Physicians and nurses have had to interact since nursing became a profession. The act of communication between nurses and physicians is a central activity in health care, and a failure to communicate has been linked with poor quality and patient errors. During the history of nursing, these interactions have been as different as each individual physician and nurse is different. The two professions have had to form relationships to accomplish their common goal: quality patient care (Manojlovich & DeCicco, 2007).
The relationships between the professions have changed throughout the years, for the most part; evolving from the traditional “superiority” of the physician/nurse as a “handmaiden” relationship to one of collegial respect between nurse-physician (Schmalenberg & Kramer, 2009). Disruptive communication occurs with alarming frequency in both nurses and physicians, and both sets of professionals agree that such ways of communicating decreases patient safety. Physician-nurse relationship and communication is something that has drawn interest for some time.
In 1967, Stein reported that nurses’ relationships with physicians were based on a “game playing” model, in which nurses gave recommendations regarding care without appearing to direct or disagree with the physician (Sterchi, 2007). By the 1990’s the physician-nurse interactions had evolved into a model in which nurses used informal, overt strategies to involve themselves with physicians in the decision making process. Nurses used negotiation skills to convey their ideas and opinions to physicians, who in turn listened to the nurses (Sterchi, 2007).
These changes in relationship increased nurses’ influence on patient-care decisions made by physicians. Miller and Thomas found that physicians perceived there to be higher levels of collaboration between physicians and nurses than did nurses (Sterchi, 2007). It has also been found that communication between nurses and physicians tends to be better in areas where there is nursing specialization such as in an intensive care unit, Obstetrical department or in the Emergency department.
The very nature of a specialty unit promotes teamwork and emands greater communication due to the acuity of the patient. In fact, Chaboyer and Patterson did a study and found that nurses who specialized in a certain area perceived greater levels of physician-nurse communication than did hospital generalist nurses (Sterchi, 2007). Unfortunately, not every member of these professions has come around to this new way of thinking. A number of physicians still feel that nurses should stand up when they come through the nurses’ station, and be seen not heard when it comes to patient care.
These tend to be the physicians that allow their attitude and arrogance to become disruptive and abusive, often times sacrificing quality care to prove the point (Sirota, 2007). Gender-related power issues still create problems, especially for female nurses in their working relationships with both male and female physicians. Nurses report that male physicians continue to exercise control over the largely female nurse group (Sirota, 2007). Class can also play a factor in the Doctor-Nurse communication.
Traditionally, most nurses came from lower social classes than most physicians and a difference in educational level is a factor affecting the balance of power. Dysfunctional relations impact job satisfaction, nurse retention, the nursing shortage, and the profession of nursing as a whole. Some nurses would rather leave the profession than deal with disruptive/abusive physicians and circumstances that lead them to feel helpless and victimized. Feelings of inferiority can lead to nurses not speaking up or giving their opinion about a specific problem with a patient, which can lead to poor patient outcome (Sirota, 2007).
Statistics show 70% of medical errors can be attributed to poor communication between nurse and physician (Sirota, 2007). Medical errors lead to higher morbidity/mortality rates in healthcare facilities; these errors can sometimes be avoided all together if these relationships between healthcare providers are improved. The nurse-physician relationship affects every aspect of patient care and the health care delivery system. This relationship has such an impact on ealth care that many agencies such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and the American Medical Association (AMA) have published guidelines and recommendations for healthcare facilities to follow that promote positive nurse-physician interactions and communications (Sirota, 2007). Nurses have many advantages now that they did before. It is only through advancing attitudes and education that we, as nurses, level the playing field between the two professions. More nurses today are receiving degrees, and have the self-confidence to confront physicians that are being disruptive.
Whether the confrontation is verbal or having the courage to initiate the chain of command, they are gaining more respect for the profession of nursing. Nurses need to consciously put forth an effort to improve the lines of communication between the nurse and physician. Nurses are educated to see the broader health care picture whereas physicians have been educated to focus on the “case”. Most physicians are not taught communication skills as part of their general medical education (Sirota, 2007). Improved communication will positively impact patient care.
There are several routes that can be used when preparing for this task. As nurses, we can not let negative behavior from physicians push us into angry communication or discourage further efforts of communication. One solution that nurses can champion is the formation of a task force within their specific facility with the sole purpose of improving nurse-physician relations. A strict policy and code of conduct can be produced and utilized as a way to ensure accountability. The task force’s main function can be to track and follow up on any reported offenses to the policy or code of conduct.
There should be a zero-tolerance policy for disruptive behavior. When nurses and physicians are aware of what type of behavior is acceptable and unacceptable, they can gauge their own attitudes and behavior to those guidelines. These acceptable behaviors will promote high quality patient care, and employee job satisfaction and retention. Research shows that disruptive behavior by physicians significantly contributes to nurse burnout, decreased job satisfaction, and decisions to leave the profession Sirota, 2007).
The policy and code of conduct should also outline ramifications of unacceptable behavior. All nursing staff and physicians would be inserviced on the code of conduct and policy pertaining to behavior. Posters and flyers should also be a way of communicating what behavior is acceptable and unacceptable. The task force should also come up with a reporting tool/tracking device that will be readily available in all departments so unacceptable behaviors can be reported and followed up on.
These reports will need to be investigated thoroughly and handled according to policy so that the fear of retaliation is reduced. The use of tools such as Situation, Background, Assessment, and Recommendation (SBAR) can also ease tensions and promote quality of care by ensuring clear concise reporting. SBAR was initially developed by the military and refined by the aviation industry to reduce the risks associated with the transmission of inaccurate and incomplete information (Rodgers 2007).
Some organizations add an additional R in which the listener “repeats back” what he or she has heard. Dr. Michael Leonard has done extensive work with the SBAR and believes the nurses and physicians have been educated differently, and thus, communicate as if they are speaking a different language (Rodgers 2007). Standardized protocols for medical and nursing interventions reduce the need for nurses to call physicians and help nurses manage patient care more efficiently (Sirota, 2007).
Something that technology has also brought about that helps with communication is e-mail and mobile phones. The use of regular nursing/medical staff meetings also helps to get everyone involved on the “same page. ” Even though technology has advanced communication in many ways between the nurse/physician, there is some ways in that it has also hindered communication. With the introduction of electronic medical charts and computer charting came efficiency in work and enhanced safety, but it also eliminated the need of face-to face dialogue between the medical staff Robinson, Gorman, Slimmer, & Yudkowsky 2010).
This results in incomplete or fragmented communication. Another area that contributes to miscommunication between physicians and nurses is differences in language. Physicians that English is not their first language are often difficulty to understand and there is a misunderstanding of the urgency of a situation due to tone (Robinson, Gorman, Slimmer, & Yudkowsky 2010). Nurses can work toward improving working relationships with physicians in two ways. The first way is by Empowerment.
By staying up-to-date with advances in their specialty, nurses can take pride in their expertise. Continuing education, specialty certification, and participation in professional organizations, clinical research, and conferences are good ways to stay in touch with developments in your field. Participating on interdisciplinary committees also empowers nurses to have an equal say in facility policies and procedures. The second was is by improving communication. This can be accomplished when nurses feel empowered to approach physicians as equal professional colleagues.