Are conflicts with doctors putting patients at risk?
When a physician asks for additional suture material for wound repair and the nurse realizes there is none left, the doctor explodes in anger.
In the middle of putting on a patient’s cast, a physician calls a nurse "stupid" for failing to hold the arm in exactly the right position.
Do these scenarios sound all too familiar? If physicians are disrespectful to nurses in your ED, this is not only bad for morale and staff retention, it’s unsafe for patients, says Judy Davidson, RN, ED clinical nurse specialist at Pomerado Hospital in San Diego. "It is known that when physicians are not polite to nurses, that the nurses are less likely to report changes in condition, which may affect patient care," Davidson says. "Patient outcomes are worse when there are adversarial relationships."1
To address conflicts with physicians, use these proven strategies:
• Allow disagreements to be aired.
When tension occurred between nurses and physicians at Paradise Valley Hospital in National City, CA, staff were inclined to bring complaints to the ED nursing or medical director, says Alison McManus, RN, BScN, CEN, clinical educator for the ED.
To encourage communication and problem resolution at the staff/physician level, a liaison committee was created consisting of staff nurses, ancillary personnel, and physicians. The committee recently addressed a conflict regarding physicians deciding which room a patient was to be placed in, instead of consistently involving the charge nurse in the decision. "Communication between the groups has improved, and physician and charge nurses are now required to collaborate on patient room assignment," she reports.
• Start a "peer review" system.
Paradise Valley’s ED is developing a system to allow nurses, physicians, and patients to anonymously offer compliments or constructive criticism to staff by writing comments on index cards placed in collection boxes.
All staff will be assigned a number known only to the administrative assistant, with comments reviewed by department directors and placed in the staff member’s mailbox. Staff can respond as they want with the feedback, says McManus. "In the case of criticism, staff can choose to ignore it or can act to change their behavior," she says. "It is really about creating awareness that a behavior has been witnessed, in the hopes that staff will be motivated by peer and patient feedback to change it."
Ideally, nurses and physicians would communicate directly with one another, but sometimes people aren’t comfortable doing this, notes McManus. "The peer/ patient review program will allow an opportunity to share thoughts and feelings that may otherwise go unspoken."
• Report problems with abusive physicians.
Nurses need to report all occurrences of verbal abuse, because this is the only way for administration to take notice of a trend, advises Davidson.
"The first time a problem is reported, it is likely that the person who reviews it will wait to see if it happens again, especially if the problem is verbal and not physical," she says. "If a trend develops, action will be taken."
If you report disruptive behavior on the formal hospital quality report form, it cannot be "swept under the carpet," adds Davidson. "It has to be logged in the system, and the volume of these complaints is tracked by the hospital insurance company."
When reporting an incident, Davidson recommends the following:
— Use the words "disruptive physician behavior." "This is a key term that nurses should be familiar with," she suggests. "Check that box or write that phrase into the report."
— If you know for a fact that the same problem has already occurred with a particular physician, write the words "trend in behavior, previously reported."
— If the incident occurred in front of a patient or family member, say so. "Administrators will take greater note because the behavior may impact patient satisfaction," says Davidson.
• Support other nurses.
In an ED, you can hear when a physician is being disruptive, says Davidson. Don’t leave the nurse alone, she advises. "Gather around your colleague," Davidson says. "Give disapproving looks, and help the nurse to move the conflict away from the patient care area."
She suggests saying the following to verbally abusive physicians: "Talk to me later when you are not so upset." "Your tone is not appropriate." "We should have this conversation in private. I will speak to you when you have calmed down."
A leader such as a charge nurse or supervisor should intervene and say, "Let’s talk about this in private," Davidson says. "At that point, most physicians will stop the conflict but refuse to talk in private."
Report the situation to a supervisor so that he or she can perform a one-on-one follow-up with the physician later, she says.
Experienced nurses need to stand up for new staff when a "bullying" physician is on duty, urges Davidson. "With the nursing shortage, we also have come to advise the physician, We only hire good nurses. They are very difficult to find. If you are disrespectful, we won’t have enough staff to assist you.’"
Reference
- Rosenstein AH, O’Daniel M. Disruptive behavior & clinical outcomes. Nurs Manage 2005; 36:13-26.
Sources
For more information on conflict resolution in the ED, contact:
- Judy E. Davidson, RN, MS, CCRN, FCCM, Clinical Nurse Specialist, Palomar Pomerado Health System, 15615 Pomerado Road, Poway, CA 92064. Phone: (858) 613-4159. E-mail: [email protected].
- Alison McManus, RN, BScN, CEN, Clinical Educator, Emergency Department, Paradise Valley Hospital, 2400 E. Fourth St., National City, CA 91950. Phone: (619) 470-4321, ext. 3552. E-mail: [email protected].
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