The landmark report on diagnostic error NASEM published in 2015 made eight recommendations to improve the quality and safety of diagnosis.5 More research is needed that addresses the first recommendation, to facilitate more effective teamwork in the diagnostic process among healthcare professionals, patients, and their families, because diagnosis is a social phenomenon.10
Nurses and physicians represent the two largest groups of healthcare professionals in a hospital setting, and one way to think about a “team” in the context of the ED and diagnosis is to begin with the physician-nurse dyad. According to the theory of distributed cognition, the physical organization of work in an ED is such that nurses are usually the first point of contact between a patient and the ED.
When a patient arrives, nurses are typically the first to assess the patient and estimate the severity of illness.26 Nursing assessment is used to triage patients and prioritize those who may have a significant risk of morbidity and mortality. Thus, nurses have a critical role in diagnosis by virtue of the nursing knowledge that develops as nurses interact with patients to recognize patterns and trends in patient behavior and disease presentations.27 However, there is risk as well because incorrect recognition can play a role in misdiagnosis.
Nurses are uniquely positioned to gather patient input because of the monitoring and surveillance functions that put nurses in frequent close contact with patients and allow them to see and hear things the physician does not.28 As part of the monitoring function, nurses assess trends in quantifiable physiological parameters such as vital signs and other less perceptible manifestations of illness such as anxiety or depression.
Nurses also play an important role in how communication affects diagnosis, such as acting as patient advocates, answering patient questions, providing support, and educating patients about their conditions. Physicians at times use language that is not easily understood by lay people, and time pressures or frequent interruptions in the ED further restrict physicians from fully engaging with each patient. Therefore, nurses often fill the gaps and translate jargon into terms the patient can comprehend.29
Any shortcomings in eliciting all relevant information from a patient can contribute to diagnostic error.29 In one study, about 10 percent of diagnostic errors were attributable to breakdowns in history taking.30 By encouraging patients to become more actively engaged, nurses can help assess how well a patient’s clinical course aligns with the presumed diagnosis and identify cases where the diagnosis may need to be revised or reconsidered.12,29
For example, because nurses care for fewer patients than physicians, they have more time with patients to allow them to tell their story fully without interruptions, which demonstrates respect for the patient and may increase patient engagement.29 However, patients who are frequently interrupted by clinicians (or even family members) or are not given time to talk about their symptoms in their own words may limit discussion of their symptoms, which can result in significant diagnostic possibilities being missed.29
The relationship between distributed cognition and the role of nurses in the diagnostic process is not without its challenges. It has been said that nurses make up a key part of “the diagnostic safety net,”12 because they often identify key signs and symptoms (e.g., cardiac arrythmias, hypoglycemia) that contribute to a diagnosis before a physician or advanced practice provider sees the patient. Yet many nurses do not view themselves as key players in the diagnostic process or believe they should have a role in diagnosis because they do not view it as being within their scope of practice.13
Gleason and colleagues briefly describe the historical, regulatory, ethical, and legal precedents contributing to this stance and conclude that “this is clearly a misperception.”13 The misperception comes in part from using different terms for the same function. For example, identifying illness severity is a nursing role and part of nursing assessment but also part of the diagnostic process. In addition, ongoing professional silos and disparate workflows create barriers to nurses’ sharing ideas and impressions about a patient’s presentation with physicians, so nurses do not receive feedback that could help them refine or enhance their clinical reasoning.
Finally, communication and hence information flow between physicians and nurses is critical to the diagnostic process. Several factors create barriers to effective communication but two are especially relevant when viewed through the lens of distributed cognition: differences in perspective and the words or language each group uses.
ED physicians use a hypothetical-deductive model of clinical reasoning almost exclusively in generating possible diagnoses.31 However, nurses include an inductive approach, aggregating specific observations to make ever broader categories of information to understand the symptoms and their impact on the patient.32 This difference has implications for information flow and communication because while physicians’ clinical reasoning is grounded in objective data, nurses also incorporate subjective impressions such as intuition into the overall gestalt of what they observe.
In addition, physicians and nurses do not always use the same language when they speak to one another; even the word “diagnosis” can have very different meaning depending on whom one asks.13 These differences arise because nurses do not “see” the world through the same lens as physicians. Differences in perspective and language use contribute to framing effects and context errors that may lead to diagnostic error.29 One study, for example, found that physicians and nurses had different perspectives on the same clinical situation that affected perceptions of what was important or urgent.33
