Development and psychometric testing of a scale assessing the sharing of medical information and interprofessional communication: the CSI scale

In recent years, much attention has been paid to quality and safety of hospital care. Many authors have argued that this depends on an organization that ensures the continuity of information and interprofessional collaboration [1, 2]. In fact, team working seems to play a major role in creating safer patient care [3, 4]. The collaboration between physicians and nursing staff has been widely studied, in particular in intensive care units [5‐7]. In intensive care units, it has been shown that effective collaboration between health care professionals will improve patient outcomes, as well as reduce medical errors, In addition, good cooperation between nurses and physicians is a characteristic of the “magnet hospitals”, which have lower nurse turnover and greater job satisfaction [5, 8, 9].

Although numerous studies have documented the benefit of effective team collaboration, especially between nurses and physicians, a collaborative model between physicians and nurses continues to be the exception [5, 10]. The lack of collaboration and communication, and its consequent negative impact on the provision of healthcare and patient outcomes has been pointed out for years [11, 12].

Several authors have defined and modeled this complex and multidimensional phenomenon of interprofessional collaboration [13‐16]. Among existing definitions of this concept, Henneman [14] described it as “labouring together, sharing communication and decision-making …” as Baggs and Schmitt [13]. For these authors, collaboration means “nurse and physician cooperatively working together, sharing responsibility for solving problems and making decisions to formulate and carry out plans for patient care”. More recently, interprofessional collaboration has been defined as “the process of developing and maintaining a partnership between a team of health professionals and a client in a participatory, collaborative and coordinated approach to share decision-making around health and social issues” [17].

Most of the authors agree that the field of interprofessional collaboration includes the need to develop communication and coordination between professionals, and to better share medical information and problem-solving strategies. The Canadian Interprofessional Health Collaborative (CIHC) developed an integrative approach composed of six competency domains: interprofessional communication, patient-centred care, role clarification, team functioning, collaborative leadership and interprofessional conflict resolution [16]. The two first domains support the others. Communication skills seem to be essential for all professionals and involve the ability to communicate effectively with others, especially those from other professions. Furthermore a study concluded that “physicians are from Mars and nurses are from Venus”, noting that the lack of communication can be attributed to various reasons [18]. There are indeed many reasons, ranging from the nature of the nurse-physician relationship to differing work philosophies, responsibilities, social status or culture, gender inequality, and competence of nurses [18‐20]. Casey underlines that physicians and nurses train separately, keep separate patient records, report to different hierarchies, read different journals, and use different jargon [21]. Moreover, a study carried out by our team showed that nurses do not know what the patient has been told, that this information is not recorded in the patient’s file, and that as a result it is difficult for them to adapt what they say to patients, which in turn has an impact on the quality and coherence of the information actually delivered [22]. However, information provided to patients has become a central part of care provision. Patients want to be involved in their own health care, and they cannot make the right decisions about treatment if they are not sufficiently informed about the possible side effects and complications, as well as how their treatment might affect their daily lives. In hospitals, multiple interactions exist, which in general involve several physicians as well as paramedical professionals, who may or may not be working in a structured team. This work organization, involving many different health professionals, not only requires good communication but also effective coordination of the different actions undertaken, in order to avoid repetition, inconsistency, or incoherence in caring for patients.

So, improvement programs for healthcare professional practices, focusing on communication and collaborative practices, are imperative to develop quality and safety of hospital care. To bring about change, professionals need to assess their levels of team collaboration, in particular their communications skills to share medical information so as to ensure coordination and continuity of care.

Our study produced the validated CSI scale consisting of 13 items and 3 subscales measuring several elements of interprofessional communication, including the sharing of medical information between healthcare professionals, communication between physicians and communication between nurses and nurse assistants. Confirmatory analysis (SEM) supported the possibility of calculating a global score of communication between healthcare professionals bringing together the two dimensions related to interprofessionals’ communication. This self-perception questionnaire is the first one developed in the French context. It exhibited excellent psychometric properties. The results of this study provide evidence for high construct, divergent and discriminant validity. Internal consistency was over 0.80 as recommended [34, 36]. Items had strong factor loadings with the three principal component analysis-identified factors and accounted for more than 2/3 of the variance. For modelling, the PLS approach was chosen because of the non-normality of the data [38]. The statistical validation strategy presented herein follows most of the recommendations of 'good practice’ for score validation [40].

This scale is short and easy to use. It explores healthcare professionals’ perception of their ability to communicate and to share medical information delivered to patients. These dimensions are key factors in patient satisfaction and safety [1‐3]. The instrument is usable by the whole team, including nurse assistants and is not limited to intensive care units.

Nevertheless, there are a number of study limitations concerning the methodology of the study. First, the study sample was chosen by convenience and may not be representative of the variety of settings and of the general population of healthcare workers. Although our study included several different kinds of units, it was not exhaustive. Selection bias may be present because healthcare professionals who have a particular interest in promoting interprofessional communication are perhaps more likely to have responded to the questionnaire. However, while the rate of participation by healthcare professionals was amply sufficient to obtain relevant data for the validation study, it cannot be seen as a reliable estimate of the perception that professionals have in the Nantes university hospital, and so our results cannot be generalised. As this was the first time that nurse assistants were interviewed on this large sample, it may explain why they, in particular, were reluctant to respond. Secondly the date at which the survey was conducted (June and July), close to the holiday period, could also be a factor that reduced the response rate. The reasons why some professionals did not answer the questionnaire remain to be explored. The sample is issued from a big university hospital in one region of France only, and results might be different in other hospitals and regions. The application of the findings to all hospitals is therefore limited.

A number of limitations concerning the instrument development can also be noted. First, the expert review of the items, from outside experts, did not occur to validate the items in the initial instrument. Secondly, our instrument only explored two facets of the concept of interprofessional communication, that is to say the sharing of information and communication between team members. Moreover interprofessional communication is measured within a multi-disciplinary practice perspective, and not within a collaborative practice perspective. Thirdly, we hypothesized that health professionals understand and can articulate what constitute interprofessional communication. Finally, Table 2 showed that the dimension related to communication between nurses and nurse assistants had an important ceiling effect and that the distribution of the score was not normal. A further validation process is required to reduce this ceiling effect, for example a test of a new response pattern. Further psychometric analysis is also needed to establish test-retest reliability, sensitivity to change, concurrent validity and cross-cultural validations in other countries. Moreover, our items might also be validated by comparing them against the descriptors for the CIHC’s interprofessional competency domain [16], and our findings should be completed by more work considering others dimensions of interprofessional collaboration assessment. According to authors, developed instruments propose specific dimensions about coordination [28, 29], cooperation [29], partnership [29], problem solving, decision making process [29, 30], and leadership [25, 41].

The CSI scale exploring interprofessional communication should assist researchers and quality managers who wish to assess levels of effective communication in clinical units. It should help team members to explore how they work and share information together in order to enhance their healthcare practices. The sharing of medical information within the healthcare team ensures the quality of information delivered to the patient. Conversely, absence of cohesion and inconsistencies between physicians and nursing staff, and their different modes of expression towards the patient, often generate anxiety and result in insufficient information reaching the patient. One line of approach is therefore the improvement of communication between physicians and nurses/nurse assistants. They could both benefit from a better definition of their roles, by undertaking further training in conflict-resolving, in effective methods of asserting their own opinions and knowledge, in listening skills, and in conducting collaborative ward rounds. These methods for training teams, in order to improve interpersonal skills, have already been validated in the field of aviation or other industries, and in hospitals they have also shown their value in improving the quality and safety of care delivered to the patient.