 2003 AJN Table of Contents
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Issues Update
American Journal of Nursing -
March, 2003 - Volume 103, Issue 3
Professional Respect
The CWPA and Magnet facilities work to improve nurse–physician relationships.
There was a time when nurses were treated as handmaidens to physicians.
While great strides have been made toward equalizing the
nurse–physician relationship, there
is still room for improvement.
However, health care administrators are taking
measures to foster positive nurse–physician relationships. And the
ANA Commission on Workplace Advocacy (CWPA) Work Group
on Nurse–Physician Relationships
is striving to give more nurses the tools to effectively
deal with physicians and other health care workers whose behavior crosses
the line.
A national approach
“Nurses don’t call doctors willy-nilly at 2 am or because
they don’t have anything else to do,” said Donna Warzynski,
RNC, MHSA, CNA, chairperson of the CWPA work group. “The reality is
that nurses are sometimes afraid to call particular physicians because of
the reaction they will get. They’ll exhaust all their options before
placing that call.”
For the past several months, Warzynski’s team of
nurses has focused on the issue of poor working relationships.
They’ve reviewed literature (See “Nurse– Physician
Relationships: Impact on Nursing Satisfaction and Retention,”
AJN, June 2002) and talked
with staff nurses to get to the root of the problem.
“What we discovered is that many of the problems
have to do with communication issues,” said Warzynski, president of
the Wisconsin Nurses Association. “There also seems to be a lack of
courtesy and respect for nurses’ expertise and knowledge. For
example, if a nurse tries to clarify or determine the rationale for an
order, he or she risks being taken to task for it or gets demeaning
comments, like ‘How would you know that?’ or ‘I can have
your job.’”
Warzynski said some physicians tend to think of staff
nurses in the acute care setting as their employees, even referring to the
RN who assists in procedures as “my nurse.”
“Until the last few years, no one has done
anything about correcting that thought process,” she said.
In an effort to improve professional relationships,
the CWPA work group wants to create tools to help nurses effectively deal
with disruptive behavior as it occurs, as well as workplace policies that
promote mutual respect among all health care providers.
“For example, we want to develop a sample policy
that not only addresses disruptive behavior, but also protects the person
who is speaking out about this behavior in good faith from any punitive
response,” she said.
Warzynski said that other health care administrators
should take the lead from facilities awarded Magnet status by the American
Nurses Credentialing Center. The Magnet Nursing Services Recognition
Program rewards facilities that place a high premium on their nursing care
and show that they promote collaboration and respect among workers.
Magnets for respect
A nurse for more than 25 years, Barry Hawthorne, MSN,
RN, CNAA, remembers a time when RNs would give up their chairs when
physicians arrived at the nurses’ station. He also remembers
frequently being at the receiving end of a chief resident’s
objectionable behavior while working as a staff nurse until a psychiatric
nurse liaison gave him some concrete advice.
“She taught me to say to the physician,
‘Your behavior is inappropriate, and I will not tolerate it.’
Then you either get out of the room, turn your back to the person or hang
up the phone,” said Hawthorne, a member of the North Carolina Nurses
Association. “It catches the physician’s attention.”
Now the chief nurse executive at NorthEast Medical
Center (NEMC) in North Carolina, Hawthorne passes on that advice to nurses
in conflict. His need to do so, however, is more the exception than the
rule.
He and other administrators at NEMC, a Magnet facility,
have worked diligently to create a climate of respect. One signal to
physicians that disruptive behavior will not be tolerated was the creation
four years ago of the Medical Staff Quality Improvement Committee, which
oversees such complaints and has the power to suspend physicians, revoke
their hospital privileges, and report them to the state licensing board.
If a nurse–physician problem occurs, the nurse
fills out documentation similar to an incident report. Hawthorne then
discusses the problem with the nurse and, if needed, takes the problem to
the committee, which examines the situation and determines if immediate
action is needed.
The chief of the specific department is notified. If
there are three or more complaints within six months, then a higher level
of action is taken, such as mandating a physician to attend
anger-management classes.
“We’ll also walk bedside nurses through the
process, so they know that we deal with problem behavior instead of just
saying, ‘Oh, that’s just Dr. Smith,’” Hawthorne
said.
In another program to elevate nurse–physician
relationships, NEMC has a night-shift clinical mentor whose sole
responsibility is to help RNs make the transition from new graduate to
professional nurse.
As part of that program, which began in July 2002, the
mentor developed a quick guide that details what information nurses need to
have on hand before they call a physician. In addition to helping with
clinical issues, the mentor also assists the new nurse in placing those
potentially difficult calls.
Hawthorne believes these NEMC actions have led to
creating high-quality nurse–physician relationships.
“You just don’t see those behaviors of old
happening anymore,” he said.
Administrators at Fox Chase Cancer Center, a Magnet
facility in Philadelphia, also pride themselves on creating a culture where
nurses are valued and respected. And the hospital’s specialty status
helps foster positive nurse–physician relationships.
“Because cancer is a chronic illness, patients
have ongoing relationships with nurses. Further, nurses are able to hone
their expertise, because the care delivered at Fox Chase is so
focused,” said Joanne Hambleton, MSN, RN, CNA, vice president of
nursing and patient services. “As a result, physicians generally view
nurses as competent and having the ability to manage patients’ needs
appropriately. There’s a lot of respect for nurses—and
physicians. It goes both ways.”
Additionally, administrators decided to develop a
communications standard to demonstrate that the center values every
employee and that everyone—irrespective of age, race, or
occupation—should be treated with respect.
“We think we have a really good environment
here, but we think we can make it better,” said Hambleton, a
Pennsylvania State Nurses Association member.
In June 2002 a team of four physicians and four nurses
representing different departments began meeting monthly to describe what
they believe to be inappropriate behavior and to develop a mediation
process.
At the meetings, members discussed numerous
hypothetical situations. For example, when a doctor doesn’t respond
to a nurse’s page, that physician is being disrespectful of the RN,
Hambleton said. On the other hand, if a nurse disagrees with one
doctor’s plan of care and calls another to alter it, that’s an
example of an RN being disrespectful of the physician.
Once the hospital board approves the standard,
employees will be taught about what the standard means and how they can
build greater self-awareness to regulate their behavior and improve
communication skills, Hambleton said.
“We work in a stressful, high-paced environment,
and sometimes we take shortcuts in communicating because we just want the
job done,” she said. “We need to take the time to communicate
effectively and think about how our behavior makes people feel.”
Another high-paced environment and Magnet facility is
St. Luke’s Episcopal Hospital in Houston, which Rosemary Luquire,
PhD, RN, CNAA, senior vice president and chief quality officer, likened to
a small city.
“With some 2,000 physicians on staff and 5,000
employees, there’s always going to be somebody behaving in a way they
shouldn’t behave,” said Luquire, a Texas Nurses Association
member. “Yet the relationships between physicians and nurses are
quite good. Respect is based on recognition of each other’s
professionalism and competency. Our employees are excellent and therefore
are well-respected by the medical staff.”
She credits those positive relationships to several
other factors, such as the facility’s long-standing commitment to
“collaborative practice teams.” These teams are composed of
physicians, nurses, and others who focus on meeting the needs of particular
patient populations.
Luquire also said St. Luke’s historically is very
patient focused and has strong standards of care and high expectations from
staff—all of which help build positive working relationships. St.
Luke’s maintains a strong continuing-education program to ensure
nurses’ competence, and also routinely offers programs that outline
professional behaviors and build communication skills, she said.
Susan Trossman is the senior reporter for the American Nurse at the ANA.
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