IN THE JANUARY issue of Nursing2007, I explored the topic of "Nurse/Physician Relationships-Improving or Not?"1 I also invited nurses to complete a survey about their professional relationships with physicians. The questions were similar to those posed in a Nursing90 survey of nurse/physician relationships that drew 1,100 respondents.2 These results were reported in Nursing91.3
Nearly 900 nurses participated in this survey. In this article, I'll report on their responses and compare them with those from the earlier poll. Then I'll discuss how nurses' opinions of their professional relationships have changed over the years.
Let's start by examining the results of this survey. Please note that numbers have been rounded and that not all respondents answered every question.
Glass half full or half empty?
More than half of respondents-57%-say they're generally satisfied with their professional relationships with physicians; a significant minority, 43%, reports dissatisfaction.
In 1991, 43% of respondents expressed satisfaction with their relationships with physicians and 56% were dissatisfied. The near reversal of these percentages after 17 years suggests that the scales have tipped in a more positive direction among nurses surveyed.
When asked to state overall satisfaction with nurse/physician relationships on a sliding scale of 1 to 5, respondents replied as follows:
As you can see, most nurses-74%-are at least moderately satisfied, but more than a quarter are generally dissatisfied. Overall, the positive trend is encouraging.
Only a few nurses who say they're satisfied with their relationships with physicians provided comments. Most say they work in an environment that fosters mutual interdependence, teamwork, and collaboration, such as the ICU, CCU, and postanesthesia care unit. Respondents believe that physicians are more likely to respect and appreciate nurses' knowledge and skills when they work closely with nurses and get to know them well. This perception is supported by similar findings in the current literature.4
You'll recall that a sizable number (43%) of current survey participants say they're dissatisfied with their overall relationships with physicians. Most of these are staff nurses working in medical/surgical units or CCUs, despite the fact that most respondents working in CCUs said they were more satisfied. Although the percentage of dissatisfied nurses has dropped from 1991, general dissatisfaction remains.
Dissatisfied nurses give many reasons for their negative feelings, and even nurses who report overall satisfaction say they're dissatisfied with certain aspects of their relationships with physicians. Let's look more closely at why.
Characterizing relationships
Here's how nurses characterize their relationships with physicians in their clinical settings:
Although this aspect of relationships has improved some since the earlier survey, respondents' comments indicate that they perceive several factors to be at play here:
* male physicians' perceptions of traditional sex and cultural roles
* physicians' arrogance and feelings of superiority
* nurses' feelings of inferiority
* hospital culture or policy reinforcing a subordinate role for nurses.
What's in a name?
Physicians and nurses have an ongoing perception of social and professional inequality, with nurses being viewed by both groups as subordinate. I've recently observed an informal cultural trend in many health care facilities: Nurses are encouraged to use their first names with both patients and staff; physicians expect to be addressed as Doctor. (See First names or last?)
I believe that if nurses returned to using their title and last name with physicians, other staff, and patients, this change could lead to a more formal culture that might encourage greater civility in nurse/physician relationships.
Manner of speaking
How do physicians speak to nurses? When nurses were asked if physicians address them in an unprofessional way, here's how they responded:
Over half (57%) of respondents to the 2008 survey say they have better working relationships with younger physicians than older ones. This is up slightly from 53% in 1991.
Although attitudes seem to be improving slightly, nurses still express a strong perception that physicians see them as less than equal professionally. Of the 511 survey respondents who say that they're dissatisfied with some aspect of their professional relationships with physicians, by far the most common and troubling cause, reported by 71% of respondents, was that physicians display unprofessional behavior that's demeaning, dismissive, or intimidating. Almost half of nurses surveyed (46%) feel they're treated with disrespect and condescension, like "handmaidens." Some respondents say that older physicians treat them with arrogance and disrespect; others said that younger physicians display more of this behavior. Some said that physicians from cultures where women are subservient are more apt to treat nurses as subservient. This finding is similar to other reports in the literature.5
Nurses expressing dissatisfaction most frequently comment on physicians' lack of respect for them as knowledgeable professionals. They also report that some physicians' behavior can be extremely negative, running the gamut from insults and profanity to temper tantrums and screaming. Here's a sampling of comments:
* "Even after 20+ years of being a nurse, I still find that many doctors talk down to nurses and see us as being beneath them. I've seen an improvement in the younger doctors, but the older doctors often treat nurses with disdain and rudeness."
* "Working in an OR, [I find] about half of the surgeons are rude, crude, overbearing, demanding, and disrespectful of nurses and techs."
A matter of judgment
About two-thirds (66%) of respondents don't think physicians understand what they do as nurses, although 68% believe that physicians with whom they work respect their professional judgment.
Nurses were asked how frequently physicians consult with them about the care and treatment of their patients. They responded as follows:
Thirty-five percent say that physicians routinely make rounds with them; 65% say this isn't done regularly.
In 1991, 68% of respondents felt they were misunderstood or not understood, and this hasn't changed. Now about 67% of respondents perceive a gap in physicians' understanding of nurses' roles and cite ongoing problems with communication and collaboration.
Of the 511 survey respondents who say they're dissatisfied with some aspect of their professional relationships with physicians, 70% said that physicians don't understand their roles and responsibilities as a nurse. Similarly:
* approximately 60% say that physicians don't communicate with them about their concerns for a patient
* roughly 50% said that physicians don't listen to what they have to say about patients.
When a physician is disruptive
Most nurses (67%) have witnessed disruptive behavior by physicians in the past year. About the same number (70%) said their facility has a process for dealing with disruptive physicians, and although most say the process is somewhat or moderately effective, only 6% believe the process is very effective and 21% percent believe it's not at all effective. Only 35% say they're very comfortable reporting physicians' disruptive behavior.
Because disruptive behavior by physicians has been holding steady-it was also 67% in 1991-the study findings confirm that this is still a major problem in the workplace. Although most health care facilities seem to have a process in place to deal with disruptive physicians, few respondents to this survey have confidence in it. Some feel it works against them if they report problems with physician behaviors.
It's clear that facility administrators must support and enforce a zero-tolerance policy for disruptive behavior among professionals and all staff. However, comments from dissatisfied nurses indicated that most health care facilities, even ones that promote code-of-conduct policies and sanctions for disruptive behavior, tend to ignore their own guidelines when physician behavior is concerned. Some nurses think that this occurs because physicians are seen as having the most power within a hierarchy; others point to a business-related need to cater to physicians so they'll admit more patients. Some respondents remain skeptical that hierarchal institutional attitudes will ever change.
Here are a few sample comments:
* "There's lots of coddling of physicians to maintain or enhance market share. Hospitals don't employ doctors, yet depend on them to bring in patients."
* "Abusive behavior by physicians toward nurses is allowed to continue, despite code-of-conduct policies. Until administrators take up the cause and decide to address the issue, it will continue."
How have things changed?
In comparing data from the current survey with that of the survey done 17 years ago, it seems that nurse/physician relationships have improved slightly but that much remains the same. Most respondents in the current survey still experience some disrespect, a sense of inferiority, a sense of being ignored or misunderstood, and poor communication in their professional relationships with physicians. Further, most nurses surveyed believe that health care facilities fail to support sanctions for physicians who behave badly. Some reported a sense of passive submission to this situation, believing it's to be expected and unchanging. The unfortunate effect of current nurse/physician relationships is nurses' decreased morale and professional self-concept. Most important, unsatisfactory relationships can seriously impact the overall safety, welfare, and clinical progress of patients.
Improving relationships with physicians
As nurses, we must take responsibility for doing everything possible to help improve our relationships with physicians in several areas.
Nurses need to collaborate closely to share information about mutual dissatisfaction and suggest strategies to deal with it. Remember: We have power in numbers!! Urge nursing and your facility's administrators to support nurses in these efforts.
Important ways to improve nurse/physician overall collaboration include workplace empowerment for nurses,1 nurse/physician rounds, team meetings, collaborative educational programs, and collaborative membership on hospital committees.6
Nurses must participate on institutional committees and in decision making. This involvement will enable nurses to work toward initiating programs to educate physicians about their roles as well as assertively address their misconduct. Physicians will be more apt to communicate when we educate them to realize that this is a requirement and when we use tools to facilitate meaningful communication, such as the SBAR (Situation-Background-Assessment-Recommendation) technique.4 If physicians are required to take the time to listen to nurses' concerns and receive a complete orientation about the nursing process, they might eventually come to see nurses in a more respectful light.7,8
The bottom line is that nurses aren't expendable. In the current nursing shortage, the climate is ripe for us to speak up as a group and let the facility administrators know that they need to pay attention to nurses' legitimate concerns about nurse/physician collaboration, then correct deficiencies.
Perhaps most important, improving relationships between nurses and physicians will benefit both professional groups, by improving job satisfaction and productivity, and will benefit patients, by enhancing their overall safety, welfare, and clinical progress. This can be accomplished by promoting greater nurse/physician professional respect, improving communication and collaboration, educating physicians about nursing roles and skills, and addressing physician misconduct.9
First names or last?
Here's how responses to the 2008 survey compare with responses in 1991.
What irks nurses?
From nurses' anecdotal comments, many communication problems are linked to the overall issues of nurses' subservience to physicians and physicians' disrespect and arrogance.
* "I feel that physicians don't always recognize the knowledge and experience base that nurses have and often overlook it as a resource."
* "My job isn't taken seriously. They don't even know what my responsibilities are."
* "On one hand, the physicians dismiss your judgment, and on the other, they expect you to remind them to place orders and follow up on patients' test results."
* "Even the younger physicians seem to feel that we're questioning their professional judgment when we ask questions about [their] plan of care or certain treatments."
* "Most physicians don't let us nurses know what their plans are for the patient. We try to explain to the patient but have to decipher illegible progress notes and make an educated guess."
* "Doctors are often irritated or condescending when called with postoperative concerns or problems, but heaven help you if you don't call and the problem intensifies later."
Respondent snapshot
Who responded to our survey? Here's a brief profile:
* Place of employment: By far, the most respondents (78%) worked in a hospital.
* Job title: Most respondents (56%) were staff nurses.
* Specialty area: Most respondents (39%) worked in medical/surgical units followed by critical care (23%) and EDs (13%).
* Educational level: The largest proportion (39%) had a BSN, BS, or BA, followed by AD (22%); RN diploma (15%); MSN, MS, or MA (13%); LPN or LVN diploma (7%); PhD (1%); and other (4%).
* Length of nursing career: Most respondents (51%) had more than 15 years of experience.
Overall, the current survey group is generally similar to the 1991 study group. More than 75% of nurses completing each survey were employed in hospitals, with 40% working in urban facilities in both 2008 and 1991. More than 50% of the respondents then and now were staff nurses in medical/surgical units or CCUs.
Level of education among survey participants in 2008 increased somewhat from 1991; more master's level nurses responded in 2008 (13% versus 8% in 1991) and almost 1% of 2008 respondents had PhD degrees compared with none in 1991. RN diploma nurses dropped from 21% of respondents in 1991 to 15% in 2008.
REFERENCES