In 1967 Leonard Stein described the "doctor-nurse game," whereby nurses suggested ideas in ways that allowed physicians to claim them as their own. As long as a nurse didn't confront a physician, their dance was maintained-with the nurse in her "proper" lower place, not his equal in stature.
My first full-time nursing job, in intensive care in the U.S. Army Nurse Corps, seemed an exception to this rule. Nurses and physicians made patient rounds together, discussed care options, and collaborated on staff development. We valued each other and took pride in our teamwork. In retrospect, though, I wonder if this was because we were just very good dancers-we all knew our respective dance steps and tried not to step on one another's toes. FIGURE
In the 1970s there was a concerted effort for the "assertiveness training" of nurses. But it meant that we wanted a new dance with physicians, one in which neither partner dominated the other. Has there been a backlash on the part of physicians against nurses' attempts to boogie as equals?
But overall, in 32 years of practice I've found too many physicians arrogant and condescending toward nurses, even abusive. In one hospital, nurses, administrators, and other physicians did nothing about a surgeon who had tantrums if the operating room temperature wasn't just right (he actually threw instruments at nurses). The nursing director dismissed it as "stress." It was an environment I couldn't stay in for long.
As stressful as such environments can be for nurses, they can be a matter of life and death to patients. In 1986 Knaus and colleagues reported in the Annals of Internal Medicine on factors predicting patient outcomes in 13 hospital intensive care units. Communication between nurses and physicians was the single most important predictor of mortality rates. Also, one of the characteristics of Magnet hospitals (shown to have lower mortality rates than non-Magnet hospitals) is good nurse-physician relations.
This month, AJN publishes a multisite survey of nurses', physicians', and administrators' perceptions of nurse-physician relations and the influence of "disruptive physician behavior" on nurses' morale, satisfaction, and retention (see page 26). More than 92% of survey respondents said they'd witnessed physicians' disruptive behaviors, yet there were significant differences between physicians' and nurses' perceptions on all questions.
The survey's author, Alan H. Rosenstein, is a courageous physician for disseminating this study. Nonetheless, I disagree with his opinion that improving nurse-physician relations cannot be addressed until facilities tackle such issues as mandatory overtime and inadequate staffing. Nurses must take responsibility for their role in perpetuating that stale, old, damaging dance with physicians by changing their own steps. For example,
* chief nurse officers should call for a replication of this survey in their institutions, insist on a zero-tolerance policy of any employee's abusive behavior, and work with chief medical officers to develop a plan for improving nurse-physician relations.
* staff development personnel should work with new nurses to help them hone their skills in communicating with physicians (for example, when discussing a patient's change in status).
* nurses should show up for patient rounds with physicians and actively participate.
* nurses should stop referring to physicians as "Doctor So-and-So" while physicians address them by first names. Whether we use last or first names, we must stop perpetuating such inequality.
* advanced practice nurses should insist on being included on signs, in telephone messages, and in advertisements as members of primary care practices, so that a patient would no longer hear, "You have reached the practice of Doctor So-and-So," without also hearing "and Nurse Practitioner Such-and-Such."
Remember, it takes two to tango.