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How Can We Improve the Doctor-Nurse Relationship?

The discussion has been going on since the early days of modern medicine: How exactly should doctors and nurses interact, and how can we improve the relationship between them? For the last 40 years, we’ve slowly been moving away from the notion that nurses are completely subordinate to doctors, mere task workers who follow orders. Instead, nurses are now seen as knowledge workers. There is a new emphasis on interdisciplinary collaboration, which should theoretically bring docs and nurses closer together in the hospital hierarchy. But does it?

A 2013 survey found that the state of doctor-nurse relationships is still in need of improvement. It’s important to note that the study was fairly small and relatively unscientific – readers of an article were simply asked to weigh in with their thoughts. Here’s the breakdown of how the survey respondents described the state of nurse-physician relationships:

  • Just OK: There’s still a mixture of collaboration and conflict – 66%
  • Poor: There are too many unprofessional clashes – 31%
  • Strong: There’s finally a climate of mutual respect – 3%

So how do we explain the proliferation of lukewarm survey responses?

Despite efforts to make medicine less paternalistic, there is still a general perception that doctors are in charge, giving orders that both nurses and patients must follow. Gender-based power issues are likely still a problem as well – older male physicians may continue to view the largely female nursing workforce as subordinates. And finding ways to communicate effectively remains as challenging as ever. While technologies like email and computerized order entry keep doctors and nurses in touch 24/7, they may offer up their own opportunities for confusion or result in less face-to-face interaction.

There’s also a fundamental difference in perspective between nurses and doctors. Nurses are trained to see the big picture, to view the patient holistically – while physicians have been taught to focus on “the case” and strategize treatments and cures, without necessarily considering the emotional, social, or cultural factors that affect the patient.

It’s clear that hostile or adversarial roles between providers can threaten patient safety and lead to nurse burnout that translates into high staff turnover. So what can we do, to improve the nurse-physician relationship?

The Internet is full of op-ed style articles with suggestions for relationship improvement strategies, many of them written by doctors or nurses. The suggestions seem to fall into two distinct categories: personal strategies and organizational strategies.

Personal strategies, like those outlined in this blog post, often focus on making nurses feel more empowered. These include the suggestion that nurses stop apologizing for interrupting a doctor, participate in rounds, equalize the name game by addressing doctors by first name, and learn to speak up when they see something amiss, like a physician who routinely does not wash hands before touching a patient.

But organizational culture is also an important determining factor in nurse-physician relationships. Hospitals should have policies in place that make it clear the organization will not tolerate disruptive behavior from physicians. Here’s what the Joint Commission has to say, in a Sentinel Alert from 2008:

“Intimidating and disruptive behaviors are often manifested by health care professionals in positions of power. Such behaviors include reluctance or refusal to answer questions, return phone calls or pages; condescending language or voice intonation; and impatience with questions. Overt and passive behaviors undermine team effectiveness and can compromise the safety of patients. All intimidating and disruptive behaviors are unprofessional and should not be tolerated.”

Writing for the Huffington Post, a physician makes the case that strict hierarchies can endanger patients, by making it harder for those lower in the hierarchy to speak freely:

“The greatest challenge and the ultimate goal is to create a friendly and personal environment where nurses and doctors are able to question each other’s decision-making without fearing an angry or defensive response. Even the greatest nurses and best-trained physicians make mistakes. In order to mitigate these potential medical errors, nurses and doctors must obtain a level of communication where it is okay to question a medical decision or provide productive feedback on any aspect of patient care.”

An article from NursingCenter.com makes the compelling argument that education can be the great equalizer, allowing nurses to feel more empowered and more “equal” to other members of the care team:

“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. 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.”

American Sentinel University is an innovative, accredited provider of online nursing degrees,  including RN-to BSN and advanced degree programs that prepare nurses for a specialty in case management, infection control, and executive leadership.

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