Physician/nurse conflicts studied
The study’s intent was to shine a light on a rarely discussed issue in hospital work life that is a contributing factor to the nursing shortage: disruptive physician behavior. But, as one of its authors notes, it also points out a significant threat to the health and performance of nurses.
The study, authored by Alan H. Rosenstein, MD, MBA, vice president and medical director of VHA West Coast in Pleasanton, CA, is titled "Nurse-Physician Relationships: Impact on Nurse Satisfaction and Retention." It appeared in the June 2002 issue of the American Journal of Nursing. Drawn from 1,200 responses from nurses, physicians, and hospital executives, it notes that disruptive physician behavior, as well as an institution’s response to it, is a contributing factor in nurses’ decisions to leave their positions. Such behavior runs the gamut from verbal abuse to physical and sexual harassment.
"I think the biggest finding is the overall issue related to the feelings about work environment, and peoples’ willingness to work in certain environments," notes Rosenstein. "There are lots of issues, but one that often is overlooked is the issue of the day-to-day working relationship, with physician behavior as a contributing factor."
Morale significantly impacted
The study also showed that such behavior impacts nurses’ morale. "One of the key factors in nurses’ satisfaction has to do with value, appreciation and respect, and their desire to do their job as a nurse — to get the best possible patient outcome," Rosenstein explains. "When they have poor communication and a lack of teamwork, all of those issues are belittled."
The study showed that 90% of the nurse respondents had witnessed some type of disruptive activity, and 30% said such awareness played a role in their decision to leave their positions. "Besides actually leaving, some nurses said they would do everything possible to avoid certain physicians — like taking days off or checking their schedules," he adds.
When victims of such behavior don’t leave their positions, there can be attendant health and productivity impacts because of disruptive behavior, Rosenstein notes. "Perhaps they may not be able to fully concentrate on their duties. They may not be quite as productive," he offers. "They may become distracted or frustrated. In addition, there are some causative factors between error and safety having to do with stress and the ability to concentrate."
Stress manifests in different ways
And of course, there are the physical manifestations of stress. "These range from psychosomatic symptoms to actual physical illness, like heart disease," says Rosenstein. "People under stress end up with generally lowered immunity and resistance and diseases stemming from that condition."
What can be done?
Respondents offered a number of strategies to identify and combat disruptive physician behavior. Rosenstein cites these as his top four:
• Raise awareness levels: Nurses are well aware of these kinds of situations, but the awareness of both physicians and administrators needs to be raised, based on the study. "Administrators thought they were very much aware and supportive, but nurses ranked their awareness as low," says Rosenstein.
• Try to provide vehicles that increase nurse/physician contact and communication: "It could be as simple as making sure that when a doctor shows up for work he interacts with nurses, or you could develop committees and other types of vehicles," Rosenstein observes. "Some respondents even suggested that doctors actually go on rounds with the nurses."
• The institution needs to adopt a zero-tolerance and code-of-conduct behavior policy: "Participation in inappropriate behavior has to have a harmful outcome for the participant," says Rosenstein. "The culture has to be set to support this."
• Specific educational programs and seminars should be put on to focus on conflict management, team building, time management, and even things as simple as telephone etiquette: "This came up several times in the study," notes Rosenstein.
What can you do?
Given that negative interaction between physicians and nurses is essentially a personnel issue, one might assume that occ-health professionals would interface with their human resource department to address the problem. But that’s not necessarily the case, says Rosenstein. Often the medical department is involved because studies have shown that communication problems can impact patient outcome, he explains. VHA Inc. has conducted a number of education programs about team building and conflict management, and many were initiated by intensive care units, emergency departments, and obstetrics departments, he explains.
"Doctors are trained to be autocratic. They need to be dominant," Rosenstein offers. "So they approach a medical situation from the point of view that this is what the presentation is, and these are the things I need to do. They focus more on that and less on being sensitive to the social ramifications of their behavior. There’s a fine line between the need to get things done and disruptive behavior."
This appears to be supported by the finding that while a vast majority of nurses have witnessed or experienced disruptive behavior, only 2% or 3% of all physicians participate in such behavior. "Many day-to-day interactions are not that dramatic," says Rosenstein.
Nevertheless, it is clear that nurses’ health and job satisfaction can be dramatically impacted. If victims do not actually report the behavior, is there any way an occ-health nurse or physician might be able to pick up signals?
"Cues can certainly be picked up," says Rosenstein. "The day-to-day interactions with people accustomed to working with the nurse is one way. You may suddenly notice a change of behavior or routine. You might notice depression or lack of energy. Nurses may not really be fulfilling their duties the way they used to or perhaps they are becoming careless or slow. What you should look for is a significant change in the normal routine that has been going on for awhile." Educational sessions can address issues such as stressful situations, where disruptive behavior often occurs, he explains.
Additionally, nurses should be approached in an environment of friendship. "Someone needs to work on those early cues and have some sort of vehicle to be able to report them, whether it’s an occupational heath professional or the chief nursing officer," he recommends.
[For more information, contact: Alan H. Rosenstein, MD, MBA, VHA West Coast, 4900 Hopyard Road, #320, Pleasanton, CA 94588. E-mail: [email protected].]
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