Nursing News

Improving the Physician–Nurse Dynamic

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By Jennifer Larson, contributor

August 26, 2011 - Can doctors and nurses learn to get along well enough to collaborate? Can they truly be partners in providing excellent patient care?

Many health care experts now say “Yes.” But that hasn’t always been the case.

Conflict by tradition

For many years, a hierarchical model, with physicians at the top of the hierarchy, was the norm in most hospitals and health care organizations.

According to writer Suzanne Gordon, who has written extensively about nursing and health care issues, nurses were traditionally socialized to be deferential, while doctors were socialized to be commanding.

Additionally, she said, they may not fully understand each other’s roles and abilities. Physicians are comfortable with the medical model, while nurses are comfortable with the nursing model, but they may not be very familiar or comfortable with the other’s model.

“So I think that both groups are set up to not be able to communicate and function as team members,” said Gordon, who is a visiting professor at the University of Maryland School of Nursing and assistant adjunct professor at the University of California, San Francisco School of Nursing.

Poor communication is an ongoing problem in the health care arena. A 2005 study by Vital Smarts in conjunction with the American Association of Critical-Care Nurses, entitled “Silence Kills: The Seven Crucial Conversations for Healthcare,” found that fewer than 10 percent of clinical staff would directly confront a colleague about their concerns. The reasons cited by many of the respondents for their reluctance to speak up included poor teamwork, disrespect or abuse, as well as fear of retaliation. Some also cited a belief that it wouldn’t do any good to bring up their concerns.

“I think the norm is failed communication, and the exception is good communication,” said Gordon.

And yet, communication failures can pave the way for harm to occur to patients.

“Really terrible things can happen” when communication breaks down, noted Robin DiMatteo, Ph.D., a professor at the University of California, Riverside, who has conducted extensive research in dyadic interactions in health care.

Prescription medication errors and other adverse events have long been linked with poor communication. In fact, The Joint Commission cited communication failure as the leading root cause of sentinel events that were reported to the commission between 1995 and 2004.

So it’s up to an organization’s leadership team to step up and encourage their physicians and nurses to work together to provide the best possible patient care. And they need to make a concerted effort to change the situation, by not only instituting policies but by also following up with training and ongoing education about better communication, DiMatteo said.

“Removing power differentials…and making it very clear that the doctor and nurse are on the same team can tremendously improve patient care,” DiMatteo said.

Gordon agreed, noting that nurses need psychological safety in the workplace to speak up if something has gone wrong. Nursing schools can and should play a major role in teaching good communication skills so that nurses can learn how to communicate effectively. Then, once they are in the workplace, hospitals and health care organizations should support them in using those skills and provide additional training for improvement, she said.

“It can’t just be one shot,” she said. “It has to be recurrent.” 

Creative solutions to encourage collaboration

The old hierarchical model may not be as common as it once was, but it still exists, said DiMatteo.

However, a growing number of health care providers are willing to try something new if it can benefit their patients. Two fairly new strategies are gaining in popularity as effective ways to combat the old “us-vs.-them” dynamic.

The first is the establishment of interdisciplinary teams that encourage teamwork and collaboration.

Earlier this year, the nurse and physician leadership at Long Beach Memorial Medical Center in California established interdisciplinary teams that review patient charts; they call the groups “discharge huddles.”

Led by a nurse and a physician, the group creates and reviews daily goals for a patient and then share the information with the patient and his family. They review the goals again the next day to determine how the treatment plan is progressing. Every member of the team has a clearly defined role, and everyone understands that everyone else has a vital role to play.

“This is working for us, and it’s changing the culture of our medical staff,” said Judy Fix, chief nursing officer and senior vice president for patient care services.

Like a growing number of others, the hospital also instituted a standardized communication tool; they chose S-BAR, which stands for Situation-Background-Assessment-Recommendation, a technique that was developed to bridge the different approaches toward communication.

Long Beach Memorial has noticed improvement in its patient satisfaction scores and patient length of stay as a result of these efforts, Fix said. 

“And we’re seeing (improvement) in the area of nurse communication, physician communication and discharge readiness for the patient,” she said, adding that the hospital plans to expand the discharge huddle model beyond the five units that currently use it.

A second strategy growing in popularity is the interdisciplinary education model that requires nurses and doctors to begin learning and collaborating together while they’re still in school.

In 2009, leaders from the Goldfarb School of Nursing at Barnes-Jewish College and the Washington University School of Medicine in St. Louis, Mo., decided to organize a joint inter-professional simulation experience for their students. They wanted the nursing students and the medical students to get a chance to work together and establish mutual respect, which would be the building blocks of future relationships and collaboration.

“Our goal was to work together more collaboratively with each other,” said Beth Haas, MPH, the director of the Clinical Simulation Institute at the Goldfarb School of Nursing. “It’s been highly successful.”

By working together on standardized patient cases, the medical students were able to learn more about how a nursing assessment works, and the nursing students were able to learn more about the medical assessment model. They became more familiar with each other’s roles as members of the health care team, and they began to trust each other more.

Haas said, “Both sides felt that each other’s partner had valuable information to bring.”

The UCLA School of Nursing and the UCLA School of Medicine launched a similar program a few years ago.  The schools offer a joint class for third year medical students and advanced practice nursing students to discuss key issues in health care.

According to Maggie Dewan, NP, MSN, the result has been a series of thoughtful, lively discussions that have helped the students overcome communication barriers and improve relationships with other types of health care practitioners.  The students are able to clear up misconceptions about each other before they take root.

“We believe this course is helping them to develop more collegial attitudes, rather than hierarchical attitudes,” said Dewan, a lecturer in the school of nursing and one of the program’s tutors. “Because this is a team…and we all work together for the good of the patient.”


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