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HCPro

Leaving Venus and going to Mars


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How to teach your nurses to work with physicians, not against them

Editor’s note: The following is adapted from HCPro’s new book Stressed Out About Communication Skills by Kathleen Bartholomew, RN, MN. For more information about this book or any other from our library, visit www.hcmarketplace.com.

When the elderly woman arrived from the skilled nursing facility, she was in a Bair Hugger® because her core body temperature was 95.7oF. The report said she had end-stage renal failure and had been nonresponsive for more than 24 hours. Five elderly children surrounded their mother, nodding their heads as the physician told the family what he was going to do to save their 93-year-old mother’s life. No one in the family asked a single question.

Stat orders were given to administer three units of fresh frozen plasma, followed by almost a page of additional stat orders. After the physician left the unit, the nurse overheard the family’s disbelief that their mother might actually make it through this crisis—they had assumed she would die.

The nurse was not only stressed by the page of stat orders, but was morally troubled, as she would not have executed this plan of care for her own mother. The orders seemed above and beyond what would be expected for a 93-year-old comatose patient. She approached the resident who wrote the orders, but he would not listen; he was in a hurry to attend a patient in another unit. What’s a nurse to do?

The nurse consulted with her charge nurse. Then both went into the patient’s room and asked whether there was a family spokesperson. The three then sat down in a private area, with the charge nurse leading the discussion. She asked about the patient’s and the family’s wishes. The family representative shared that she was very surprised by the physician’s orders but that they did not know what to say to him. She asked the nurses for their opinions. The nurses shared with the family member that if it was their own mother, they would let her die. The woman said again that they wanted a peaceful death for their mother, but that they didn’t know what to say to the doctor.

Doctors can be intimidating to family members. In this case, the family representative and charge nurse did some role-playing, and the nurse helped the family members to write down a set of specific questions they had about their mother’s condition—for example, “What are the chances for survival on the current plan of care?” and “What lab values would tell you that this really was the end to her renal disease?”

The physician was paged to the room. After speaking to the family, he discontinued all stat orders and changed the plan of care to comfort care. The family was grateful, and the physician then wrote orders that ensured their mother’s comfort.

A closer look at nurse-physician relationships

Relationships between nurses and physicians have been classified into the following categories: neutral, teacher-student, collaborative, and collegial. It helps to know the different types of relationships so you can identify a plan to move toward collegiality, where power is equal and your opinion is valued.

  • Neutral nurse-physician relationships. Identifying neutral physicians is easy: They see no need to talk to you whatsoever. Like preprogrammed androids, they come to work, perform their tasks, and leave. If you approach them, they look up at you with a face that says, “What are you doing here?” There is absolutely zero emotional investment. Neutral relationships with physicians are characterized by the total absence of a relationship.

    Imagine that a relationship is like a doorway. These physicians have shut the door—and some have never opened it. How do you crack the door and let a little relationship in? How do you nudge neutral relationships into a more collaborative mode?

    – Focus on your shared humanity. Share a near-miss or clinical error, or invoke laughter by sharing something funny that happened on the unit.

    – See the physician as more than a cog in the wheel of healthcare. Acknowledge the time and energy he or she puts into the job. Why is this physician different? What unique talents does he or she bring to the unit? Verbally acknowledge the physician’s specific contribution with a compliment.

    – Engage the heart and soul of the physician. Share a poignant moment about a patient. Stories are powerful connectors.

  • Teacher-student relationships. Relationships that focus on knowledge are very common in teaching hospitals. New residents actively seek the input and knowledge of experienced nurses, and this collegial exchange then becomes the foundation for reciprocal relationships when the residents become attending physicians. Teacher-student relationships are characterized by professionalism because they are built on mutual respect.

    Nurses usually do not hesitate to contact these physicians, and attending physicians answer professionally. But the focus of these relationships is education, and physicians, in discreet ways, still retain their power—which in the end does not empower nurses. Use the tips listed above in the “Neutral nurse-physician relationships” section to move these relationships into the collaborative and collegial categories.

  • Collaborative nurse-physician relationships. The only difference between collegial and collaborative relationships is power. In collaborative relationships, the physician always has the last word. How do you move physicians from collaborative to collegial relationships? This process takes time, because the physician must learn to trust his or her team members.

    When physicians see a nurse’s rationale, insight, and interventions, they begin to appreciate and trust the nurse’s knowledge and judgment. This trust is the foundation of good nurse-physician relationships and takes time to build. To move from collaborative to collegial relationships, nurses must demonstrate and document their skill set to build trust, and insist on working as a team to implement the plan of care.

  • Collegial nurse-physician relationships. Recognizing the different categories of nurse-physician relationships is like knowing where the goal is on a soccer field. When you are working with a physician and can pinpoint his or her style, you can see how far you need to “move the ball.”

    Not only do collegial relationships exist, but they are ego-boosting for both physicians and nurses. When a nurse’s intellect is respected and his or her powers of observation are utilized to the fullest, there is a rewarding sense of fulfillment for the nurse in knowing that his or her opinion often makes a significant difference in a plan of care.

    Collegial relationships can only occur when a physician leader knows how to use and extract all the human talent around him or her to form a cohesive team. These kinds of physician leaders know their patients are in good hands because they have created the optimal situation for patient safety—a team.

    Spin a web of successful communication

    Think of a collegial relationship as a complex matrix of fine spiderweb threads between yourself and the physician. This spiderweb forms the fabric of your relationship. Every time you have a communication experience that is positive for both of you (clinical or nonclinical), another fine line is spun. Building this metaphorical web is the single most important thing you can do for patient safety. Your web, or relationship, then becomes the sticky trap that will catch a multitude of human errors.

    How do you encourage collegial nurse-physician relationships? Being a consistent, honest, and professional communicator sets the stage for collegial relationships. Remember that positive feedback in healthcare for both nurses and physicians is rare. Always take the time to personally thank—or send a thank-you note—to these collegial physicians. Small gestures go a long way in nurturing collegial relationships.