Nurse-Physician Relationships

Though the nurse-physician relationship should be the strongest relationship that nurses have to meet the needs of the patient, it frequently is not. Both sides have a role in the inadequacies of this relationship. Conflict does occur and this conflict can act as a barrier to effective patient care. Collegial relationships are those where there is equality of power and knowledge. In contrast, collaborative relationships between nurses and physicians focus on mutual power, but typically the physician’s power is greater. The nurse’s power is based on the nurse’s extended time with patients, experience, and knowledge. In addition to power, this relationship requires respect and trust between the nurse and physician. Due to these factors, it is a complex relationship.

Nurses have long worked on teams, mostly with other nursing staff. However, the nurse-physician relationships have become more important in the changing healthcare environment with the greater emphasis on interprofessional teams. Nurse-physician interactions and communication have been discussed for a long time in healthcare literature.

Physicians, however, are not the only healthcare providers nurses must work with while they provide care. (For example, nurses work with other nursing staff, social workers, support staff, laboratory technicians, physical therapists, pharmacists, and many others.) There are also other members joining the healthcare team such as alternative therapists (massage therapists, herbal therapists, acupuncturists, etc.), case managers, more actively involved insurers, and so forth. The future will probably bring other new members into the healthcare delivery system. Nurses need to develop the skills necessary to participate effectively on the team, which requires collaboration, communication, coordination, delegation, and negotiation. Communication and delegation are discussed in other chapters. It is difficult to practice today in any healthcare setting without experiencing interprofessional interactions such as nurse to physician. Effective teams:

· work together (collaborate).

· recognize strengths and limitations.

· respect individual responsibilities.

· maintain open communication.

Positive professional communication is critical. Both sides should initiate positive dialogue rather than adversarial positions. Cooperation and collaboration are also integral to the success of this relationship. A frequent question discussed in the literature is “Why is there conflict between nurses and physicians?” The structure of work is different for physicians and for nurses, and this has an impact on understanding, communicating, collaborating, and coordinating. This perspective identifies the key elements as sense of time, sense of resources, unit of analysis, sense of mastery, and type of rewards as described by the following:

· The nurse is focused on shorter periods of time, and time is usually short, with frequent interruptions. The physician’s sense of time focuses on the course of illness.

· If a physician gives a stat order, the physician has problems understanding what might interfere with the nurse’s making this a priority. There is a lack of understanding of the nurse’s work structure.

· Physicians often are not concerned with resources, though this is certainly changing as physicians recognize that there may be a shortage of staff as well as issues about costs and reimbursement for care. They, however, may not be willing to accept these factors as relevant when their patients need something. There are, of course, other resources such as equipment availability, supplies, and funds that can cause problems and conflicts. Nurses are typically more aware of the effect that these factors have on daily care and the work that needs to be done.

· Unit of analysis is another factor; for example, nurses are caring for groups of patients even though care is supposed to be individualized. Physicians may not have an understanding of this if they have only a few patients in the hospital.

· Physicians also do not have an understanding of nursing delivery models, and often nurses themselves are not clear about them. This affects nurses’ ability to explain how they work.

· The sense of reward is different. Nurses work in a task-oriented environment and typically get paid an hourly rate. Most physicians are not salaried and are independent practitioners, though some are employees of the organization (hospital, clinic, and so on).

Conflict and verbal abuse are related. Verbal abuse occurs in healthcare settings between patients and staff, nurses and other nurses, physicians and nurses, and all other staff relationships. This abuse can consist of statements made directly to a staff member or about a staff member to others. A common complaint from nurses regards verbal abuse from physicians. In addition to impacting quality care, verbal abuse affects turnover rates and contributes to the nursing shortage, so it is has serious consequences.

How can this problem be improved? A critical step is to gain better understanding of each profession’s viewpoint and demonstrate less automatic acceptance of inappropriate behavior. This requires that management become proactive in eliminating negative communication and behavior. Some hospitals have tried a number of strategies to deal with verbal abuse. The IOM recommends increased interprofessional approaches to care delivery and the need for increased