Rethink Is Possible AND Necessary

There is a troubling strain of conventional wisdom that suggests that nurse-doctor relationships are dysfunctional, and that is one big reason for our unacceptable problems of quality of care.

Karen Bartholomew, RN, an international speaker and healthcare culture expert and Dr. Joseph Bujak, a speaker and consultant on physician relationships, clinical quality and patient safety, writing in Hospital Impact, claim “that the two most important people responsible for our patients’ care frequently never talk to each other, and when they do the interchange is often dysfunctional.

“No wonder 22 patients die an hour from avoidable harm.”

What makes this article more disturbing is their assertion that changes in medical practice over the past 20 years leave “physicians and nurses lamenting that it was ‘better’ in the old days.”

The authors point to structural changes in both the practice of medicine and hospital operations as reasons for this unacceptable breakdown in communication.

Physicians – “Physicians have progressively become more sub specialized, diffusing responsibility and challenging the ability to integrate care.  Coverage groups expanded, reducing the number of days on-call so that the primary attending physician is often unreachable.”  The authors point to physician rounding – sometimes before the patient is even awake – and the demands for improved productivity mean that there is little or no time for the physicians to locate the primary nurse.  “Sadly, physicians often don’t even know the names of the nurses who care for their patients.  How easy it is to be disrespectful of someone who remains anonymous – especially over the telephone.”

Nurses – The structural changes in hospital operations have also adversely impacted nursing.  “Twelve hour shifts make the continuity of care more difficult.  Only 40 percent of the nurse’s work is actually nursing – they are performing clerical duties, locating missing medications, trying to find equipment or on the telephone on hold.”  In a typical patient care cycle, the authors point out that “one nurse admits (the patient), another gives care, and yet another discharges in 48 hours – another example of why failed communication is the number one cause of medical error.”

But all is not lost.  Ms. Bartholomew and Dr. Bujak argue that structural changes can also make things better, a rethink of the physician-nurse relationship: 

1. The expansion of hospital intensivists and hospitalist physicians is reducing the number of doctors who are involved in complex cases
2. Team rounding is becoming more prevalent
3. Physician availability for an entire shift improves the frequency of nurse-physician communication
4. Situation-Background-Assessment-Recommendation/Request (SBAR) is “improving the nurses’ understanding, supporting their professionalism, and helping them prevent the entrapment of physicians when a lack of necessary information precludes good communication
5. Personalization of the nurse-physician relationship is essential.  Physicians should know the names of the nurses they deal with, and nurses should insist on identifying themselves before each encounter
6. Brief weekly – at least monthly — education opportunities for nurses provided by a physician
7. Charge Nurse presentation of a case scenario at weekly physician rounds – an unheard of practice at most institutions, the authors say
8. Executives must lead what will amount to a cultural transformation at most hospitals “by insisting on daily communication, physicians knowing nurse names, creating joint education and celebratory venues and bedside rounding and actually living the values of the organization by zero tolerance of disruptive behavior — same rules for all roles”

It has taken a long time for healthcare quality to slip to these disturbing levels in quality and safety, and our turnaround will not be “on a dime.”

The bigger question will be whether hospitals can sustain the focus that will be required to make these kinds of changes in an era of unprecedented cuts in funding that will prompt more focus on costs and productivity.

These valuable eight points are more of inside the box solutions. 

I wonder how we will manage the nurse-physician relationship outside the box – when we are forced to redesign how we deliver care because can we cannot sustain what we are doing now.

A healthcare system “rethink” is not only possible, it is necessary.

© 2011 John Gregory Self

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