WHEN CARE PROVIDERS DISAGREE:
Be Prepared. Be Professional. Be Polite.
By Joan Tupponce

Nurses and physicians don’t typically have dramatic fights like those portrayed on television shows. However, nurses serve as doctors’ eyes and ears and are obligated to tell physicians when they feel treatment plans need revision.

For example, a nurse may find a patient’s pain level has increased since the physician’s last round. Or, a nurse in ICU may suggest weaning a patient off a ventilator earlier than the doctor first recommended.

“As professionals, the very first step that we owe to other professionals or providers is that we – the nurse who is uncomfortable – make our suggestions or comments directly to the provider,” explained Judie Snipes, privacy officer for Roanoke Memorial Hospital and a nurse for 41 years.

Nurses agree that physicians welcome and depend on their feedback, but using the right approach can facilitate communication.

“If I’m going to wake a doctor up in the middle of the night to say the pain medication is not helping, it’s important to be prepared,” Snipes said. “I need to know the patient’s vital signs, and I need to articulate clearly why I think the treatment is not working. If I am on the phone, it is critical that I have the chart available so that I can quickly answer any questions the doctor might have before he responds to my request.”

“Have the courage to make that call if it’s the right thing to do” Betsy Blair, vice president of quality/risk at HCA Richmond Health System

Eileen L. Dohmann, vice president of nursing at Mary Washington Hospital in Fredericksburg, pointed out that physicians are hard-pressed to make a decision when a nurse calls and simply says the patient has a fever. Mary Washington is one of many hospitals that train nurses to use a communication method called SBAR, which stands for Situation, Background, Assessment and Recommendation.

“This gives nurses a mental process to go through before they call physicians. It teaches them how to give the whole picture,” Dohmann said.

Don’t leave off the last step, she added. Physicians do appreciate concrete recommendations.

“Most times, the physician says, ‘That’s a great idea. Thanks for calling.’” Dohmann said. “Physicians value nurses, but I think we forget that – especially when we’re working all night and all we can think about is, ‘I have to wake somebody up and they might get short with me.’”

Those midnight calls are especially daunting, Dohmann said, for new nurses who are still gaining confidence. At Mary Washington, new nurses are encouraged to role play through such uncomfortable situations with preceptors. These mentors serve as coaches and remind new nurses that the physician they need to wake up is, after all, on call.

Remain professional
If the physician is abrupt or unreceptive when approached with suggestions, nurses say they try to remain professional and remember that they are patient advocates. Dohmann said new nurses may feel frustrated when they’re explaining a situation but the physician cuts them off.

“In that case, I suggest they say, ‘Doctor, I’m sorry this is taking longer than you would like, but I want to make sure you have enough information to take care of this patient,’” Dohmann said.

Betsy Blair, vice president of quality/risk at HCA Richmond Health System, has been with HCA for about 30 years and a nurse since 1980. She encourages new nurses to remain professional when there is a conflict.

“Have the courage to make that call if it’s the right thing to do,” Blair said. “If a physician is less than pleasant, stay calm and stay courteous and get that order for the patient. If it’s something that repeats itself, let your supervisor know about the behavior.”

If the situation becomes heated, Dohmann suggests nurses follow up with the doctor after they have both cooled off. “First of all, everybody has a bad day,” she said. “When tempers flare, you can walk away, but don’t miss the opportunity to say, ‘Can we talk about what just happened? Because this is how I feel.’”

“There is always a solution and there are few barriers when the patient is the center of your focus” Judie Snipes, privacy officer for Roanoke Memorial Hospital

When a nurse feels that dealing with the situation one-on-one is not working, nurse managers can help assess the situation objectively. “We encourage nurses and management to take the emotion out and speak of the interaction rationally because communication takes two people,” Dohmann said.

If that isn’t successful, nurse managers may take the situation to the next management level. Blair said this is particularly beneficial when a nurse is dealing with a consistently disruptive physician – meaning the physician is invoking his or her hierarchy to intimidate nurses.

“While there have been interventions on my part with physicians who have crossed the line in terms of their professional communication,” Blair said, “when you sit them down one-to-one and have that conversation, it’s rare that you have that happen again … You’re never going to change that personality if it’s a part of a person’s hardwiring, but your responsibility is to address it every time you see it.”

Following protocol
Many hospitals today have formal policies for dealing with nurse-physician communication, but nurses say they rarely need to use them because most issues between nurses and physicians are settled. Blair said that throughout her career, she has never seen a situation escalate through all the formal channels.

The policy “directs the clinician in a path,” Blair explained. “If he or she has questions about protocol, this advises the clinician with a chain of command to follow … It’s very much a common-sense approach.”

Snipes said that regardless of whether nurses have to use a hospital’s formal policy, it’s important to know how the system works. They should also be aware of the groups that support them on a daily basis.

“Every hospital has an ethics committee and other organizational resources, and they have formal medical staff peer review processes,” Snipes said. “The nurse needs to know what those are and how to access those resources.”

Patients first
The primary reason for this emphasis on good communication with physicians, nurses say, is better patient care.

“There is always a solution and there are few barriers when the patient is the center of your focus,” Snipes explained. “It is up to us to find [that solution] … look for a win-win way to get there. Do not attack each other. Attack the problem … Health care is a partnership and is all about teamwork.”

Blair said she also encourages new nurses to strive for open communication with physicians. Nurses are the patient advocates on the health-care team. “Truly, nurses and physicians are partners in taking care of the patient,” Blair said. “Develop and embrace that partnership in the spirit of patient service.”