Introduction
Nurses and doctors share a common goal of ensuring optimum health status and maximizing the comfort of their patients. However, for a long time, the physician-nurse relationship has been one of physician dominance and deference from the nurses rather than a more collaborative relationship. Traditionally, the doctor-nurse relationship has been one of power and influence with the physician expecting the nurse to have the role of an obedient observer and carrying out instructions. This relationship has evolved due to various influencing factors. Among these being the context of the workplace, training and education, multidisciplinary relationship, patient’s expectations, institutional norms, professional norms, and risk management and defensive practice (Fagin and Garelick, 2004). A good example of a change in working context is seen in psychiatry. Earlier, most psychiatry occurred in an acute in-patient ward, this is changing and psychiatry is now taking place in a variety of locations. Consequently, the style of arrangement has changed creating new and different roles for the nurse and doctors. One of the most significant changes in this relationship is the loss of the exclusive nurse-doctor pairing.
Main body
A reflection of these changes is evident in institutional and professional norms for example working shifts and medico-legal responsibilities. These to a large extent define how the interaction will occur since different requirements and expectations have been set. Radcliffe (2000) argues that the doctor-nurse relationship is affected to some extent by what patients think. The patient’s perception reflects the popular and traditional view of nurse and doctor roles. This perception is however changing due to the increase in publicity of fallibility among medics and nurses, as well as internet use which have reduced the magic and gloss of the two professions. (Radcliffe 2000; Stein et al 1990).
Physician nurse relationships define the nature of communication between the doctor and nurse. In an authoritative relationship, communication becomes strained but in a relationship of some professional equality communication becomes meaningful and useful for the patient, and respect has been maintained both ways between the doctor and nurse. Suzanne Gordon suggests that the problematic nature of the relationship between nurses and doctors has its origins in the education of doctors. In the initial stages of learning, physicians learn a lot from nurses because the nurses have more clinical knowledge. As the physicians advance, they begin to feel that they cannot learn from nurses anymore. This is because of the perception that nurses have less knowledge than physicians. This may be true to some degree but while physicians have greater knowledge of the disease process; nurses have deeper knowledge and a better comprehension of how the individual patient is coping with the treatment process (Gordon, 2004). The lack of respect for nurse’s complementary knowledge among medical students contributes largely to the creation of divisions that are carried into their professional practice. These in turn become a hindrance to effective communication. It also ought to be noted that the hierarchical organization in which medicine is frequently practiced creates a barrier to communication by discounting the contribution of other professions.
Poor doctor-nurse communications can have a devastating effect on patient safety and patient outcome. A negative environment where nursing contributions are not valued results in dire consequences for the patient. An incident in the early 1990s clearly reflects this. Following an inquiry into the high rate of mortality and a high number of potentially preventable complications at the pediatric cardiac surgery of Winnipeg Health Science Centre, the court came to the conclusion that the unacceptable number of deaths was a result of poor doctor-nurse communications and ignoring of nurses’ warnings. Despite the nurses reporting the poor performance of a new surgeon, their concerns were dismissed as illegitimate. Another inquiry into a different pediatric cardiac surgery in Bristol England passed that the poor doctor-nurse communication had a role to play in the unacceptable fatality rates. This inquiry found that nurses had failed to alert the authorities due to feelings of intimidation by the physicians (Hernandez, 2005).
A nurse-doctor study involving more than 200 nurses and doctors led the authors to conclude that when communication between the medicine and nursing professions was freer, there was likely to be the improvement of work with a more collaborative practice that benefited patients (Gordon, 2004). Poor nurse-doctor relationships cause nurses to leave hospitals, and sometimes the nursing career jeopardizing the recovery of patients. When people are responsible for a sick, vulnerable individual, the need for remaining in close and even constant communication is very high. This is especially so for doctors who stay at a patient’s bedside on average for a few minutes. Communication between the physician and nurse occurs at many points for example information sharing on the round, the information noted on the chart, and information shared over the phone. Patient care has to do with the exchange of data on assessment and evaluation which are critical processes in making decisions concerning planning the treatment regime of a patient. (Gordon, 2004)
Communication concerning changes in the status of the patient is one of many complex aspects of the dysfunctional nature of doctor-nurse relationships. The process according to nurses interviewed by Gordon is made complex by doctors who do not understand why nurses are trying to reach them, by physicians who do not want to deal with uncomfortable issues, and by a healthcare system that is increasingly becoming fragmented (Gordon, 2004).
Nurses waste a lot of time trying to get hold of doctors so that they can convey the patient’s worries to the doctor or get clarification on illegible orders or orders where the nurses do not understand what is going on with the patient’s treatment. Doctors who try to communicate well with nurses stand out because they are so few. These ones look at the assignment board to ascertain which nurses are assigned to their patients. They then look for the nurse and ask and answer the necessary questions while giving the nurse the opportunity to raise any concerns they might have about the patient (Gordon, 2004). This indicates respect for nurses and what they do.
Often nurses feel that the burden of facilitating communication has been theirs to bear for too long while doctors are so harried that they do not make time for adequate communication. Most hospitals conduct physicians rounds early in the morning when nurses are making initial evaluations of the patient, performing data collection activities, and giving personal care such as ensuring patients have been fed or have gone to the bathroom. The nurses’ contribution is critical during rounds since her knowledge about the patient is necessary for the formation of a medical plan by the physician. Failure to conduct rounds at a convenient time for both doctors and nurses compromises communication that would have occurred during the round. Many nurses hold the view that multidisciplinary teamwork cannot occur effectively since the infrastructural framework is inadequate and therefore rounds are conducted at the physician’s convenience.
Nurse-doctor communication is made even more difficult by the increasingly fragmented healthcare system in which the physician comes and goes and attends to few patients while the nurse stays longer with the patients’ Many physicians believe that the individual nurse works for them personally and not the hospital and its patients. For these physicians, their expectation is that the sole priority of the nurse is to take care of their patients. Unless a nurse is working for an individual doctor in private practice, nurses in hospitals are juggling the demands of more than one physician in a hospital setting (Gordon, 2004).
Communication and collaboration are cardinal elements of good working nurse-doctor relationships. Collaboration allows nurses and physicians to work together in problem-solving, conflict resolution, communication, decision making, and coordination. The process of collaboration allows colleagues to make decisions independently and as team members. Communication is therefore a significant process in collaboration. For there to be effective communication there has to be a balance of power among the participants and recognition of one another’s mutual value. Improved communication has benefits for both the patient and the nurse. It results in better patient outcomes and increased job satisfaction for nurses and physicians as well as decreased jobs stress (Pallas et al, 2004).
Despite these known advantages of improved communication between nurses and doctors, many health organizations still have poor doctor-nurse communication. Most of the discourse on nurse-physician communication comes from the nursing community. Some faulty nurse-physician communication patterns include the use of passive voice especially among the nursing staff and the use of deflective patterns by nurse managers when handling communication problems. Most of the discourse on nurse-physician communication that comes from the medical community is many times on legal aspects and the expectations of the physicians with regard to transfers of patients. There is little else apart from this (Weeks, 2004). The continued expansion of the role of the nurse has caused a blurring of boundaries in some areas of what is nursing care and what is medical care. This role blending may be threatening to physicians leading to a negative effect on their communication with nurses. As such some communication patterns are a means of maintaining power.
Social and gender perspectives have contributed to the status difference between physicians and nurses, which has in turn influenced communication patterns. Most physicians have different social circles from nurses leading to the decreased similarity in communication patterns. Gender stereotypes that expect men and women to be assertive and complaisant respectively also influence communication patterns. These remain unchanged even when women’s education levels are higher (Weeks, 2004). Education despite leading to more nursing responsibility and autonomy for patient care also strains communication patterns further. Physicians are taught to make independent decisions about patient problems while nursing education promotes a more collaborative and advice-seeking approach. Different educational backgrounds also lead to goal conflict as far as patient care is concerned leading to differences in priorities (Weeks, 2004).
The underlying issue in faculty communication patterns can be said to be a power struggle albeit with each group depicting the power relationship differently. The medical community views the struggle for independence and revised communication patterns as having a potentially detrimental effect on patient care and does not see the need for changes in communication patterns. The nursing community is of the view that communication patterns need to be changed and that this can be done while recognizing and accepting the status of the physician, (Weeks, 2004). This different view somewhat explains the common error in making nurse-doctor communication seminars where most of the recommendations place most of the responsibility on the nurse by giving guidelines on what the nurse should do while little responsibility for changing communication patterns is given to doctors. For instance, many of these seminars will outline what the nurse should do before she calls the doctor, what she should do in case she misses the physician, and recommends that when the doctor calls back the nurse should have the patient’s chart at hand; a recommendation that is hard to practice because most nurses handle many patients and will therefore often not sit with one chart waiting for a phone call. In addition, physicians have been known to walk around with patient’s charts after making an order for a stat medication. When the medication is started four hours later after the physician has put the chart down, a conflict begins yet the nurse could not have performed otherwise in the situation. Such issues are rarely addressed in communication seminars.
Barriers to nurse-physician collaboration exist in various health settings. They include role misunderstanding, position, and respect, real and perceived differences of power as well as varying inputs of decision making and autonomy. Increased patient awareness has also contributed to changes in the dynamics of nurse-physician communication. Greater involvement of patients in their own care requires that inter-disciplinary communication be increased so that the necessary information is availed to the patient (Pallas, Hizon, Cool, and Mildon, 2004)
Most nurses and physicians in various healthcare settings are not aware of protocols and regulations about communication. Nurses and physicians with fewer years of experience have less knowledge on communication procedures as compared to those who are older in the profession. More experienced physicians have better communication patterns as a result.
Certain work environments also have better work communication patterns for example clinics compared towards. This is perhaps due to the fact that in the clinics there is the greater delineation of roles and more contact with different healthcare professionals (Pallas et al, 2004).
Stein compared the nurse-physician relationship to a game model where the nurse made recommendations for patient care in such a way that it seemed as though the physician had initiated them (Stein, 1967). This interaction had a significant drawback which was that it stifled open dialogue. The root cause of the problem according to Stein was the training of medical and nursing students.
Conclusion
The relationship has changed and some of these changes include the introduction of males into the nursing profession, deterioration of the public esteem for physicians as well as the commercialization of medical care. Though the changes have not occurred, some of the old problems still continue to exist and this may be due to the social conditioning where men have power roles, and the media fuel this further by portraying nurses as less intelligent and having less input in healthcare decisions making. The differences in views held by doctors and nurses concerning communication patterns hold back advancement in nursing and also affect research into nurse-physician relations. Magnet hospitals promote positive nurse doctor communication which is characterized by a greater degree of autonomy for nurses, greater control over resources and personnel where high-quality care will be required. Positive nurse-physician communication is beneficial and has positive outcomes for all participants involved, physicians, nurses, and patients.
References
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Pallas LO, Hiroz J, Cook A, Mildon B, 2004 Nurse-Physician Relationships Solutions and Recommendations for Change, Comprehensive Report for the Nursing Secretariat and Ministry of Health Ling Term Care Research Unit.
Radcliffe, M. (2000) Doctors and nurses: new game, same result. BMJ, 320, 1085 Stein, L., Watts, D. T. & Howell, T. (1990) The doctor–nurse game revisited. New England Journal of Medicine, 322, 546–549.
Stein, L.I. (1967) The doctor-nurse game Archives of General Psychiatry, 16(6), 699-703 Weeks MB, 2004 Nurse Physician Communication – Discourse Analysis Canadian Operating Room Nursing Journal.