How Did it Come to This?

The trouble lies in that both professions make the mistake of examining the practice of the other from their own professional context and that an authoritarian relationship persists as the primary source of conflict – one in which there is physician dominance and nurse deference. Physicians have been considered – across cultures and throughout history – as almost god-like. Consider this passage, framed and hung in the hallway of a major medical center until removed because a nurse executive found it denigrating to nursing: Hold the physician in honor, for he is essential to you, and God it was who established his profession. From God the doctor has his wisdom. – Sirach 38:15

Also, through the ages, nurses have been viewed as physicians’ handmaidens. Does this perception affect nurse/physician relationships? Perhaps so, but many other factors must be considered as well.

• Studies correlating the level of nursing job satisfaction and nurse-physician relations consistently show poor relations to be one of the greatest sources of stress.
• Cultural conditioning with men assuming the power roles has contributed to the historical caste-like relationship of nurses and physicians, where gender concentration has been predominantly female for the former and male for the latter.
• Compounding this is the portrayal of nurses by the media. Nurses are typically depicted as less intelligent, less scholarly, more irrational, and less individualistic than their physician counterparts. Further they have been portrayed as having a lower capacity to exercise clinical judgment.

The Oppressed Nurse: Fact or Fiction

Historically, nurses learned early in their training not only to respect physicians, but to fear them. Independent problem solving and critical thinking were not encouraged. Instead, nurses often sought gratitude, praise, and approval from physicians, which superseded the need to be competent professionals. Take for example a 1968 study where 21 of 22 nurses administered an unknown drug (placebos, unbeknownst to the nurses) at twice the labeled maximum dose, ordered by an unknown caller alleging to be a physician. When questioned, the nurses reported that their primary concern was to follow the physicians’ order.

Susan Jo Roberts, a nurse researcher who replicated Paulo Freire’s classic research on oppressed group behavior, ascertained that her sample group of nurses exhibited symptoms of oppressed group behavior as defined by Friere. That is, because nurses feel powerless and frustrated, they seek approval by physicians, their perceived oppressors. Their frustration comes out as aggression against peers.

Today, nurses’ quest for responsibility is often thwarted by physicians who fear encroachment upon their domain. Interestingly, though, nurses are often reluctant to exercise professional accountability, and cling to a task-centered mentality. This focus often leads nurses to deem their work as meaningless.

Consider nursing’s stance on education. Many a nurse cannot, or will not, advance from the ranks of diploma and associate degree backgrounds. Yet, what may be needed most for nurses to gain the professional respect they so deeply desire is to develop the finely-tuned skills of assessment, critical thinking, and problem-solving that advancing education provides.

Confusion Reigns Supreme

Nurses often complain that physicians don’t trust their judgment. When it appears that a physician isn’t placing full confidence in nursing, the source of apprehension may be that it is nearly impossible to figure out who is who. Not only are there several ways to gain entry into nursing, but the term “nurse” is often applied to anyone from the unlicensed patient-care technician to the doctorally prepared RN. No wonder physicians, like patients, are perplexed. Depending on physician protocols, some ARNPs are permitted to insert central lines. Yet other registered nurses are forbidden to initiate a late-night call to a physician without supervisor clearance. How can a profession be respected if it cannot be clearly defined and identified?

Further complicating the issue is the blurring of the historically distinct boundaries of nurse and physician, particularly with the mainstream acceptance and use of nurse practitioners and clinical nurse specialists as acceptable providers of primary healthcare. For many physicians, this is a bitter pill to swallow.

Another objection adding to the strain between professions is that nurses often feel as though the “dirty work” is left for them in the absence of physicians or by physicians themselves. While all team members should clean up after themselves, there are many duties left to nurses that some may erroneously call “dirty work:” contact with body fluids, dealing with difficult families, discussing potential organ donation, or explaining new and sometimes painful treatments and procedures to patients. Why not look at these as opportunities for nursing to play a positive role during our patients’ crucial moments?

Roadblocks to Communication

In the eyes of the public, nurses are caring. But physicians have the power. In one study of nurses and physicians from 30 cultures, there was a significant difference between the professions with respect to power. The physician was viewed as independent and knowledgeable while the nurse was described as kind and as having minimal influence over healthcare decisions. Unfortunately nurses often view themselves as powerless, thus feeding into this image.

Other barriers to effective communication have existed between the two professions. Most of these evolve from the nurses and physicians themselves, from the character of the institution or healthcare environment in which they work, and from the values of society. Traditionally, physicians have been socialized to have an air of self assurance, confidence, and adequacy. Nurses (especially those trained in the early years) are often indoctrinated into a role of subservience.

Almost across the board, hospital nurses have strong feelings when it comes to the July influx of interns. Despite years of medical school and training, new physicians are often unprepared for their role and rely on nurses to mentor them in patient care and hospital routine. By the time the following June rolls around, most physicians have become comfortable and nurses often feel that communication lines shut down. What can be done to keep the dialogue going? Neither group can deny that nurses and physicians rely heavily on each other for information vital to patient care, troubleshooting, and risk prevention.

Let’s consider also that when it comes to adverse outcomes, regulatory agencies and healthcare professionals seek explanations. Unfortunately, this can lead to finger-pointing, a behavior that often creates an environment in which cooperation is difficult and collaboration remote.

Taking the Bull by the Horns

Nurse-physician relations are undergoing considerable change. Cost-containment measures, the loss of RN positions and addition of technicians, and the replacement of once physician-only provided care by nonphysician providers are but a few of the factors that will shape healthcare for the future. Nurses themselves need to take action to free nursing from the subservient role that has evolved. Physicians and healthcare consumers must be educated about the unique contributions nursing brings to the healthcare arena. And by all means, encouraging open dialogue between professionals is imperative. Areas of conflict between nurses and physicians must be identified, and action taken toward improvement. Behaviors, such as competitiveness and criticism, must be recognized as obstructive to effective working relationships. And both disciplines must develop productive work skills and habits to replace detrimental ones.

Nurses are often viewed as expendable and easily replaced performers of tasks. Physicians are often unaware that nurses possess skill and knowledge that they themselves do not have. But it’s nurses who often fail to become involved with the promotion and expansion of nursing’s role and scope of practice. Many say that nurses lack control over their profession; that nurses are inactive, uninspired, and uncommitted to their profession. But managed care and healthcare politics appear to have provided the vehicle for change and an opportunity for nursing to achieve a new balance.

Collaboration is the healthcare buzzword of the 1990s. It improves patient care, enhances job satisfaction, boosts productivity, and helps to contain costs. But for collaboration to take place, several key factors must be present. All parties must be receptive and interested in working together, and above all, must have respect and trust not only for the other profession but in themselves as individual professionals.

The Road to Recovery

Before any positive change in nurse-physician relationships can take place, nurses must first examine their own behaviors and beliefs. In addition, consider these strategies for improving relationships between the two professions:

• Avoid angry or sarcastic attacks. Address difficult situations without delay. Don’t avoid conflict or remain silent. This will only prolong the inevitable friction.
• Be assertive. Do not resort to aggressiveness or hostility.
• Use an empathetic, nondefensive, yet persistent approach. Acknowledge, however, that emotions do play a key role in human behavior. Realize that individuals have the right to feel any way they choose. After acknowledging feelings, redirect the focus of your interactions to the matter at hand.
• Seasoned nurses who collaborate successfully with physicians should serve as mentors for those who have been less successful at collaboration.
• Identify problems, define objectives, address alternatives, plan for change, and integrate the changes. Strive to reach an agreeable solution based on input from all involved parties.
• Cultivate and demonstrate mutual respect. Recognize, compliment, and praise positive attributes and actions. Validating your respect for professional roles facilitates open communication.
• Elicit a free exchange of patient care information between nurses and physicians.
• Be holistically patient oriented, not task oriented.
• Strive for professional excellence in knowledge and clinical performance. Sharpen organizational and prioritizing skills. Think one step ahead and anticipate needs, particularly during emergency situations.
• Recognize the power that nursing has to impact healthcare. Nurses must become involved with policy-making and decision making, and become politically active in and for their profession.