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Relations between Physicians and Nurses


Introduction

Relations between physicians and nurses are sometimes strained.  Physician-nurse conflict, tension, and stress have been thought to be contributing factors in job dissatisfaction and burnout for nurses.

Controversy arises about the reasons for physician-nurse conflict, possible solutions to this problem, and the proper relationship between physicians and nurses. 

Possible Instances of Conflict

Conflict and tension do not characterize all physician-nurse relations.  In many healthcare contexts physicians and nurses communicate and work together to serve their patients.

Conflict can occur between workers in business and professional contexts outside of healthcare, of course.  Workers may not get along because of personality differences of various sorts.  Workers may perceive they are being treated unfairly relative to coworkers.  The organization may create a situation of competition among workers.  Sexual harassment can occur.  Situations such as these may conflict and tension between coworkers or between supervisor and coworker.  Ideally, management should be made aware of such problems and take steps to address and resolve them.

Here we are not concerned with conflict between physicians and nurses that is the result of common business and personality factors such as the above but with conflict that is particular to physician-nurse relations.  What distinctive kinds of conflict are possible when physicians and nurses work together and what are the causes of such conflict?

One can consider relations between physicians and nurses from the perspective of physicians or from the viewpoint of nurses.  Some research seems to show that physicians perceive less of a problem than nurses do.  In other words, nurses seem to think there is more of the problem than do physicians.

There may be a conflict about physician orders.  For example, a nurse could disagree with a physician about the appropriateness of orders the physician has given for testing or medication for a patient, or think the physician should give orders for pain medication the physician has refrained from providing.  The nurse could feel he or she knows the patient better than the physician does or have ethical qualms about the proposed action.  Nurses can get frustrated if they feel their concerns, questions, and opinions about patient care or other processes are being ignored.

Nurses often have to call physicians to ask for clarification or instruction in how to proceed with a particular patient, and physicians are not always receptive to such calls.  Physicians are sometimes impatient when the nurse does not have all the available information about the patient at hand that the physician needs to make a decision. 

Other situations can arise in which physicians are verbally (or even physically) abusive toward nurses, shouting at them or publicly correcting them with denigrating language.  A physician might be frustrated with a new nurse who does not know how to perform a task efficiently, or with a nurse who has not administered a medication to a patient as quickly as the physician desired.  Physician workload and time pressures can make them impatient with nurses who they perceive as taking too much of their time.

Possible Causes of Conflict

As mentioned above, interpersonal conflict occurs in many areas of business and personal relationships and sometimes it is due to the particular personalities of the parties involved.  Some people are simply less friendly, more impatient, have greater expectations, etc. than others.  This can occur in relations among physicians, among nurses, and between physicians and nurses.

Reports of physician-nurse conflict appear more widespread than could easily be attributed to just the typical personality clashes one finds in the workplace and society in general.  Several possible sources of conflict between physicians and nurses that have been repeatedly suggested are (1) the power imbalance between physicians and nurses, (2) differing goals of medicine and nursing, and (3) gender conflict between physicians, who have traditionally been men, and nurses, who have been overwhelmingly women.

Power Imbalance

The power imbalance between physicians and nurses in modern healthcare in the United States is well known.  This power imbalance occurs both outside and inside healthcare. 

In American society, physicians commonly experience significant prestige, respect, and financial success, and in healthcare they enjoy great authority.  Their education is among the highest of any profession, consisting of college, medical or osteopathic school, years of residency training, and possibly additional fellowship training.  In contrast, nursing, though a highly-respected career, does not enjoy as much societal respect or financial compensation.  Clinical nurse specialists and nurse practitioners may have a graduate degree, but many nurses do not even have a bachelor’s degree.  Their educational level and status in general is much less than that of physicians.  Their authority in healthcare contexts is also typically less than that of physicians.  The physician bears primary legal responsibility for the patient.  It is the physician who makes the key decisions about patient medical diagnosis and treatment and issues orders that nurses are expected to follow.  Physicians, who in hospitals are not the direct supervisors of nurses, nevertheless wind up often telling nurses what to do.  In small private medical practices employing a nurse the nurse is often hired and employed by the physician.

Hospitals are sometimes run with a dual management/authority structure consisting of a business or administrative hierarchy and a physician hierarchy.  The physician hierarchy enjoys significant power over crucial decisions concerning the current and future direction of the hospital.  The hospital nursing hierarchy usually enjoys no comparable authority.

Consequently, both inside and outside healthcare contexts, nurses have typically seen their role as subservient to that of the physician.  This power imbalance in the workplace and the education and socio-economic difference between physicians and nurses create the perception among nurses that their opinion in the healthcare context is not as valued as well as that of the physicians, creates situations in which their views are overridden or overruled by physicians, and results in tension and frustration on the part of nurses. 

Differing Goals of Medicine and Nursing

An outdated image of nurses sees them as merely doctor’s helpers, but nursing theorists claim this is a misconception of the proper role of nursing.  One way to characterize the difference between medicine and nursing sees physicians as focused on treating the disease and curing the patient, while nursing focuses on caring for the patient as a person.  (Obviously, though, physicians are concerned that their patients receive proper care and nurses are concerned that disease be eradicated.)

The differing goals of the physician and nurse for the patient are sometimes thought to be a source of conflict.  The nurse may believe he or she is more focused on the patient’s state of wellbeing and therefore should have a larger say in their care.  A specialist physician or hospitalist treating a patient in a hospital often sees the patient less than the nurse assigned to care for that patient; consequently the nurse may feel he or she knows the patient’s care needs and what the patient can tolerate better than does the physician.  The nurse may feel that he or she deserves more responsibility and authority for the patient than is allowed by the current system, with resulting nurse frustration, resentment, tension, and stress.

Gender Conflict

Years ago, virtually all physicians in the U.S. were men and all nurses were women.  Though today there are male nurses, the large majority of nurses are still women. The majority of physicians overall are still men, though women make up a great percentage of recently graduated physicians and current medical school students.

Some believe the conflict between physicians and nurses to be partly or largely attributable to conflict between the roles of men and women in society.  Many ethicists and political thinkers claim historical oppression of women in jobs, wealth, and power in society, though some progress eliminating such disparities seems to have been made in recent years.  The physician in the hospital, so the theory goes, sees the nurse as subservient because traditionally the nurse has been female and females have been subservient in society.

All of the above factors deserve consideration as causes of conflict between physicians and nurses.  Such factors and the resulting tension and stress can lead nurses to feel denigrated, disvalued, disrespected, intimidated, and disempowered.  Nurses who feel intimidated or have low self-esteem might be less inclined to point out errors they perceive a physician to be making.  The perception of denigration and disempowerment can lead to nurse job dissatisfaction and nurses leaving the profession, and ultimately poorer patient care.

Resolving Physician-Nurse Conflict

Though many suggestions have been made, the solution to physician-nurse conflict and resulting problems is not fully clear.

One common recommendation is to improve communication between physicians and nurses.  Poor communication can result in unmet expectations and resulting frustration and poor working relationships. But while better communication would help, it alone would not seem to solve problems engendered by massive power imbalances or sexism, for instance.  And specific recommendations about how to improve communication are needed.

Another suggestion often made is that there be available an optimal method of conflict resolution.  Nurses sometimes avoid conflict or are resigned to it, whereas some form of conflict resolution fostering collaboration and cooperation might help alleviate physician-nurse tensions and achieve better overall outcomes.  This is a good suggestion, but it is not clear that it is realistic to expect physicians to participate in any such method of conflict resolution if they are satisfied with the status quo or perceive the problem to be something nurses just have to work out for themselves.

Sometimes the suggestion is made that nurses should strive for more independence, power, and authority.  Many nurses are already doing that.  Needed are ideas on how nurses can attain greater power if physicians do not wish to relinquish it.

In recent years healthcare has emphasized the importance of the role of the multidisciplinary team.  A common idea is that the physician should see his or her place as a member of the team and in that context the contributions of others are to be valued.  It should be noted, though, that the physician is likely to see his or her role as being that of team leader or director, and so nurses may still feel their contribution is dictated or marginalized. 

An important point to note is that conflict between physicians and nurses is likely to hurt the optimal functioning of the team and result in poorer patient care and lower quality healthcare, so senior management in a healthcare organization should take whatever steps are necessary to ensure the organizational culture and management support create an environment in which such destructive conflict is minimized and nurses feel more empowered.

LeTourneau has provided several useful recommendations about possible organizational responses to physician-nurse conflict.  In a hospital setting, the head physician executive (such as the medical director) and head nursing executive (such as the director of nursing) should build a relationship of collaboration and mutual respect that can act as a model for others.  They should learn each other’s disciplines and contributions.  They should also develop an organizational vision of how physicians and nurses should interact.  This vision should include expectations of their own and other’s behavior – physicians stating their expectations for nurses and nurses stating their expectations for physicians.  The vision and expectations should then be translated into standards of behavior and concrete policies to correct misbehavior (violations of the standards).  Inappropriate behavior will not change unless it results in consequences for the perpetrator. 

LeTourneau notes that physician and nursing heads need the support of hospital management in this endeavor.  Furthermore, they should examine hospital systems and policies to ensure they are not interfering with the development of better relations; for example, if nurses have to police the physicians’ compliance with medical record policies, collaboration will be difficult.  Also, opportunities for collaboration should be pursued – physicians providing continuing education to nurses, nurse serving on credentialing committees, etc. -- where they can develop respect and good working relations.

The Importance of an Organizational Response

The problem of physician-nurse conflict needs to be addressed not just by individual clinicians but by a healthcare organization’s executive leaders.  Hospital administrators and managers may prefer to avoid dealing with the problem.  Rather than trying to sweep the problem under the rug, senior management should work to develop an organizational culture in which inappropriate attitudes and behavior of physicians toward nurses and vice versa are not tolerated.

References

Barbara LeTourneau, “Physicians and Nurses: Friends or Foes?” Journal of Healthcare Management, 2004.

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