Virtual Mentor. August 2005, Volume 7, Number 8.

Clinical Cases

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Following the Golden Rule toward Respectful Relationships

Vignette 4: Physician-to-Nurse Communication.

Commentary by Richard Sheff, MD

An ICU nurse consistently informs, you, the junior resident, that he would have handled a particular problem or conversation with a patient differently, often explaining what he would have done instead. This morning, he started to correct you in front of a patient but was interrupted by the entrance of the patient's primary care physician.

Commentary

Communication between a doctor and a nurse should be simple. Both are highly trained professionals. Both share a commitment to providing excellent care to the same patient. Both need each other to make this happen. Then why does it go wrong so often?

This clinical vignette may help us answer this question. The first thing that should strike you about this scenario is that it is unusual. Why? Because most nurses are not comfortable telling a physician, even a junior resident, that he or she would have handled a problem differently. Not that nurses don’t think physicians should do things differently. Just ask them. You’ll get an earful, and it will probably be enlightening. Yet physicians almost never ask nurses for input or feedback. In fact, lesson number 1 from this scenario is that developing physicians should ask nurses for input more often than we do. As young physicians we too often believe we are supposed to be all-knowing. We are afraid that asking for input or feedback, especially from a nurse, will undermine our authority or will tarnish our persona. We are not all-knowing, not as medical students and residents, and not even as senior physicians. Willingness to listen to others, especially experienced nurses who are part of our patient care team, is a sign of a mature physician.

Respectful Relationships
If the nurse and the ICU junior resident have an effective, collegial relationship, then, although it’s unusual, the frank feedback may be welcomed as part of an exchange between 2 knowledgeable clinicians. In this case, the nurse made the mistake of carrying out the clinical exchange in front of the patient. Should you, the junior resident, address this in front of the patient as well? Of course not. You didn’t appreciate it when the nurse did this to you, so why do you think the nurse would feel any different? If you let your ego get in the way, you may have an impulse to embarrass the nurse in front of the patient with some sort of public dressing-down. All too often physicians act this way. Whether striking back to defend their stature as physicians or in a misguided effort to “teach the nurse a lesson,” physicians sometimes criticize, humiliate, and embarrass nurses in front of patients.

Do Unto Others
Instead, this is a moment to treat the nurse exactly as you would want to be treated. Complete the clinical interaction with the patient and leave the patient’s bedside. Then, in a quiet and collegial manner, ask to speak with the nurse alone. If this is a first-time event, it is appropriate to begin this interaction with a question from one colleague to another, such as:

Junior resident: You began to correct me in front of that patient just now. This is unusual, so I was wondering why you did that.

You may be surprised to hear something like:

Nurse: “I was concerned you were about to make a mistake that would have led to a patient injury. Our patient safety protocol requires us to speak up when this occurs.”

If this is the response, you could say the following:

Junior resident: Thanks for speaking up, but should a similar situation arise in the future, please ask to speak to me away from the patient.

You may want to develop a code phrase the nurse could use that would alert you to his concern and trigger an immediate pause in the clinical interaction to obtain the nurse’s input before proceeding. 

To this day, nurses often do not feel empowered to address physicians directly when they see a medical error unfolding. Instead, all they feel comfortable doing is “hinting and hoping.” The patient safety movement is changing this, providing structured communication tools between doctors and nurses that reduce errors. As physicians, we should welcome this change, not be threatened by it.

Dysfunctional Relationships
So far we have assumed this scenario represents a collegial, respectful relationship between doctor and nurse. But it is also possible that we are catching a glimpse into a dysfunctional doctor-nurse relationship. If this is the case, then we should ask why the nurse feels a need to consistently tell you, the junior resident, what he would have done differently. Sometimes physicians and nurses get into power struggles. Sometimes personalities clash. Whatever the underlying cause, a mature physician should still treat this nurse as he or she would want to be treated. This means asking to speak to the nurse privately and raising the concern as colleagues. Listen to the feedback thoughtfully. You may agree with it or disagree, and either is OK. You should then take this opportunity to state clearly that a disagreement like this should never be carried out in front of a patient. As previously mentioned, you may need to arrange a signal that allows the nurse to keep you from making an error and provides the 2 of you an opportunity to step into a private location for an exchange about the best way to proceed.

If this approach does not work, meaning either the nurse does not accept the feedback professionally or the nurse’s behavior continues, it is important for the physician to recognize that this nurse has a boss, and it is not the ICU junior resident. So you should work through the nursing chain of command, beginning with the nurse’s immediate boss, who is usually a unit manager or supervisor. You should speak directly to this person, reporting either the individual event or the pattern of behavior and ask the manager or supervisor to help solve the problem with the nurse. If this exchange fails to resolve the issue, the physician should go either to the manager or supervisor’s boss or to the chief resident and ask that person to address the problem. (If it had happened to an attending physician, he or she would report it to the department chair.) In each of these exchanges, the physician should maintain a professional demeanor, without the need to raise his or her voice.

So why do doctors and nurses fail to communicate well? The answer is failure to follow the golden rule. If someone else doesn’t follow this principle, that doesn’t justify your throwing it aside. Always treat others in the clinical setting as you would want to be treated, and you will be respected, appreciated, and effective.

Suggested Reading
American Medical Association. Code of Medical Ethics. Opinion 9.045 Physicians with Disruptive Behavior. Available at: http://www.ama-assn.org/apps/pf_new/pf_online?f_n=browse&doc=policyfiles/HnE/E-9.045.HTM&&s_t=&st_p=&nth=1&prev_pol=policyfiles/HnE/E-8.21.HTM&nxt_pol=policyfiles/HnE/E-9.01.HTM&. Accessed July 25, 2005.

Richard Sheff, MD, is chairman and executive director of the Greeley Company, a division of HCPro, Inc. in Marblehead, Massachusetts. The Greeley Company is a physician-led, national consulting and education company serving hospitals, medical staffs, and physician organizations across the country.