Doctors and nurses have been trained to be suspicious of each other.
So writes Suzanne Gordon, author of Nursing Against the Odds (Cornell UP, 2006). And while this has historical roots, it is particularly dysfunctional today. In this RealityRN interview, Gordon describes the complicated relationship between nurses and doctors—and gives practical advice for nurses to help remedy the situation.
RealityRN: Describe the history of nurse/doctor relationships.
Suzanne Gordon: The perception of nurses has long been influenced by men. According to historical, patriarchal views on society's structure, men were able to define our roles—first as women, then as nurses. Women only received knowledge men thought they should have.
Hospitals became hierarchal systems. Doctors were at the top and nurses followed in descending levels of importance. Hospitals developed into job-specific, gender-specific environments—males were doctors and females were nurses.
How does this affect health care today?
Nurses and doctors have been socialized to believe they are not each other’s healthcare partners. They are taught they belong to opposing teams; they view the other team as somehow messing with their goals, mission, or skills. Doctors sometimes think nurses don’t know anything, and nurses sometimes think doctors know the wrong thing.
Do nurses perpetuate this?
You can’t have a bad relationship without the participation of two or more parties. Whenever there’s a failed nurse/physician relationship, there’s potential for something bad happening to the patient downstream.
I don’t think nurses, any more than doctors, know how to negotiate or resolve conflict. Physicians and nurses are taught dyadic communication. They’re taught to focus on nurse/patient or doctor/patient communication—not nurse/doctor/patient communication or team relationships. There are good, historical reasons for this model, but it’s proven to be quite dysfunctional now; nurses are very critical of it.
So what should they be focusing on?
I think people have to focus on being a team—and recognizing what the concept of “team” actually means. A team is not a bunch of people doing different things in the same room. It’s not a bunch of different people engaged in power-plays around the patient’s bed. Nurses often confuse venting and communicating. Venting isn’t communicating. It’s really important for nurses to learn how to communicate well with physicians and other nurses.
Often, complaints go to the nurse manager and the nurse manager goes to the doctor.
Absolutely. And the nurse manager and the doctor, whom the nurse talks to, often have equally poor skills in negotiation, communication, and conflict resolution.
It seems like a problem of the entire work environment.
Right. It’s a systems problem. Doctors don’t communicate well with each other, so why would we expect them to communicate well with nurses? Nurses don’t communicate well with other nurses, so why would we expect them to communicate well with doctors? Between 75 and 80 percent of medical errors and injuries are caused by human error, often from shortcomings in communication.
This is not just about “being nice to each other.” This is not charm school. Patients are dying—they’re experiencing preventable complications because of errors in communication. It’s a systemic problem and it has to be solved systemically.
How can an individual nurse fix a systems problem?
A friend who’s a PT thinks that, on the first day of nursing school, every nurse is told that she’s the only one who cares about the patients. The PT felt most nurses conveyed this attitude: “I’m the patient advocate. I’m the only one who communicates with that patient. I have to protect the patient from you.”
The nurse thinks she’s working for patient advocacy, but inadvertently she’s suggesting that everyone else is the patient’s enemy.
Nurses have to admit they need help and find ways to learn better communication skills. Systems don’t change because the people who run them suddenly notice they’re flawed. Systems change because human beings in those systems force them to change.
So, really, a new mindset needs to be developed.
Yes. A team is a group of people who help each other work efficiently and effectively to fulfill a shared mission.
A new nurse, for example, should ask physicians for briefings. If a new nurse sees a doctor in a patient’s room, she shouldn’t wait for the doctor to approach her. She should go up to him/her and ask questions. She should clearly state her concerns, and not hold them in.
What about the fear of being put down by the doctor?
The nurse should always stick to the facts. For example, “I’m concerned about the patient’s blood pressure,” “The patient looks clammy,” or “The patient was acting one way and now he’s acting another.” State the reason you’re concerned and say it over and over again. If the doctor says he or she is really busy and can’t talk, you say, “I’m really concerned about this—I think you need to come now.”
In teamwork training, I teach what we call the “Two Challenge Rule.” You challenge the presenting issue twice, and if it’s serious, you go to someone else and say, “Help.”
Isn’t this good old-fashioned patient advocacy?
Yes. But advocacy is not simply having the best interest of the patient at heart. If the doctor blows you off and you do nothing, you are no longer that patient’s advocate. Advocacy means inquiry and persistent assertion for your patient and your profession. It means speaking clearly.