I worked very, very hard to care for five children while living in a single-wide trailer, attending nursing school full-time, and working thirty-five hours per week. This feat required me to drive nearly a hundred miles each day, since we lived in the country. So when the dean of the school of nursing ceremoniously pinned me at graduation, I could not stop sobbing with relief.
I was really looking forward to being a nurse, but I was shocked when in my first position the physicians treated the nurses so badly. I watched the nurse call in a temperature of 102.6 on her post-op patient. And then I watched her jump because the doctor slammed down the phone without even speaking a single word. I witnessed a physician verbally abusing a nurse and then found her crying in the locker room. At 38, I seriously questioned my choice of profession.
Every nurse I know can recall at least one disturbing physician-nurse scene, and research validates the subjective observations. More than 90 percent of nurses witnessed disruptive behavior in the workplace an average of six to 12 times per year. When asked if they knew of a nurse who left the workplace specifically because of verbal abuse by a doctor, 35 percent responded “yes.” Many of these conflicts leave deep scars. They are extremely personal, and have the power to be extremely hurtful to individual integrity and the profession of nursing. Research affirms a direct link between negative relationships and morale (Rosenstein, 2002).
After four years as a staff nurseAfter four years as a staff nurse I moved with my family to Seattle. As the manager of a large surgical unit, I witnessed poor RN-MD relationships from a new perspective, and again found no shortage of examples. When rounding one morning, I discovered from a patient’s husband that his wife had been in excruciating pain for three hours. I immediately sought out the night nurse and asked for an explanation. “I gave her every drug I could. I just didn’t want to be yelled at again by the doctor. He is so degrading and irate, and screams at me if I call before 7 a.m.” When nurses and physicians don’t communicate, it’s the patient who loses every time. The bottom line is: negative relationships equal negative patient outcomes.
A review of the literature shows that neither collaboration nor enhancing opportunities for communication improves these relationships. Studies show that poor physician-nurse relationships impact morale, job satisfaction and job retention. A survey of over 120 physicians, nurses, and administrators showed that physicians and nurses do not agree on potential solutions, barriers to progress, or responsibility for the problem. The main reason for this is that physicians do not understand the nurses’ role.
Most significant are findings that units with good relations between doctors and nurses have decreased mortality rates (Knaus 1986, Baggs 1992). In a study of thirteen intensive-care units, patient-risk-adjusted mortality increased 1.8-fold as a result of poor nurse-physician communication (Knauss, 1986).
The reason that collaboration and communication attempts to improve physician-nurse relationships have failed is because neither group understands the power differential. The dominant role of physicians and the subordinate role of nurses are rooted in the very history of the nursing profession. Early in the 1900s, physicians argued that “the nurse does not need an education, because the physician already has one.” This belief in superiority was further compounded by gender issues and the fact that most nurses were from middle-class backgrounds while physicians were often from the upper class. Based on the military model, nurses learned not to act independently unless given an order, and not to question superiors (Charge Nurse, Post-op orders, and General Surgeon, etc.).
The major problem is that neither group—nurses nor physicians—is aware of the power play that keeps the nurse subordinate and the physician in the dominant position. For example, physicians often ignore nurses, make poor eye contact with them, and quite frequently don’t know their names. Likewise, nurses often begin a late-night call to physicians with “I am sorry to bother you,” implying that the order they need is an imposition. And most critical of all, nurses generally tolerate and do not report disruptive and verbally abusive physicians.
What can nurses do differently? Always speak your truth. If the physician does not know your name, introduce yourself—and if he or she forgets, then remind him or her. Hold the expectation that as a professional, you require this courtesy. If a physician is intimidating or abusive, pull him or her aside. Describe the behavior that bothered you, the way it made you feel, and the impact it had on your relationship and ability to communicate for the common goal of what is best for the patient. Compliment physicians who create a collegial atmosphere where you can ask questions, raise concerns, or make suggestions. Physicians may not realize the behaviors they have picked up, and unless we point them out, the behavior will continue. Only a new response to an old behavior will create the collaborative dynamic we need in order to provide a healing environment.
What can doctors do differently? Publicly thank those nurses who do a great job, and you will raise the morale of the entire unit. Never tolerate poor nursing care, or complain to the manager, but rather take on the role of coach and mentor, and speak with outliers in private. Ask for feedback from the charge nurse quarterly (What do I do well? And what would you like to see more of?), and meet monthly with the unit manager. Your position at the top of the hierarchy makes you the most powerful force in creating and sustaining a truly patient-centric culture.
Research shows that good nurse-physician relationships are ego-boosting for both nurses and physicians. And the safest environment for the patient is one where staff openly communicate—where no one is afraid to speak, and where relationships are solid. Great working relationships add meaning, depth, and purpose to our everyday life. In the end, both nurses and physicians want the same things: to be valued, and respected, to belong, and to provide excellent critical caPrRe.
Kathleen Bartholomew is the author of Speak Your Truth: Proven Strategies for Effective Nurse-Physician Communication, Ending Nurse-to-Nurse Hostility: Why Nurses Eat Their Young and Each Other, and The Dauntless Nurse: Communication Confidence Builder. She can be reached at Kathleenbart@msn.com.
Bibliography
Baggs, J. B. et al. 1999. "Association between nursephysician collaboration and patient outcomes in three intensive care units." Critical Care Medicine 27 (9):1999-1998.
Knaus, W., P. P. Wagner, J. E. Zimmerman and E. A. Draper 1986. "Variations in mortality and length of stay in intensive care units." Annals of International Medicine 103: 410-418.
Rosenstein, A. 2002. "Nurse-physician relationships: impact on nurse satisfaction and retention." American Journal of Nursing 102 (6): 26-34.