In a hospital setting, good relationships are more than just the warm and fuzzy feeling that comes from being nice to one another. Hostility and intimidation can block the channels of communication between nurses and physicians, which can lead to poor patient care. Good relationships, by contrast, have been shown to reduce lengths of stay, improve efficiency, and even save lives.
In 2001, Claudia Schmalenberg, RN, MSN, and Marlene Kramer, RN, PhD, began interviewing staff nurses in Magnet hospitals to determine what they meant by good relationships. What they found led them to designate five categories of nurse-physician relationships: collegial, collaborative, student-teacher, friendly stranger, and hostile/adversarial. The first three categories were the more positive relationships, the friendly stranger was neutral but often deteriorated, and hostile/adversarial was the least positive.
Schmalenberg and Kramer, president of nursing and vice president of nursing, respectively, at Health Science Research Associates, a nonprofit organization of nurse researchers, set out to examine what types of relationships are dominant in excellent hospitals, and whether the nurse-physician climate in Magnet hospitals differs from that of other hospitals. They presented some of the findings of their research, funded in part by a grant from the American Association of Critical-Care Nurses, in the February 2009 issue of Critical Care Nurse.
Staff nurses in Magnet hospitals reported significantly more collegial and collaborative relationships with physicians than their counterparts at comparison hospitals, the authors found, and specialized units, particularly ICUs, in Magnet and comparison hospitals scored higher in nurse-physician relationships than less specialized units.
Focus on the Patient
These findings come as no surprise to nurses and nurse managers who work in Magnet hospitals who say they place a high value on relationship building. We realize that in order to do things well, people need to talk to one another, says Sonja Tennaro, RN, EdD, NEA-BC, chief nursing officer and senior vice president of clinical operations at the New York Eye and Ear Infirmary, which was designated Magnet in August 2009.
In addition to communicating daily with physicians about patient care, nurses sit on medical staff committees and participate in early-morning rounds with physicians. The hospital also instituted multidisciplinary grand rounds, where a resident and attending physician discuss a surgical procedure, a nurse discusses patient impact, the dietitian discusses dietary impact, and the social worker discusses after-care. This kind of structured communication is extremely critical so the patient has a good outcome, Tennaro says.
Schmalenberg and Kramer note in their article that regular, interactive interdisciplinary rounds are one best practice hospitals can employ to improve nurse-physician relationships, as well as patient care.
Joelle Mabalatan, RN, a nurse who works on the Eye and Ear Infirmarys inpatient floor, characterizes the atmosphere as very collegial. A nurse for four years, Mabalatan says she feels comfortable not only communicating with doctors about changes in patients conditions, but also helping residents figure out the computer system or taking action when a patient needs immediate attention and a new resident might not have the experience to take charge. Nurses should be confident in their communications with physicians, she says.
As long as you keep it patient-oriented and stick to the facts, they see you as a colleague, she explains. The nurse has to take that responsibility and make that effort to use judgment and not let fear hold them back from doing any of these things.
Stimson Schantz, MD, a head and neck surgeon at the Eye and Ear Infirmary, says he often relies on nurses to help train residents who come through the hospital because they are familiar with the complex issues his head and neck cancer patients face. The skill of the nurses, the ability to trust the nurses in that unit is paramount to the success of the surgery, he explains. They handle that, and theres a lot of respect for them handling it.
At the center of each of these viewpoints about relationships is the patient. Schmalenberg says one of the attributes of hospitals with positive relationships is prioritizing patient care above all concerns about rank, hurt feelings, or organizational politics.
When your focus is the patient and patient care, that lends a whole different atmosphere to what you do and when you do it, she says. Theyre not concerned about someones ego. On the other hand, a hospital can have a strict policy with zero tolerance for disruptive and aggressive behavior, but if managers never enforce it, the policy does no good.
Feeling EmpoweredSheryl Slonim, RN
Study co-author Kramer says nurses can and should take the lead in improving relationships, since physicians often are not aware there might be a problem. She relates the story of a nurse who worked with a physician for 17 years. Although the nurse always addressed him by name, he never returned the favor, instead only giving curt requests for information and an occasional grunt for a reply. The nurse began responding to his questions by saying Good morning, followed by his name. If he repeated his question, she would repeat her salutation until he realized he was being asked to simply acknowledge her as an individual and give her a polite greeting. He soon got the message.
Not all conflicts, however, are easily solved. Differences of opinion are bound to occur, and scripted role-playing can help train nurses in conflict resolution, Kramer says. Nurses need to learn how to resolve these conflicts constructively.
Mary Jo Tracy, RN, MSN, CCRN, is the unit director for the intensive care unit at Holy Name Hospital, a 340-bed community hospital in Teaneck, N.J., that received Magnet designation in June 2009. Having worked at the hospital since 1986, she says she feels a comfort level with physicians that comes from years of working together. Tracy says she uses staff meetings and preceptor training to help newer nurses foster positive relationships with physicians. Through shadowing, a new nurse will observe communications and discuss them at the end of the day until the new nurse is able to be the primary communicator.
Holy Name also employs some of the best practices Schmalenberg and Kramer mention. When physicians do daily rounds, Tracy says the nurse caring for the patient will have a conversation at the bedside with the physician to identify the patients needs and collaborate on care for the day. During this communication, the nurse is as much a teacher as the physician. The ICU also conducts daily multidisciplinary rounds that involve the intensivist, the primary care nurse, the clinical coordinator, and a representative from pharmacy, dietary, respiratory therapy, and outcomes management.
Although Tracy does not necessarily think the ICU at Holy Name has stronger relationships than other units in the hospital, she does think positive interactions are fostered because the hospitals units are divided into specialties. That promotes relationships because its the same nurses with the same physicians, she explains. Also, the ICUs critically ill patients require a lot of communication. Patients needs change frequently throughout the day, she says. There is more frequent communication, which I tend to think leads to healthier relationships.
Sheryl Slonim, RNC, MEd, CNA-BC, senior vice president of patient care services at Holy Name, says nurses feel more satisfied with their jobs when they have more control over their practice at the bedside. Shared accountability is necessary to achieve that, she says. And you cant do that unless the nurse and the physician are collaborating on a regular basis, Slonim says.
If a hospital is truly committed to building positive relationships, it will be evident, Schmalenberg and Kramer say. Ask nurses, What are the values of your organization? Kramer says, and if they cant tell you, look no further.
Making greater interaction with physicians a requirement of moving up the professional ladder, instilling the value of collaboration through multidisciplinary rounds, and providing support for nurses who encounter conflicts are ways hospitals can encourage relationship-building, Kramer says. Grasping the understanding that it takes all of us to get that patient well, to get that patient out in a timely manner to save money, it has to be instilled as a value of the organization, she says. And youve got to walk the talk.