May 01, 2012, By: Laura Eggertson
Theresa Brown had been working as an oncology nurse in a busy Pittsburgh hospital for three years when a physician colleague approached her to say he had just finished reading her book about her first year of nursing. “I had no idea how nurses spent their time,” he told Brown.
This veteran ICU doctor had worked with and alongside nurses for 20 years, with scant sense of the scope of their roles and responsibilities. The comment came as a revelation to Brown, who realized that she was probably equally uninformed about the daily activities and responsibilities of doctors. That mutual lack of education is one of the reasons for on-the-job tension between some nurses and doctors, Brown believes.
“Nurses get no education in working with doctors...and doctors get no education in working with nurses, or even a sense of what the most basic interaction is that they’re going to have,” Brown says. “Then you put these two groups together and say ‘Go to work in this high-tech, high-stress, high-stakes situation.’ I don’t know how people expect that to work! I can’t think of any other industry that would do that.”
The hierarchical structure of nurse-physician relationships, which has been based on education and gender, is also a critical factor in professional conflicts, researchers and experts say. The stereotype of doctors who bark orders at subservient nurses was perpetuated for generations by such medical books as The Household Physician (1902), which described the nurse as “only the instrument by whom the doctor gets his instructions carried out.”
Although changes in health-care culture, increased interprofessional education, evolving professional standards and scopes of practice, demographics and social norms are gradually transforming that traditional relationship, many nurses still report persistent conflicts with physicians.
The conflicts Brown experienced prompted her to write an opinion column for the New York Times last May.“Physician, Heel Thyself” sparked an intense debate on the paper’s Well blog and much water-cooler talk. Brown described an incident in which a physician belittled her in front of a patient and justified it by invoking a “time-honoured tradition — blame the nurse whenever anything goes wrong.” The article provoked negative and positive comments, and opened a wider conversation among experts who specialize in what is described in the literature as disruptive physician behaviour.
Many front-line nurses can recount at least one incident in which a physician yelled at or berated them, questioned their competence, or made fun of them. For Sam,* a new RN who works in Western Canada, one such experience occurred when he noted a dosage error on a painkiller prescribed for one of his patients and called a resident to adjust the dosage. Although the resident agreed to the change, he was irritated at being roused from sleep, although it was his job to be on call and available. He instructed Sam to page him only in an emergency, noting “I like to sleep my nights on call.”
Sam responded that he would page the resident if he had reason to do so — and if it was in the best interests of the patient. Many nurses, however, report feeling intimidated about calling physicians who have been dismissive or belittling.
“Where I practise, the medical model rules,” says Sam. “I often feel that because of the domination of the medical model in our hospital, nursing research and knowledge is not fully valued. I have seen nurses reprimanded for how they have spoken to a resident, when the resident himself was being verbally abusive to the nurse.”
The number of physicians who engage in this type of unprofessional conduct is small: three to five per cent, according to Dr. Alan Rosenstein, a San Francisco-based internist and researcher who specializes in documenting the effects of harassing or intimidating behaviour by physicians and nurses in the U.S. “The issue is that these three to five per cent can have a profound effect on the organization,” says Rosenstein, who has surveyed more than 8,000 nurses, physicians and administrators over the last 15 years.
As his research indicates, disruptive behaviour can also have a profound effect on patient care. In a study published in The Joint Commission Journal on Quality and Patient Safety, he and his co-author found that 18 per cent of the nurses, physicians, other health-care workers and administrators surveyed at more than 100 non-profit U.S. hospitals reported knowing of an adverse event that occurred because of a disruptive incident. “Eighteen per cent is a lot,” says Rosenstein. “I was flabbergasted by the results we were getting back.” (Canadian studies have so far not been as precise in pinpointing the percentage of adverse events attributed to communication failures or other results of poor nurse-physician relationships.)
Rosenstein emphasizes that physicians are not the only disruptive members on the health-care team. (Nurse-to-nurse bullying was examined in an article in the June 2011 issue of Canadian Nurse). But he says such behaviour generally involves the way physicians interact with nurses.
One of the biggest problems with disruptive behaviour, according to Rosenstein and the nurses interviewed for this article, is that it inhibits communication. When that happens, mistakes occur that endanger patients. Debbie, a nurse in Atlantic Canada, witnessed one such incident. Just before a surgery was to begin, a physician was yelling at staff about new consent forms and paperwork that had just been introduced. “He was making a big ruckus in front of patients and other staff,” she says. By the time the surgery started, “people were just so tense from his yelling that they weren’t able to concentrate.” As a result, he and the nurses missed the fact that the surgical procedure was set up on the wrong side of the patient. It wasn’t until an intraoperative X-ray was done that the team realized their mistake.
Studies published in Canada, New Zealand and the U.S. have confirmed that communication failures among health-care professionals play a critical role in adverse events, although the research differs on what proportion of the events are directly tied to these problems. Sherry Espin, an associate professor at the Daphne Cockwell School of Nursing at Ryerson University, notes that in the U.S., the Joint Commission (the major accreditation and certification body for health-care organizations in the U.S.) has reported that upwards of 70 per cent of adverse events are caused by communication failures.
“We know that poor communication is a leading cause,” says Espin, who is a member of the Canadian Patient Safety Institute’s working group for teamwork and communication. Because much of health-care delivery in hospitals is team based, all members of the team need to know each other’s roles and responsibilities, should share a mutual goal and must treat each other with respect, which then fosters timely and open communication, she says. “Regardless of whether it’s a patient safety issue or a patient safety incident, you need to hear everyone’s perspectives.”
The hierarchical structure of a hospital setting, where some administrators tolerate arrogance on the part of specialists or other physicians, or ignore disruptive behaviour, aggravates communication problems that can contribute to adverse events, says Josephine Ensign, an associate professor at the University of Washington’s school of nursing.
Although she notes that many health-care institutions post workplace policies that promote respect or codes of conduct, she does not believe that these will solve the problem of disruptive behaviour and its resulting communication issues. That will only happen when the culture changes, she says. “Within any institution, especially hierarchical ones, there are the formal leaders and then there are the informal change agents,” says Ensign. “If they are modelling respectful behaviour and speaking out when it’s not there, I think that’s what really is effective — not just having civility laws on the books.”
Of course, these policies and codes are ineffective if physicians are not hospital employees. Some experts think the documents are an unnecessarily blunt instrument, as well, since they address only the most egregious behaviour — not the subtle nuances that characterize many relationships.
The former dean of nursing at the University of Kansas agrees that paper codes of conduct or civility policies don’t work without enforcement. “If there are no teeth in these codes of conduct, people will just blow them off,” says Eleanor Sullivan, who is also the author of Becoming Influential: A Guide for Nurses. She urges regulatory authorities, accreditation agencies and health-care administrators to follow up on whatever codes they have. But nurses also have to be taught how to counter disruptive behaviour, she says.
Just as disruptive behaviour results in a difficult cultural climate, good communication and teamwork can produce great working environments and excellent patient care. In a community cancer clinic in Bonnyville, Alta., Robbi Allen sees the beneficial effects of positive relationships at work every day. Allen, who has been an RN for 18 years, works alongside four general practitioners in the clinic. They are “easygoing and very respectful,” she says. They don’t hesitate to ask the nurses, who are seasoned in oncology care, for help in solving problems. “There’s never a power struggle. When I need to call them, for any reason, I never get the cold shoulder. I always have immediate access to them. It’s a really open relationship of trust and respect.”
Allen believes the socialization among physicians and nurses that occurs, of necessity, in a small town where their children play sports and attend school together contributes to excellent working relationships. A smaller setting also ensures that care providers take on many roles, rather than specializing in a few. “When you work in the city, if you have a code, you call the code team. When you have a difficult IV, you call the IV team. When you’re rural, you are the team,” she says.
The type of practice setting can make a huge difference in how relationships evolve, says Dr. Susan Phillips, a family doctor and professor of medicine at Queen’s University. In family practices, doctors have a clearer sense of what nurses do, and they are working together day in, day out, she says. “I couldn’t function without my nurse and wouldn’t want to function without my nurse. We do different things, but our relationship is not a hierarchical one.”
In hospitals, on the other hand, two kinds of hierarchical relationships compete — one based on power, the other on gender and the historical reality that most doctors have been male and most nurses female, Phillips says. She was co-author of a study on the effect of gender on nurse-doctor relationships. “From the research that we did, it would seem to me that the male-female hierarchy was the one that was most operative, rather than the doctor-nurse one,” she says.
Phillips and lead author Barbara Zelek found that in the responses to scenarios presented to study participants, female nurses were more collegial with female doctors but also more ready to criticize and instruct them. With male doctors, female nurses were more likely to either go along with errors the physician made or make gentle suggestions, for example, about different medications. “They would not undermine the authority of a physician, if the physician was male,” Phillips says. “Nor would they intervene, even when they observed practices of the male physicians that were neither optimal nor evidence based.”
Overall, Phillips believes patient care is better served by nurses who are willing to be proactive and speak up about potential errors, as female nurses do to female doctors. “It’s safer for the patient,” she says.
As more women become not just general practitioners but specialists, Phillips thinks the nurse-physician relationship will evolve and become more egalitarian. She hopes, however, that changing attitudes about what team members can contribute, rather than just changes in the sex of the players, will be the impetus for improving the relationship. “I would hope that what actually changes is the hierarchical view about caregivers, so that we see doctors and nurses as different, rather than one as better than the other.”
Policy changes and a greater willingness to discuss these relationships may also shift attitudes, according to Rosenstein and other experts. Academic research about the effects of difficult nurse-physician relationships on patient safety and popular articles like Brown’s about the impact on nurses and other staff are raising awareness about disruptive behaviour, he and Sullivan both say, and that is helping nurses speak out and encouraging administrators to take action. “Now, people who used to be afraid to deal with it or thought they were out there alone recognize this is a prevalent problem,” Rosenstein says.
Credentialing agencies are also recognizing the importance of good interprofessional relationships, and considering whether an institution fosters them before handing out their seal of approval. The Magnet Recognition Program, administered by the American Nurses Credentialing Center, for example, considers interdisciplinary care and collaboration, says Jan Moran, assistant director of Magnet Operations in Silver Spring, Md.
Institutions must provide examples of how everyone on health-care teams is involved in communicating about and generating treatment plans and education programs for patients, indicating that a good level of teamwork between physicians, nurses and other health-care professional exists. All organizations seeking accreditation with Magnet also have to submit the results of nurse satisfaction surveys, which include a category on nurse-physician relationships. “Magnet really looks for that mutual respect among the team,” she says. “When you think that someone’s life is often dependent upon care providers, you cannot have a gap in communication.”
Many Magnet hospitals offer leadership classes for nurses, physicians and everyone else on the health-care team, and many leadership positions at their hospitals involve communication training, Moran says.
Counselling and educational programs for disruptive physicians are springing up across North America. The programs are aimed at the underlying stresses and problems, which may include addictions, that often contribute to difficult behaviour, says Rosenstein, who, in addition to running a practice, is the medical director for Physician Wellness Services in Minneapolis and a health-care management consultant.
More interprofessional education is also being built into health curricula at universities, but much of that education still takes the form of theoretical scenarios and case studies, says Maria Tassone, director of the Centre for Interprofessional Education at University Health Network in Toronto. True interprofessional learning involves two or more professions coming together to learn about, with and from each other, Tassone says. She contrasts that with multi-professional education, which simply puts health-care professionals in the same room.
The value of interprofessional education comes from sharing decision-making and accountability for care, resolving conflicts and understanding each profession’s role and contribution to the health-care team, she says. It also comes from explicitly addressing power and hierarchy — the “elephant in the room,” Tassone says.
Over the last 10 years, many health-care professions have begun to understand the importance of this type of education, she says. Tassone credits the 2002 Romanow report on the future of health care for recommending that investments be made in interprofessional education.
Most Canadian universities with faculties of medicine and nursing have some kind of an interprofessional education program, she says. There is no national standard, however, that requires exposure to interprofessional learning — something Tassone, a physiotherapist by training, wants to see for students in all the health-care professions.
The University of Toronto’s interprofessional program is unique in that one of its mandatory pieces is a practical component in a clinical setting, such as a structured placement, Tassone says. She’d like to see such practical learning occur in nursing and medical schools across the country. So far, however, the interprofessional component of students’ learning competes for space as one of the core blocks of education students receive.
“The goal is for interprofessional education to be embedded in students’ schedules everywhere,” says Tassone. “We’ve started the journey, but we’re not there yet.”
*The names of some RNs have been changed at their request.
Improving relationships between physicians and nurses in the workplace requires changes on many fronts, according to the people interviewed. Here are a few of their suggestions:
- Make individuals aware of the impact of their behaviour on colleagues and on patients.
- Provide courses on stress management, conflict management and communication for all members of the health-care team.
- If an organization has a code of conduct, ensure that it applies to the entire health-care team, including physicians, and that is enforced equitably and consistently.
- Find additional ways to demonstrate the value of nurses, such as changing the time rounds are conducted in hospital to ensure primary patient care nurses, not just clinical case managers, can participate.
- Consider symbolic changes, such as renaming nursing stations patient care stations, and nursing lounges team lounges.
- Offer assertiveness training to nurses to help them cope with difficult physician behaviour.
- Ensure that the consequences of any disruptive incidents are transparent, and hold workshops or facilitate open discussions for all team members about the effect of difficult relationships.
- Establish signals — a Code Pink or a Code White — nurses can use when having trouble with a physician so others on the team can rally around to witness and even comment on the behaviour.
Laura Eggertson is a freelance journalist in Ottawa, Ont.