Can We All Get Along? The Doctor-Nurse Relationship

February 6th, 2012

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By , BSN, RN

As the case of Amanda Trujillo continues to garner attention one of the many areas of concern the story has raised is the relationships between nurses and physicians. Collaboration and communication are at the heart of any successful work relationship. In the environment of healthcare nurses and doctors are the two most important groups of people involved and yet there are still huge disparities in how these two professions work together.

The Game

In 1967 Leonard Stein, MD wrote an article for the Archive of General Psychiatry entitled The Doctor-Nurse Game. In it he describes a relationship where nurses make suggestions for patient care frequently and physicians “willingly and respectfully” consider them. If the nurse can make the suggestion without appearing “insolent,” the doctor can seriously consider the suggestion and neither will violate the rules of the game.

Object of the Game.—The object of the game is as follows: the nurse, is to be bold, have initiative and be responsible for making significant recommendations, while at the same time she must appear passive. This must be done in such a manner so as to make her recommendations appear to be initiated by the physician.

Both participants must be acutely sensitive to each other’s nonverbal and cryptic verbal communications. A slight lowering of the head, a minor shifting of position in the chair, or a seemingly non-relevant comment concerning an event, which occurred eight months ago, must be interpreted as a powerful message. The game requires the nimbleness of a high wire acrobat, and if shattered; the penalties for frequent failure are apt to be severe.”

Sound familiar? Did Amanda Trujillo violate the rules of the game by requesting case management provide a hospice consult? Were the consequences that she was accused of stepping out of her scope of practice and fired? How can that be? Stein’s article was published almost 45 years ago and we all know the paradigm between men and women, doctors and nurses has so advanced from that. Or has it?

In 1990, Stein revisited his original theory and noted that nurses had changed their role. They had become more educated, their productivity had increased, and they had become more autonomous health professionals. In direct contrast, merely one year later, the Nursing91 survey reviewed responses from 1100 participating RNs. The results showed only 43% of nurses reported feeling satisfied with their relationships with physicians while 68% doubted doctors even understood what they did.

Flash forward again, to 2007. So much in healthcare has changed. Interdisciplinary collaboration is the name of the game and everyone acknowledges that good communication is crucial to patient safety. Yet, in a review of literature Theodora Sirota, APRN, BC, PhD, notes in Nursing 2007 nurses still report the same negative issues between themselves and doctors, and these same issues lead to the same job dissatisfaction and causes problems for nurse retention.

In 2009 and 2011 we see the same issues being discussed. Seemingly, despite all the education and years of progress, the communication and relationships between nurses and physicians is still a huge topic for discussion and still in need of change and improvement.

How We Communicate

In 2009, nurses Claudia Schmaenberg, RN, MSN and Marlene Kramer, RN, PhD, identified five type of nurse-physician relationships:

  • Collegial – These are characterized by equal parts trust, power and respect. Both professions use the words peers and equals in describing the relationship. Physicians ask for the nurses opinions and value their contributions.
  • Collaborative – Marked by mutual trust, power and respect. The two groups acknowledge they listen to each other and plan care together but the doctor is still considered to be “on top.”
  • Student-Teacher – Either the physician or the nurse can be the teacher. With residents and at times with attending physicians who are dealing with comorbid diseases outside of their specialty, nurses may take a teaching role.
  • Friendly Stranger – This is a fairly formal relationship where information is exchanged in a neutral tone. “The physician comes in, checks the patient, writes orders, and leaves. That’s about it . . . or, if I watch for him to tell him something about his patient, he may listen, but then he just grunts and walks off. Sometimes, I don’t even know that the physician has been in until I see the orders on the patient’s chart. I’ve worked with that doctor for over 17 years and he still doesn’t know my name, although I address him by his name every morning. That’s just the way it is.”
  • Hostile/Adversarial – Relationships are marked by anger, abuse, real or implied threats, or resignation.

It is not unusual to find all of these relationships happening at the same time on the same unit. Some of that is just personality. How people click. Some of it is institutional personality, how nurses and doctors have always interacted in that department—tradition, if you will. In a large, nationwide study, 96% of the 714 nurses surveyed indicated that they had either experienced or witnessed abusive behavior; 31% indicated that hostile nurse-physician relationships existed.

How Do We Fix It?

Fixing a personality is the realm of psychiatrists and psychologists. Improving our environments and our tools and techniques should be the responsibility of administration, management, and the doctors and nurses themselves.

One suggestion, tried at numerous facilities, has been the institution of the SBAR. Situation, Background, Assessment and Recommendation is an old friend to nursing. It is a guide for staff on the best way to communicate a lot of information in a succinct way when a patient’s situation is escalating. SBAR establishes a clear framework for members of the care team to discuss a patient’s condition. The technique has been shown to significantly improve communication and provide for greater patient safety.

Make it personal. If nurses and physicians would make even a small effort to know each other communication would be enhanced. Nurses, introduce yourselves every time you see the doctor until he remembers your name. Doctors, commit to knowing the names of the men and women who take care of your patients every single day. When you know even a little about one another it is much more difficult to behave badly and become disruptive.

Do not tolerate disruptive behavior. The Joint Commission (JCAHO) declared, in 2008, that “intimidating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes, increase the cost of care, and cause qualified clinicians, administrators and managers to seek new positions in more professional environments.”

What this means is administration must commit to supporting nursing when physicians behave badly. This is not to say nurses don’t cause disruption sometimes too, but most reported problems are with physicians being disruptive towards nurses.

“Intimidating and disruptive behaviors include overt actions such as verbal outbursts and physical threats, as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities. Intimidating and disruptive behaviors are often manifested by health care professionals in positions of power. Such behaviors include reluctance or refusal to answer questions, return phone calls or pages; condescending language or voice intonation; and impatience with questions. Overt and passive behaviors undermine team effectiveness and can compromise the safety of patients. All intimidating and disruptive behaviors are unprofessional and should not be tolerated,” according to JCAHO.

These are just a few suggestions found in nursing and medical research, business and education journals, professional blogs and, lets face it, the good book. It’s called “The Golden Rule” for a reason.

Nurses and doctors have been a team since the professions began. In all these years it is hoped that we have learned, grown and accommodated for the special qualities that make our professions different and for where they merge. Nurses should not fear being yelled at or condescended to or even being fired for caring for their patients within their scope of practice. A surgeon I know once said to me, “I love nurses.” I said I knew he did but was curious as to why. He explained, “nurses are there 24/7, so I don’t have to be.” Docs, please remember that. We really aren’t here to make your lives more difficult, nor are we here to be your puppets. We are educated, licensed professionals whose goals are the same as yours. Returning our patients to health. Let’s try to talk and work with each other that way.

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