Several weeks ago I asked the question, "Have physician-nurse relations improved?" From your responses it appears that the answer is, "Yes, but ... we have a way to go."
Thus, as a follow-up, I would like to move from past to present and share two "best practices" that some healthcare organizations have begun to implement, and perhaps you would be willing to share some of your own.
Best Practice #1: Nurse-Physician Councils
My former hospital in New Hampshire painfully recognized almost a decade ago that physician-nurse relationships had reached an all-time low. Nurses didn't feel supported from administration, their peers, or physicians. Physicians didn't feel that nurses were respectful of their time or cognizant of effective communication tools, particularly after hours to address nursing and patient concerns. Things culminated in a poorly-managed case in which the i nurse asked the on-call physician to come in to take care of an urgent medical problem, the physician refused, and the nurse did not go up her chain of command for fear of retaliation. Fortunately, the patient survived despite our "best efforts" and we realized that something had to happen. That "something" was the nurse-physician council, a group of formal and informal nurse and physician leaders who came together with the mission to improve and optimize nurse-physician relationships and communication. This council met on an ad hoc basis and addressed such issues as:
- Nurse-physician culture (e.g., trust, respect)
- Nurse-physician communication (e.g., consistent use of SBAR and other patient safety tools to optimize clinical effectiveness)
- Nurse-physician protocols (e.g., inter-disciplinary rounding, coordinating schedules so that physicians and nurse could work together, staggered shifts)
- Nurse-physician clinical and functional pathways (e.g., agreement on when things would happen and when physicians and nurses were obligated to respond to each other's needs and concerns regarding patient care)
- Nurse-physician behavioral issues (e.g., disruptive and dysfunctional behaviors on both sides)
In short, this council was charged with addressing mutual issues of concern that both parties felt had an impact on patient safety, nurse-physician relations, morale, turnover and mutual frustration. The creation of this council was an important cultural touchstone and indicated a mutual awareness of the need for the two most important clinical groups to work in greater harmony and attention to each other's needs and concerns.
Best Practice #2: Nurse-Physician Dyads
Part of the reason for the traditional conflicts between nurses and physicians is that the pattern of work is so different. Nurses work full-time in a clinical setting while physicians are balancing the demands of the office, emergency department, operating room, etc. This has led to enormous discord as patients are increasingly ill and nurses are seeking partnership with physicians who are immediately available and who can provide timely and efficacious treatment. There has been a growing realization that nurses and physicians will never work effectively together if they don't lead together. This has led to the creation of the nurse-physician dyad in which a nurse and physician manager lead their clinical units in all phases of clinical operations including:
- Joint oversight of both physician and nursing performance
- Joint establishment of clinical and functional protocols and "evidence based" practices
- Joint oversight of the operational plan and budget
- Joint oversight of supply chain management and inventory
- Joint peer review and performance improvement activities
- Joint modeling of effective collaborative culture, communication and conflict resolution
This requires a cultural shift for both nurses and physicians. Both must adapt to the need to: modify perceived roles and identity; create effective inter-disciplinary teams; co-manage clinical activities that have an impact on quality, safety, service and cost; and modify traditional behaviors and attitudes that inadvertently create tension and potential conflict.
High-performing organizations are taking a hard look at traditional nurse and physician roles and responsibilities and are redesigning them to enable a new level of collaboration and mutual respect. Interestingly, there is resistance on both sides for this change; with greater professional standing comes greater responsibility. The "good old days" of the physician refusing to come in when the nurse expresses a legitimate concern or the nurse going on break when there are urgent patient needs must end. What may result is a shift in not only the way nurses and physicians work together but also in the ways they view themselves.
These changes don't come easily and they take time. The key is to come up with the "best practices" that meet the needs of your nurses, physicians and patients consistent with your organizational history and culture, and to implement them in a timely and efficacious way that has the endorsement and support of most (if not all).
What nurse-physician best practices have come to your organization? Do you have other best practices to share?
Jonathan H. Burroughs, MD, MBA, FACPE is a certified physician executive and a fellow of the American College of Physician Executives. He is president and CEO of The Burroughs Healthcare Consulting Network and works with some of the nation's top healthcare consulting organizations to provide "best practice" solutions and training to healthcare organizations.