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Consider the evidence-then tell us what you think.
RECENTLY, my father was hospitalized for an extended period. He was surprised at how hard the nurses worked and how little he saw of the doctors. "I never knew what nursing was all about," he told his nurse. "Don't worry, sir," she replied. "Neither do the doctors." - Staff nurse, Minnesota
SIXTEEN YEARS AGO, Nursing91 led off a major survey report on nurse/physician relationships with this quote. Of over 1,100 nurses responding to the survey, only 43% reported feeling satisfied with their relationships with physicians, and 68% doubted that physicians understood nursing responsibilities.1
The issues raised in the survey were based in part on an earlier essay in The New England Journal of Medicine called "The Doctor-Nurse Game Revisited."2 Written by three physicians, it described a rigid hierarchy that placed physicians firmly in charge. Even though nurses regularly offered expert advice about patient care, they were expected to defer to physicians. By engaging in this characteristic behavior, nurses and physicians prevented open conflict-but they also avoided direct communication with each other. Nurses consistently reported feeling frustrated and dissatisfied with working relationships that devalue their professional worth.
In the last 16 years, much has changed in the health care environment. Health care professionals now recognize that interdisciplinary collaboration and good communication are crucial to patient safety. In fact, agencies such as the Centers for Medicare and Medicaid Services, Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and Institute for Healthcare Improvement expect health care facilities to promote good communication and teamwork to prevent errors and improve patient outcomes.3,4,5
In this article, I'll discuss the current state of working relationships between nurses and physicians. I invite you to share your experience and opinions by responding to the survey on page 56.
A review of the literature on nurse/physician relationships reveals the following:
* Nurses report that the same negative issues between nurses and physicians that have existed for years persist.6,7
* These issues continue to make nurses dissatisfied with the nurse/physician relationship, contributing to poor job satisfaction among nurses and hampering nurse retention.7
* Nurse/physician relationships have improved in certain health care situations, such as operating room and intensive care settings where teamwork is crucial.8
Now let's look at the major issues contributing to poor nurse/physician relationships.
Inappropriate, disruptive, or abusive behavior by physicians.
In light of the ongoing nursing shortage, poor nurse/physician relationships have far-reaching implications within health care settings. Research shows that disruptive behavior by physicians significantly contributes to nurse burnout, decreased job satisfaction, and decisions to leave the profession.9 In one study, 31% of respondents said they knew of nurses leaving the hospital as a result of disruptive physician behavior.7
Nurses have always reported difficulty dealing with physicians who are rude, unpleasant, dismissive, belittling, or intimidating. This kind of behavior is reported to be more prevalent among older physicians than among younger ones who were reared in a more egalitarian social climate.1 Nurses report that these negative behaviors appear to be related to gender issues, power gaps, hierarchical traditions, or an attitude that nurses are their handmaidens rather than valued professional collaborators.
In my experience, physicians who engage in negative behavior with nurses tend to do so because of deeply ingrained personality characteristics related to a need for coercive power and self- glorification. These physicians probably treat others outside of the health care setting the same way. Some physicians get away with the behavior because many nurses feel intimidated by it and are afraid to address it or can't figure out how to deal with it. Consequently, the behavior continues unchecked.
Dismissive attitudes about nurses. Nurses report that physicians may take them for granted, don't know or understand what nurses actually do, don't listen to what nurses have to say about patients, don't take nurses' assessments seriously, fail to incorporate nurses' assessments into care plans, or are difficult to contact.7,10 These problems may have less to do with the physicians' personality characteristics than their lack of knowledge about nursing responsibilities.
Another consideration is the difference in how nurses and physicians approach patient care. Nurses are educated to see the broader health care picture; they tend to focus on holistic issues and the more human aspects of care. Physicians have been educated to focus on "the case"; they're concerned more with strategies for medical cure or management and may not focus on emotional issues, discharge planning, social and cultural concerns, and helping patients live with their disease and treatment.11,12 Most physicians aren't taught communication skills as part of their general medical education, and some may also wish to avoid dealing with intense emotional states in their patients.13,14 Nurses report that physicians don't spend enough time discussing care options with patients and families.1
Many nurses still feel that physicians don't understand, respect, or care to listen to nursing perspectives on patient care. Different perceptions of the patient and the patient's needs often result in misunderstanding and conflict between nurses and physicians and can become a breeding ground for anger and dissatisfaction.
Power/gender issues. Gender-related power issues still create problems, especially for female nurses in their working relationships with both male and female physicians. Some physicians, especially older ones, tend to see themselves as being in complete control, with nurses serving as subordinates present to do their bidding. Nurses report that male physicians continue to exercise control over the largely female nurse group.15 In this traditional model, being male automatically confers superior power.
The old "doctor-nurse game," first described by Stein in 1967,16 continues to exist. Many female nurses, despite believing their expertise to be more appropriate in a particular situation, still feel the need to defer to physicians. Some nurses have learned and still choose, consciously or unconsciously, to preserve and protect the physicians' traditionally "superior" professional status by deferring to them at all times. However, male nurses have reported that physicians treat them more respectfully and with greater collegiality.17
Class issues can also be a factor: Traditionally, most nurses came from lower social classes than most physicians. However, class backgrounds of those entering nursing and medicine tend to be more equal now than in the past.
A difference in educational level between most nurses and the physicians with whom they work is another factor affecting the balance of power. Current reports attest to a mild "acceptance" by some nurses that the power level between nurses and physicians will always be unequal because physicians generally have more education than most nurses.
Nurses who have this attitude may be confusing differences in educational levels with differences in professional philosophy, roles, functions, professional knowledge, and clinical focus and experience between the two professions. The roles, functions, and kinds of expertise nurses and physicians have may be different, but they're equally important to patient care.
Communication/collaboration issues. Poor communication between nurses and physicians was the most important factor causing dissatisfaction with nurse/physician working relationships in the Nursing91 survey, and it continues to be cited as the most significant issue in the current literature.9 The JCAHO reported that communication failures among professionals caused 70% of 2,455 reported sentinel events, with about 75% of the patients dying as a result.18
Communication problems stem from all the factors affecting nurse/physician interaction I've just discussed, but particularly power/gender issues and dismissive attitudes toward nurses. Poor communication persists as long as physicians view their roles and functions as fundamentally superior to those of nurses. When physicians don't understand or appreciate the value of nurses' observations and judgments, they're slow to respond when nurses try to contact them-a common nursing complaint.
If nurses feel disrespected, misunderstood, or devalued by physicians, they may feel angry and helpless and avoid communicating. Poor communication leads to misunderstandings, errors, and ongoing conflict between nurses and physicians.
Rosenstein showed that nurses see a strong association between disruptive physician behavior and adverse events, errors, and poor patient outcomes. One nurse commented, "Most nurses are afraid to call Dr. X when they need to and frequently won't call. Their patients' medical safety is always in jeopardy because of this." Asked if they were aware of any potential adverse events that could have occurred from disruptive behavior, 60% of 1,487 respondents to the question said yes.9
The good news is that when nurses and physicians work closely together in small, high-acuity areas such as intensive care units, they tend to work in a climate of mutual respect, good communication, and nurse/physician collaboration.8
Nurses can work toward improving working relationships with physicians in two interrelated ways:
* Empowering nurses. Feeling secure in their knowledge and clinical expertise empowers nurses. 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. Nurses should also establish informal collaborative work groups with other nurses where they can recognize and share their clinical expertise. Participating on interdisciplinary committees also empowers nurses to have an equal say in facility policies and procedures. Simply put, knowledge is power.
* Improving communication with physicians. This can be accomplished when nurses feel empowered to approach physicians as equal professional colleagues. This means that nurses must assume responsibility for the quality of their relationships with physicians. Experiencing professional empowerment helps nurses stay focused on approaching all physicians in a collegial, respectful, and problem-solving-based manner, no matter how badly any individual physician may behave. As nurses, we can't let negative behavior by physicians push us into angry communication or discourage further efforts to communicate.
To address these problems, nurses need administrative support from health care facilities to establish and enforce a zero-tolerance policy for disruptive behavior. Code-of-conduct policies and procedures must be developed, disseminated, and enforced consistently, with feedback provided to all parties. (These policies would apply equally to a nurse or any other staff member who's abusive to others.) Staff-development initiatives to increase staff awareness of the problem and its consequences is an important first step toward improving communication among health care professionals.7,9
Rather than placing the burden for dealing with verbal abuse on the recipient, institutional policies and procedures provide an interdisciplinary framework for dealing with problem behavior in a constructive way. For example, in some facilities the medical director is responsible for counseling a disruptive physician about his behavior, then proceeding with disciplinary action if the behavior recurs. In some cases, the nurse, physician, and others involved may be brought together with a mediator to discuss and address the disruptive behavior.
Nurses' use of communication tools such as SBAR (Situation, Background, Assessment, and Recommendation)19 can also ease tensions and promote quality care by ensuring clear and concise reporting of patient issues to physicians. Standardized protocols for medical and nursing interventions reduce the need for nurses to call physicians and help nurses manage patient care more efficiently. Use of technology such as e-mail and mobile phones also facilitates communication.20
Increased collaboration between nurses and physicians-for example, via regular nursing/ medical staff meetings-helps move all clinicians away from an adversarial, "us versus them" mind-set. In some facilities, nurse-managers encourage collaboration by routinely surveying physicians and nurses for feedback on communication problems. Programs that promote interaction between medical and nursing students help these future professionals understand each others' roles and responsibilities better.
It's not surprising that nurses and physicians still have relationship problems because these conflicts are rooted in human factors such as personalities, attitudes, feelings, and communication styles. For things to change, nurses have to approach the problem directly and initiate strategies to improve things, rather than merely complaining about them.
What do you think? Are nurse/ physician relationships improving, the same as ever, or worsening? Help us evaluate the current status of nurse/physician relationships-and constructive approaches to the problem-by completing the following survey. We'll publish the results in an upcoming issue.
To help us evaluate the current state of nurse/physician relationships from a nursing perspective, please complete the following survey. Take it online at http://www.nursing2007.com; it's fast, easy, and free (if you can't take it online, please photocopy and fax it to 215-367-2155 or mail it to Nurse/Physician Poll, Nursing2007, 323 Norristown Rd., Suite 200, Ambler, PA 19002-2758).
Respond to the following by circling the number or checking the box corresponding to your answer. If you wish, send additional comments on a separate sheet. Share this survey with your colleagues and encourage them to reply. The deadline is February 28, 2007.
1. Editors of Nursing91. The nurse-doctor game. Nursing91. 21(6):60-64, June 1991. [Context Link]
2. Stein L, et al. The doctor-nurse game revisited. The New England Journal of Medicine. 322(8):546-549, February 22, 1990. [Context Link]
3. Centers for Medicare & Medicaid Services. http://www.cms.hhs.gov. [Context Link]
4. Joint Commission on Accreditation of Healthcare Organizations. http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/.[Context Link]
5. Institute for Healthcare Improvement. http://www.IHI.org. [Context Link]
6. Peplau HE. A glance back in time: Nurse- doctor relationships. Nursing Forum. 34(3):31-36, July-September 1999. [Context Link]
7. Rosenstein AH. Nurse-physician relationships: Impact on nurse satisfaction and retention. AJN. 102(6):26-34, June 2002. [Context Link]
8. Lingard L, et al. Getting teams to talk: Development and pilot implementation of a checklist to promote interprofessional communication in the OR. Quality and Safety in Healthcare. 14(5):340-346, October 2005. [Context Link]
9. Rosenstein AH, O'Daniel M. Disruptive behavior & clinical outcomes: Perceptions of nurses and physicians. AJN. 105(1):54-64, January 2005. [Context Link]
10. Fagin CM. Collaboration between nurses and physicians: No longer a choice. Academic Medicine. 67(5):295-303, May 1992. [Context Link]
11. Leonard M, et al. The human factor: The critical importance of effective teamwork and communication in providing safe care. Quality & Safety in Health Care. 13(Suppl. 1):85-90, October 2004. [Context Link]
12. Haddad AM. The nurse-physician relationship and ethical decision-making. AORN Journal. 53(1):151-154, 156, January 1991. [Context Link]
13. Buckman R. Communications and emotions. British Medical Journal. 325(7366):672, September 28, 2002. [Context Link]
14. Maguire P, Pitceathly C. Key communication skills and how to acquire them. British Medical Journal. 325(7366):697-700, September 28, 2002. [Context Link]
15. Zelek B, Phillips SP. Gender and power: Nurses and doctors in Canada. International Journal for Equity in Health. 2(1):1, February 11, 2003. [Context Link]
16. Stein LI. The doctor-nurse game. Archives of General Psychiatry. 16(6):699-703, June 1967. [Context Link]
17. Porter S. A participant observation study of power relations between nurses and doctors in a general hospital. Journal of Advanced Nursing. 16(6):728-735, June 1991. [Context Link]
18. Joint Commission on Accreditation of Healthcare Organizations Sentinal Event Statistics (2004). http://www.JCAHO.org. Accessed September 2006. [Context Link]
19. Leonard M, et al. SBAR technique for communication: A situational briefing model. http://www.IHI.org. Accessed July 10, 2006. [Context Link]
20. Tjora AH. The technological mediation of the nursing-medical boundary. Sociology of Health and Illness. 22(6):721-741, November 2000. [Context Link]
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