurses as key partners for communication and collaboration. Thus, a secondary analysis was used to further explore this area of communication because secondary qualitative analysis allows for an in-depth analysis of an emergent issue that was not fully addressed in our initial study (Heaton, 2008). The secondary analysis we present here centers on the rehabilitation practitioner–nursing dyad from the perspective of rehabilitation providers. We define rehabilitation practitioners as occupational therapists, occupational therapy assistants, physical therapists, and physical therapy assistants. Nursing is defined as registered nurses (RN), licensed practical nurses (LPN; also known as licensed vocational nurses in some states), and certified nursing assistants (CNA).

We utilized thematic analysis to understand rehabilitation practitioners’ perspectives of communication with nursing given its effectiveness as a method for secondary analysis of qualitative data (Braun & Clarke, 2006; Clarke & Braun, 2014; Long-Sutehall, Sque, & Addington-Hall, 2011; Vaismoradi, Turunen, & Bondas, 2013). First, BF and NL read transcripts for familiarization before analyzing each document independently of each other for emerging themes and subthemes regarding communication in the rehabilitation practitioner–nurse dyad. Once candidate themes were developed, BF and CW compared them with selected quotes and the entirety of data. Through this regular process, emerging themes were added while preliminary themes were refined, deleted, or clarified in collaboration with the entire team (CW, BF, JM, NL) during weekly meetings. Next, candidate themes and subthemes were reviewed by the team (CW, JM, NL) for verification. When discordant themes, categories, or relationships emerged among team members, the team would discuss and re-code as appropriate until consensus was met and all data were again validated. Transcripts were coded using a qualitative software program Atlas.ti (Version 7.5.6) for ease of data management.

Results

Our analysis revealed three overarching themes which we describe in Table 1. The theme communication between rehabilitation practitioners and registered nurses or licensed practical nurses describes the perspectives of rehabilitation practitioners on exchanging information with RNs or LPNs. The theme communication between rehabilitation practitioners and certified nursing assistants describes the perspectives of rehabilitation practitioners on exchanging information with CNAs. Finally, the theme communication between rehabilitation practitioners and nursing leaders describes the perspectives of rehabilitation practitioners on communication with a nurse leader during team meetings.

Table 1.

Themes and Subthemes Emerging From the Findings.

Themes	Subthemes	Major topics of communication described by participants
Communication between rehabilitation providers and registered nurses or licensed practical nurses	Static communication	• Patient status and safety concerns such as weight-bearing precautions, pain levels, and tolerance of recent therapy treatment
	Action-oriented communication	• Pain management and need for medication to control pain
		• Clarifications for topics directly related to patient safety during therapy treatment (e.g., weight-bearing status, presence of hip precautions)
Communication between rehabilitation providers and certified nursing assistants	Static communication	• Positioning (e.g., bed and wheelchair)
		• Mobility (e.g., transfers to the bed, wheelchair, bedside commode, or toilet)
		• Fall prevention (e.g., pressure pad)
	Action-oriented communication	• Safe transfers
		• Adherence to hip precautions during daily activities such as toileting
Communication between rehabilitation providers and the nursing team	Static communication	• Patient’s plan of care
		• Patient’s weight-bearing status and hip precautions to ensure safety
	Action-oriented communication	• Pain management
		• Mobility status

For each of the three themes previously introduced, we discuss two emergent subthemes also described in Table 1. The first subtheme, static communication, describes an exchange of information intended to apprise other team members about the patient’s status or needs. This type of communication is a simple way to convey information to nursing. For example, a rehabilitation practitioner could write down information about a patient’s therapy session in a communication log as a way to share this knowledge with nursing. The second subtheme, action-oriented communication, describes an exchange of information in the context of action. Information exchange under this subtheme emphasized the need for action coupled with the exchange of information. For instance, a rehabilitation practitioner could collaborate with nursing to manage pain immediately when a patient experiences marked discomfort during therapy.

In addition, we identified various topics that were commonly communicated between rehabilitation practitioners and nursing. These topics are listed in Table 1. We discuss these topics within the subthemes to illustrate what is being communicated and how these topics are communicated with nursing. The major topics that were identified by rehabilitation practitioners included ensuring patient’s safety, providing fall prevention strategies, and developing a patient’s plan of care.

Communication Between Rehabilitation Practitioners and Registered Nurses or Licensed Practical Nurses

Given the RNs’ and LPNs’ licensed status and roles in direct medical care delivery and supervision, the rehabilitation practitioners similarly discussed communication with RNs and LPNs in their focus groups. Thus, we present communication with RNs and LPNs under one theme. In the context of PAC hip fracture rehabilitation, communication for this theme most frequently addressed pain management and patient safety using strategies described by the subthemes static communication and action-oriented communication.

Static communication.

The exchange of information under this subtheme occurred through the use of face-to-face interactions or written documentation (e.g., 24-hr report or a communication log). The topics addressed by static communication conveyed information regarding patient status and safety concerns such as weight-bearing precautions, pain levels, and tolerance of recent therapy treatment. Rehabilitation practitioners expressed a preference for verbal in-person interactions given their convenience in a fast-paced environment. For example, one participant described, “I think face-to-face [communication] with the nurses is the best. You can write everything down, but face-to-face, most often, it’s the best way to go.” When using written documents to convey information, the use of a 24-hr report or a communication log to share information with RNs and LPNs helped share a wide range of information with many people, across shifts. One participant described,

[nursing] has this big book in the nursing station, so we [rehabilitation practitioners] write on that too. It’s a 24-hour book, so everybody [across shifts] could see it [information, we wanted to convey about], a specific person, any problems that occurred during therapy, so that they [nursing] could follow-up.

Action-oriented communication.

Information exchange under this subtheme was done under the context of an action. For example, rehabilitation practitioners consistently described patients’ pain as a barrier to therapy participation. To this end, if a patient is assessed for pain prior to start of therapy, a patient may perceive that they do not need pain medication. However, once the patient begins to move with the therapist, pain often arises and limits participation in treatment. As a result, study participants emphasized the importance of working with RNs and LPNs to manage pain to facilitate participation in therapy. The practitioners consistently emphasized that patients may not experience pain until they start to move as part of their therapy session, thus illustrating a need for rehabilitation practitioner–nurse collaboration to maximize patient participation. One rehabilitation practitioner described partnering with RNs and LPNs to emphasize the potential for pain during movement and ensure that pain medication was dispensed before therapy to facilitate patient engagement:

Letting them [nursing] know what time we’re going to see them [the patient], because when I was able to tell the nurses they [the patients] have pain only when they move or when they get up … we’re going to be walking and doing an activity. They’re going to need medication a half hour before [the treatment session].

Another participant described that real-time collaboration with RNs and LPNs in their facility allowed for pain medication to be issued for pain immediately following a report of patient discomfort during therapy:

With communicating with nursing, we [rehabilitation practitioners and nursing] have walkie-talkies. So, if we need pain pills right away, we [rehabilitation practitioners] just tell them [nursing], what room number, who’s the charge nurse, where they’re [the patient] at, if we’re in the room or in the gym. And if we need pain pills right away. So, we could just tell them, and they’ll come over with the pain meds.

Rehabilitation practitioners also used action-oriented communication strategies to build upon information already transmitted through static communication. For example, although information essential for ensuring patient safety (e.g., weight-bearing status, presence of hip precautions) was expected to have been stated in patient-specific hospital discharge documentation, rehabilitation providers described that this was not always the case. As a result, patient safety and timely treatment were compromised. One strategy rehabilitation practitioners utilized to obtain essential patient information was to ask their unit’s RNs and LPNs for this information, who would then serve as a liaison with other team members (e.g., physicians) across the care continuum to obtain or clarify any necessary material:

Many, many times they [patients] come [from the hospital] without hip precautions stated in their transfer sheets, and the weight-bearing precaution is not stated … I have to ask the charge nurse to call the hospital or medical records to get further reports. And sometimes we need to call the orthopedic surgeon.

Communication Between Rehabilitation Practitioners and Certified Nursing Assistants

This theme describes communication between rehabilitation practitioners and CNAs whose primary role includes providing patients with support for personal hygiene and activities of daily living. As primary caretakers, communication in this theme most frequently addressed patient safety during mobility and day-to-day activities such as toileting.

Static communication.

Information exchange under this subtheme occurred through verbal interactions where rehabilitation practitioners described strategies for safe positioning (e.g., bed and wheelchair), mobility (e.g., transfers to the bed, wheelchair, bedside commode, or toilet), and fall prevention. A key area of education centered on identifying strategies to prevent falls, such as using a pressure pad or alarm. One participant described, “So we usually put them [high fall risk patients] in resident rooms close to the nursing station, educating the CNAs that this patient might need pressure pad [seat alarm] on them.” Similarly, another participant described the need to share information verbally with CNAs regarding topics that include adherence to hip precautions during movement to ensure safety:

Making sure nursing [CNAs] is safe toileting [the patient]. Like rolling the person with the pillow [hip abduction pillow], to put the bed pan underneath, and to me, that’s number one concern … because they’re [CNAs] going to be toileting [the patient]. So, we don’t want to cause any further injuries or, you know, cause a second surgery [by dislocating the hip].

Action-oriented communication.

Participants emphasized that hands-on instruction and return demonstration for specific techniques to increase patient safety were necessary during communication with CNAs. Participants explained that the CNA’s role as the key staff member who provides the majority of self-care support and has the greatest level of interaction with the patient warrants a strong emphasis on action-oriented training to improve safety.

Action-oriented exchanges of information could occur at any time and were intended to provide CNAs with actionable strategies and practice to support patient care. One rehabilitation practitioner described going beyond verbal instruction and instead chose to demonstrate transfer strategies when the need arose. The practitioner described, “Usually, just on the spot, when we’re [rehabilitation practitioners] in their [the patient’s] room getting them out [of bed], we have a CNA come in and [we will] show them how to transfer [that specific patient].” Hands-on training also focused on safe mobility that incorporated patient-specific safety strategies and hip precautions, which often incorporated written instructions that served as a clinical reminder. A participant explained, “We [rehabilitation practitioners] also provide training to the CNAs so when they transfer patients, they need to follow that [hip precaution] and sometimes I write it down and give them a whole handout with hip precautions.”

Communication Between Rehabilitation Practitioners and Nursing Leaders

This theme focused on the communication between rehabilitation practitioners and nurses in a position of leadership who must relay information to all nurses on the unit or floor, across shifts. This form of communication could occur in many different ways, including during interdisciplinary team meetings, care plan meetings with the patient and family, or discussions with a nursing supervisor. As such, there is a wide range of information that is conveyed by rehabilitation providers or is relevant to therapy treatment that must be disseminated to the nursing team.

Static communication.

Rehabilitation practitioners often convey to a nursing representative updated information regarding the patient’s care needs. Although face-to-face interactions occurred during formal team meetings, they were also described by study participants as taking place during informal interactions with a nursing supervisor. Following this sharing of information, each nursing representative independently decides how to act upon these data in accordance with their facility’s protocol. Although this aforementioned approach was commonly described by our participants, one rehabilitation practitioner expressed their facility’s use of established organizational communication channels (i.e., static communication strategies) to share information with nursing supervisors. As a result of this access, rehabilitation practitioners are able to disseminate necessary information to the entire nursing staff without communicating with each nursing team member:

We have a communication system between our department [rehabilitation] and the Director of Staff Development who’s the supervisor for the CNAs. [We tell the Director of Staff Development] “Hey, this patient requires a two-person assist; they’re on hip precautions or toe-touch weight bearing, or whatever the case may be.” And then she [Director of Staff Development] will update it on their [the patients’] care guide, which the CNAs will carry around with them …

Study participants also emphasized the importance of conveying information to a nursing representative about the patient’s recovery, abilities, care needs, and areas of concern during interdisciplinary meetings. Participants across focus groups consistently described mobility as a common topic of static communication between rehabilitation practitioners and the nursing representative. For example, rehabilitation practitioners regularly informed the nursing team about a patient’s mobility status and what strategies could be effective during care:

So, in those meetings [interdisciplinary team meetings], we discuss the patient progress and then it is communicated to the department [nursing] that the patient is [now] able to stand up [to transfer], so, we don’t need to use a lift.

When it was not feasible to communicate with a nursing representative and there was an immediate need to communicate information to all nursing practitioners, participants frequently used a patient’s medical record to share patient information with the nursing team. However, this could also be a challenge when there was a lack of interoperability between the rehabilitation department’s documentation software and the nursing department’s electronic medical record system. One rehabilitation practitioner described navigating communication barriers to convey information about the patients’ plan of care to the nursing team:

We [rehabilitation practitioners] come and we clarify [physician orders for therapy] what we’re going to do [plan of care for OT and PT], we put it in the computer. And since we’re [rehabilitation practitioners and nursing] not linked [in a common computer platform], we print out [all rehabilitation documentation]. And we put them into the physician order section [of the patient paper chart] so that everyone knows what our plan of care is and what we’re doing.

Action-oriented communication.

The rehabilitation practitioners described the importance of not only informing the nursing team on patient statuses but also actively working with nursing staff to implement new care strategies as the patient’s needs progressed. This rehabilitation provider–nursing collaboration included active collaborative discussion leading to joint problem-solving. For example, one participant described working with the nursing team to address pain management during an interdisciplinary team meeting:

… we [the interdisciplinary team] have HMO and PPS [insurance benefit utilization] meetings … And then there’s always a representative from nursing there. And we go over any concerns, if they [patients] still have pain. And then what could be done.

Discussion and Implications

To improve PAC patient outcomes and adhere to national quality priorities, it is necessary to support coordinated care that reduces fragmentation through effective communication among health care practitioners. To this end, the findings from this study address a sparsely researched area between two key groups of PAC staff: rehabilitation practitioners and nursing practitioners. The findings reveal that although communication among rehabilitation practitioners and the three nursing categories we presented (i.e., RNs and LPNs, CNAs, nursing leaders) similarly centered on a wide range of topics related to patient status and ways to enhance safety, each message was conveyed differently depending on the recipient and the information’s urgency. As such, the two subthemes we presented (i.e., static and action-oriented communication) broadly describe how rehabilitation practitioners conveyed information or actively collaborated with nursing staff to act with the goal of responding to patient needs and facilitating interdisciplinary collaboration.

Although static communication often relied on electronic medical records and communication logs for rehabilitation practitioners to communicate with nursing, they also posed a barrier to communication due to incompatibilities among the different systems used (e.g., facility documentation and rehabilitation contractor). This is reflective of past findings citing challenges to electronic medical record interoperability and the negative impact that limited electronic information exchange can have on care coordination (Robinson, Gorman, Slimmer, & Yudkowsky, 2010; Shachak & Reis, 2009). Thus, facilitating communication between rehabilitation practitioners and the remainder of the interdisciplinary team is one strategy to improve care quality. One such way to improve communication is through the development of electronic medical records that allow for consistent communication between different members of the care team.

In our study, action-oriented communication focused on active education and problem-solving strategies between rehabilitation practitioners and nursing to ensure patient safety. These results reflect the findings from previous studies which have linked interdisciplinary collaboration and training to improving patient outcomes (Arling, Abrahamson, Miech, Inui, & Arling, 2014; Christie, Macmillan, Currie, & Matthews-Smith, 2015; Fathi et al., 2016; Ouslander et al., 2011). For example, one study found that incomplete or inaccurate information regarding weight-bearing status or hip precautions could result in a failed surgery or at minimum delay early mobilization for patients who experience a hip fracture (Rashid, Brooks, Bessman, & Mears, 2013). One other study articulated nursing’s role in assisting patients and their need for clear instructions to keep patients safe, information that rehabilitation providers often provided (Bonner, Castle, Men, & Handler, 2009).

Although improving interdisciplinary communication is a key factor for improving health care delivery and patient outcomes in PAC, several barriers have been suggested including differences in practice cultures, resources, and status (Arling et al., 2014; Tjia et al., 2009; Zwarenstein et al., 2009). Communication among practitioners is further affected by interpersonal relationships and interdisciplinary perceptions of caring, acceptance, and empathy (André, Nøst, Frigstad, & Sjøvold, 2017). Thus, future efforts to improve interdisciplinary communication must consider the complexity of PAC and range of facility-specific contexts.

In addition, our study does have limitations. The study included a sample from one large urban county, thus results are limited in its generalizability. Similarly, the study also focused only on rehabilitation for older adults with a hip fracture; therefore, future studies need to evaluate other patient populations in similar settings. However, even though the study focused on older adults with hip fracture, the rehabilitation practitioners in the study also treated other patients and communication with nursing is frequently done to communicate needs of all patient populations. In addition, only rehabilitation practitioners from SNFs participated in the study. Thus, future research should examine other health care practitioners’ perspectives, including patients and families, on how to provide effective communication to improve care coordination. Yet, despite these limitations, the findings from this study address a gap in current evidence. Communication is a complex and essential component of care coordination. To improve patient outcomes and deliver high-quality post-acute rehabilitation care, effective interdisciplinary communication is vital.