AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. January 2010, Volume 12, Number 1: 3-5.

From the Editor

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Job Description: Nurse, 2010

Nurse, 2010

This month’s issue of Virtual Mentor explores teamwork in health care by examining various aspects of the nurse-physician relationship. With health care becoming ever more complex, and national health system reform on the horizon, efficient and effective teamwork is more important than ever. A common thread in all contributions to this issue is the recognition that teamwork is a pillar of safe, quality patient care and that collaboration with other members of the team is part of a profession’s responsibility to patients, and, therefore, an essential element of medical professionalism.

This month’s issue might not be so urgently needed if teamwork in medicine were easy to achieve. But a variety of historic, gender- and status-related assumptions and expectations create barriers to physicians’ and nurses’ working together collaboratively. The three clinical cases presented illustrate some of these sources of tension and how they manifest in the clinical environment.

The first clinical case describes a common result of nurses’ being “stuck in the middle” of patient advocacy and medical hierarchy. Ann Hamric, PhD, RN, offers a thorough commentary that examines the shared and distinct perspectives of physicians and nurses that can both contribute to moral distress and relieve workers from it. She also introduces the theme of hierarchies and power gradients that underlies the traditional, and often contemporary, nurse-physician relationship. The clinical pearl picks up on the coronary illness of the patient in this case and discusses the diagnostic and therapeutic benefits of heart catheterizations—with a Shakespearean twist.

The second case presents a medical-business-ethics dilemma: the conflict between a nurse practitioner and a physician hired to supervise her work. The case commentary by Erin L. Bakanas, MD, focuses on the physician-supervisor’s primary obligations to the patient and explains why professionalism demands that physicians and nurses make an effort to create the collaborative relationships that are so crucial to effective patient care.

Expanding on the topic of advanced practice nurses’ relationships with physicians, and connecting some aspects of teamwork to health care reform, the policy forum contribution from Randy Wexler, MD, MPH, argues that, although nurse practitioners are part of the answer to our primary care shortage, the deficit will be reduced only by the creation of patient-centered medical homes overseen by physician-led medical teams.

To flesh out a nurse’s perspective on the many practice and status questions associated with advanced practice nursing, Susan Schrand, MSN, CRNP writes an op-ed essay questioning the need for enforced collaboration between physicians and nurses. She says the mandate is applied to nurse practitioners but not to dieticians, physical therapists, and other medical professionals who practice independently without physician supervision. She argues that such collaboration occurs naturally as part of professionalism and warns that this mandate will hurt nurses more and more as the need for primary care grows and physicians are further outnumbered by advanced practice nurses.

Part of the solution to ineffective teamwork culture is to address it at the administrative and organizational level by introducing a standardized system for giving a voice to nurses, who often feel powerless to advocate for their patients. The third clinical case depicts the clear need for such a system. Commentary by organizational ethicist Becket Gremmels offers a helpful framework for case analysis that focuses on employee rights. Physician Lisa Cannada’s commentary describes how physician-nurse drama can cause patient care to recede from focus and outlines types of policies that hospitals might implement to protect medical institutions from the harms of workplace romance.

In this month’s medicine and society piece, Beth Ulrich, EdD, RN, discusses gender equality in medical and other professions. She then outlines some gender stereotypes that contribute to physician/nurse conflict but concludes that they are certainly not the sole cause of conflict. She, like many contributors, believes that understanding the knowledge and skills other medical professionals bring to patient care is an essential component of a high standard of professionalism. The op-ed piece by Lisa Rowen, DNSc, RN, also explores the role of gender in the traditional nurse-physician relationship. She goes on to examine the unique relationship between women physicians and women nurses and explain how women’s status in both professions has changed as egalitarian organizational structures have become more widespread.

Allison Grady’s commentary on Makary et al.’s 2006 article in The Journal of the American College of Surgeons highlights the importance of teamwork and the great divergence of perceptions between physicians and nurses on teamwork itself. It brings to the forefront both the fact that teamwork is viewed as a proxy for patient safety and that, currently, there is no standardized or effective tool to achieve many team functioning goals.

In the health law section, physicians and nurses are reminded of their respective codes of ethics. Krishna Lynch, RN, MJ, and Rita F. Morris, RN, MJ, then summarize interesting case law on medical malpractice and liability for physicians and nurses working together, and they establish that effective communication is crucial to successful and litigation-free teamwork.

A principal goal of this issue is to give voice to both nurses’ and physicians’ perspectives on topics of mutual concern. Physicians and nurses share a core knowledge base and an ultimate commitment to the highest standard of patient care. Yet their many differences, caused by a multitude of factors, generate tension as they share the responsibilities of patient care and ethical advocacy. Understanding each other’s knowledge and scopes of practice better will improve both teamwork and communication and provide better experiences for patients and the medical professionals themselves.



Elena M. Yates, MD/PhD Saint Louis University St. Louis, MO

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