Nursing News

Changing the Physician–Nurse Dynamic

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By Debra Wood, RN, contributor

July 1, 2010 - Health care remains a high-stress environment, with patients’ well-being often hanging in the balance.

Carole Kenner, DNS, MSN, BSN, FAAN
Carole Kenner, DNS, MSN, BSN, FAAN, suggests that joint rounding, combined with simulation and other training, can foster better working relationships.

Good outcomes depend on nurses, physicians and other members of the care delivery team working together and communicating effectively, which experts say can be accomplished with more emphasis on integrated training and new teamwork models.

“Interdisciplinary teamwork is core to providing patient-focused care, quality and safe care,” said Carole Kenner, DNS, MSN, BSN, FAAN, dean and professor of Northeastern University’s School of Nursing in Boston. “It’s one of the key issues today.”

Kenner suggested physicians and nurses rounding together and training together to foster relationships that can lead to cooperation and make team members more comfortable speaking up.

Herb Perry, RN
Herb Perry, RN, encourages modeling of proper communication techniques between clinicians and zero tolerance policies for disruptive behavior.

Herb Perry, RN, nurse manager of surgical services and the stroke unit at Long Island College Hospital in Brooklyn, N.Y., reported patient care will suffer if nurses and physicians fail to work as a team. Physicians and nurses on his unit round together and discuss anticipated dispositions. 

“It’s face-to-face, voice-to-voice and offers an opportunity for questions,” Perry said. “The old Tarzan and Jane thing is a thing of the past. When approached the right way, doctors respect input from the nurses, because they know the nurses are here for 12 hours of the day.” 

Cynthia Mailloux, Ph.D., chair of the department of nursing at Misericordia University in Dallas, Penn., recommends health care academic programs start training people from different disciplines to work together before licensure. Misericordia University participates in a consortium of nursing and medical schools, which developed programming to provide inter-professional learning.

“We need a more collaborative working environment,” Mailloux says. “When that type of [collaborative] environment exists, we increase the quality we provide to patients as well as safety.”

Cynthia Mailloux, Ph.D.
Cynthia Mailloux, Ph.D., suggests starting collaboration training while people are in school learning to be nurses and physicians.

Team Training

“Taking care of patients is a team effort, but traditionally we do not train together,” said Carol Cheney, MS, director of simulation and innovation for the Arizona region of Banner Health in Mesa, Ariz. “The more we can start training and teaching them together, so they have a greater understanding and role respect, you see a true team dynamic and approach to patient care.”

Banner Health trains all levels of health care professionals, including medical students, residents and attending physicians, and new and experienced nurses using simulated scenarios created by nursing and physician subject experts. 

“There is a desire to work together better, but the big challenge is schedule, getting them to the same place together,” Cheney said.

Cheney said the team training focuses on a shared mental model—thinking the same thing for the same reason—and on communication and checking back about what someone thinks another person on the team has asked for.

“They watch each other’s back,” Cheney said. “We need to respect [each other], rather than the former captain-of-the-ship mentality, to keep moving forward. We’ve seen errors made with that mentality.”

Teamwork differs from working as an individual in a group, which offers more autonomy.

“True collaboration is required in a team,” Cheney said. “There has to be openness and a willingness to compromise. The concept is continuous improvement and superior outcomes.”

Fostering communication takes time and practice. Earlier this year, the neonatal intensive care unit at Mercy Medical Center in Baltimore began implementing TeamSTEPPS, a team-training program developed by the U.S. Department of Health and Human Services’ Agency for Healthcare Research and Quality (AHRQ) and the Department of Defense Patient Safety Program.

Nurses, physicians and other staff learned how to use the program’s tools, such as holding a morning brief to review admissions for the day and to problem solve, and then putting decisions into practice. The team conducts ad hoc huddles to discuss changes to the daily plan and to debrief together after events to learn how to improve.

“We’ve learned little strategies to help resolve conflict,” said Vickie Maenner, RN, CRNP, a Mercy NICU nurse practitioner and TeamSTEPPS instructor. “It’s worthwhile. All units should become TeamSTEPPS trained.”

Zero Tolerance for Bad Behavior 

Teamwork occurs when clinicians respect each other. Bad behavior—shouting, throwing things, demeaning someone—can quickly destroy collaboration efforts. Many hospitals, including Long Island College Hospital, have adopted policies that clearly state such behavior is not acceptable.

“Disrespect and unprofessional behavior is not tolerated,” Perry said. “It’s usually handled and nipped in the bud immediately.”

Hospital administration must support the policy and back it up, Perry said.

Disruptive clinicians may benefit from conflict management, communication and assertiveness training.

“People do not start out the day wanting to be disruptive, but it’s a stressful environment,” said Alan H. Rosenstein, M.D., MBA, medical director of Physician Wellness Services in Minneapolis, which works with physicians to understand the consequences of their behavior. By improving home and work life, disruptive events decrease. Many physicians understand they feel stressed, but they think they can handle it. They don’t realize the consequences of their actions.

“Some physicians, once they understand what they are doing, will modify their behavior,” said Rosenstein, adding that the goal is for physicians to learn how to depend on and trust the nurses and other staff. “You need to understand how to work with them in the best possible manner to get the best patient outcomes.”

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