Theories in Clinical Problem Solving: Communication between Nurse and Physician
The Nightingale Pledge of 1893 proclaimed that: “I will do all in my power to maintain and elevate the standard of my profession…With loyalty will I endeavor to aid the physician in his work” (Fowler, 1999). At the dawn of feminism, allegiance to the (traditionally male) physician was associated with oppression and subservience. In 1960, the Nightingale code was revised indicating nurses’ increased assertiveness and a bigger sense of collaboration in providing care instead of being merely secondary to other medical professionals. Then came the 1976 revision, which suggested an increased consciousness of advances in technology, different types of prejudicial bias, medical paternalism and more autonomy of the nursing practice. Furthermore, the 1985 revision stated, “With loyalty will I endeavor to work closely with the health team.” Nursing sought to emphasize its honorable status as a profession in a world that gives high regard to professions (Fowler, 1999).
On the one hand, the medical profession traditionally created physicians who were independent and self-reliant with autonomy, accentuated expertise, and responsibility more than dialogue, interdependence and deliberation. On the other hand, nursing traditions have been dissimilar, highlighting chain of command and pursuing bureaucratic rule. Separately, physicians and nurses may try hard to win over the remaining image of their professions—there is, however, the pressure of tradition (Davies, 2000). It was in 1967 which started the contemporary issue on the doctor-nurse relationship through a paper published in a psychiatric journal, which compared the relationship to a ‘power struggle’. While both professions occupy only one patient care ‘space,’ they communicated in an indirect and calculating manner, with lack of reciprocity, akin to a bad marriage (Stein, 1967). Faulkner (1998) avers that at the core of all patient care is the need to communicate with others effectively. But how can such core be realized if until the present, the nurse-doctor relationship continues to be problematic, specifically regarding the issue of abusive treatment of physicians towards nurses?
II. Case Study
The Emergency Room typically witness doctors of various specialties to be summoned to attend to patients and admit them afterwards. For this paper, the case will be in a Level 1 Trauma Center, where various specialty doctors are called to assess the trauma and advise if they need to intervene with patient care. The case happened during a very busy day for traumas and there was only one room available. To make matters worse, a patient with multiple gunshot wounds was admitted. The call was made and the doctors began arriving, with all the ER personnel committed specifically to the trauma rooms only. While taking care of the trauma patient, one of the surgeons suddenly began yelling at a new nurse. The surgeon hurdled vindictives at the nurse: “What are you stupid?” “I told you exactly what to do!” “Can’t you handle any instructions?” The nurse was embarrassed and left the room very upset. The surgeon called over another nurse and commented, “I guess she can’t take the heat.” Since at that time the trauma room had enough people to ensure smooth operations, the charge nurse went to report the incident to the ER Director. The whole scenario was explained to him along with all the comments the surgeon made. The charge nurse wrote them down earlier so an incident report could be initiated. The ER Director was not pleased and waited until the trauma patient was stabilized and then summoned the surgeon to his office. The Director told the surgeon that his mannerism will not be tolerated in the ER and asked him to leave and not to come back only after a formal apology was made. The surgeon was also told that the Director will discuss his case with the Fellow in charge of him. The Director then proceeded to declare that the ER Nurses are one of the most valuable members of the team and no one will treat his nurses or any staff with disrespect. It was found out later that it was an intern who did all the yelling.
Culture in the healthcare environment has been, through the ages, occupied by images of the nurse as a ‘handmaiden’ in a male-dominated society (Kelly, 2006). The balance of power has disadvantaged the nurse. Culture of organizations have deviated from professional collegiality—and oftentimes have failed to advance the nurse’s function. Nurses have raised their concern regarding the inadequate supervisory response to horizontal hostility in the workplace (Farrell, 1997). Professional and institutional norms underscore an important factor of the nurse-doctor relationship on reciprocal interdependence. However, once disagreements arise on decision making and communication between doctors and nurses, the objections raised by nurses are typically supported by the ubiquitous ‘You are not here as much as we are’ dictum. In playing the nurse-doctor competition, the evident subservience to the physician is imbibed prematurely in the nursing and medical training, making doctors use counter-phobic approaches assuming an all-knowing pretense to conceal their apprehensions to fail (Fagin & Garelick, 2004). Conventional sociological research on the nurse-doctor relations typically underscores its patriarchal character (Dingwall & McIntosh, 1978).
How the nurse and the doctor interacts significantly influences quality of patient care, satisfaction on the nurse’s job, retention versus turnovers, and decreased expenses (Kramer & Schmalenberg, 2003). Studies on the influence of the doctor-nurse communication on patient outcomes and workforce challenges indicate that healthcare personnel report being disrespected, undervalued, discouraged, or overworked (ONS, 2005). Usually, these negative experiences come through a disruptive behavior or verbal abuse by a doctor. Threatening behavior results in a negative work atmosphere which stifles communication, increases resentment and limits interaction to only those which are totally required so as to prevent more contact (ONS, 2005). A related result of such hostile work environment is the likelihood for obstructions to workflow. With limited communication, crucial data or information may likely be delayed or not relayed at all, which will have harmful impact such as unnecessary prolonged patient stay, or injury or even death to patients (ONS, 2005).
Hostile work environments in health care organizations are prevalent and often results in absenteeism, inefficient care provision and disharmony among healthcare providers (Heath, et. al., 2004). Another study gives evidence that a handful of health care professionals—1,500 RNs, 250 pharmacists and others—have considered abusive behavior as typical in numerous health care workplaces and can influence medication errors (Phillips, 2004). Another survey suggests that half of respondents felt that intimidation has adversely affected how they address queries on medication orders or order clarification, while majority asked for assistance from a colleague to interpret an order (Iyer, 2007). Nurses have gained better expertise and confidence in their skills, and in some clinical areas, can even be considered as equals among doctors—they want to shift from being ‘dependents’ to mutual interdependency and autonomy (Fagin & Garelick, 2004). To enhance their standing, more and more nurses are redefining themselves by becoming nurse practitioners or nurse consultants (Radcliffe, 2000).
Verbal abuse is the most common form of assault toward nurses in the health care setting. To meet the demands of the health care system and achieve a successful outcome in providing care, teamwork and a harmonious doctor-nurse relationship are imperative. Modern changes in nurses’ roles had a profound impact by selling nursing to management rather than being led by clinical imperatives and patient quality care.
III. Nursing Theory
King’s Interacting Systems Framework Theory. The model is composed of four key concepts, namely: health, social systems, interpersonal relations and perceptions (King, 1981). As a process of human interaction, nursing is characterized by actors where each perceives the other actor in the situation and, using communication, the actors set objective and search for measures to realize these objectives. The formation aspect in interaction is communication—a process whereby information is transferred from one individual to another, either directly (person-to-person) or indirectly (written notes or telephone) (King, 1981). In this framework, communication is important in setting common objectives and as a result, shared objectives setting assists in realizing objectives. Shared objectives setting and mutual decisions on the approaches to realizes these objectives need communication that is affective and instrumental (Caris-Verhallen et al., 1997).
King’s theory views interaction as an open system which is in constant interface with a variety of environmental factors. An open system is a place where the nurse has the gratis to pause for a moment and take a break from his/her stressors, e.g., physician’s verbal abuse. It is a place where the nurse can apply her defense and coping mechanisms against the stressor and the place where he/she can defend his/herself. The general ward and special ward units are the areas observed to have an open system of interaction. King’s theory pertains to nurse-doctor communication and is not applicable to the delivery room, neonatal intensive care unit, and operating room where there are closed systems of interaction due to the nature of work. Stipulating stressors in these areas prevent the nurse to strive for his/her coping mechanism and soon act only after the duty.
All human activities that connect one person to another are forms of communication. As in other professions, communication is a vital aspect of professional nursing. Good interpersonal relationships among physicians and nurses are essential for both life and health of patients. King’s dynamic conceptual framework of interacting systems is applicable to holistic care, ensuring close interaction between individuals in order for the nurse to be an effective health care advocate.
IV. A Borrowed (Non-Nursing) Theory
The Deep Theory. The lawyer’s theory on Professionalism centers on the ultimate incentive to obey rules, focusing on three common categories, namely: duty-based, goal-based, and rights-based theories (Coquillette, 1994). Introducing professional identity is at the core of personal morality. The Deep Theory upholds the law and advocates obeying the rules, compelling the role-defined ethics. The goal-based theory centers on the attainment of an objective by moral relativism of following the other person’s good ends. On the other hand, the right-based theory follows democratic scheme which upholds an individual’s rights and freedom—it is a potent instrument in upholding what is ethically and morally right following the dictum of “Do not do unto others what you do not want to do unto you”. The duty-based theory centers on the nature of a professional duty. The Deep theory highlights the imperative to defend the rule of law as an ideal, to serve the justice system upon which democracy is founded and to advance humanism. (Coquillette, 1994)
As verbal abuse by the physician towards nurses is very rampant in most health care delivery settings, observing the Deep Theory will likely result in smooth communication and interaction among all health care providers, particularly between nurses and doctors. If doctors will be morally upright in treating nurses as their collaborators, if doctors will respect the rights of nurses as co-partners, and if doctors will uphold their duty to provide a high professionalism in the conduct of their roles, a seamless doctor-nurse relationship is very attainable. The Deep theory is not applicable in military nursing field because the military has its own rules of strict discipline and authoritarian canon. The Deep theory can protect the nursing law and preserve the relic of its oath, can put justice upon the hands of the nurses to enjoy equal rights and equality in the health profession and be respected as an individual and an expert in providing high quality care.
V. Comparing the theories
The focus of King’s theory is man as a dynamic individual whose opinions on persons, events and objects affect how he behaves and interacts, including how he handles his health (King, 1981). A dynamic person is healthy if he/she can adjust and endure using defensive coping measures against the sources of stress (Selye, 1976). Nurses are well trained and have proven to have effective coping skills and defense mechanisms to address the various demands of the work environment. However, nurses are trained to be sensitive, caring and emotional professionals—which is why the coping skills and defensive mechanisms are not successful in solving the physician-nurse communication dilemma.
The main issue here is to stop the stressors, check the physician’s disruptive behaviors, specifically the verbal abuse. The Deep Theory will inculcate the essence of professional identity as the center of personal morality among the health care team. The physician-nurse common goal of restoring health back to the patients is a practice of a role-defined ethics, which is respecting the genuine identity of a professional’s duty. The Deep Theory lacks the holistic approach, thus compromising the therapeutic power of communication. This theory is humanistic in essence with respect to one’s morale and legal duty; however, it lacks holistic care. Combining the two theories will spell the difference—complementing each other’s weaknesses and enhancing each other’s strengths—and can become consistent with holistic and humanistic theoretical paradigms. Both theories can be used in conjunction with other theories not only to facilitate compassionate care, but also support an awareness of the range of patterns and attitudes one may choose to use in both positive and unpleasant relationships.
Overall, these theories highlight the interpersonal relationships between the nurse, patient, peers and colleagues. There are tools available which can be used to evaluate the outcomes based on these theories: the Nursing Communication Observation Tool and the Job-Satisfaction-Communication-Importance instrument.
VI. Conclusion and Summary
The holistic control of Imogene King’s Interacting Systems Framework Theory and the humanitarian, ethical and legislative authority of the Deep Theory can balance the professional identity and personal morality on the nurse-doctor relationship. Having a more comprehensive framework can help identify the scruples of an act while the law can provide sanctions or reward to a certain act. The combined theories can promote therapeutic communication and the authority of legal implications. Lateral and horizontal violence among healthcare professionals have been extensively reported and documented. Such behavior can result in serious negative outcomes for registered nurses, their employers and for patients in their care. Lateral violence and bullying are toxic to the nursing profession and have a negative impact on retention of quality staff. All healthcare organizations should implement programs to eliminate workplace violence and disruptive behavior, including a zero tolerance policy related to violence of any sort, professional Codes of Conduct, and educational programs to assist nurses in constructively managing lateral violence and/or disruptive behavior, including behavioral interventions. All health care organization must work seriously to make their facilities to be free from any form of violence or negative behavior that can adversely affect their operations.
The nature of the doctor–nurse interaction is changing in substantial ways. Moving away from the traditional relationship, with its considerable differences in power and influence, nurses and doctors are now becoming equal partners in the clinical domain. Although it is important to understand the historical factors that have determined each profession’s roles and responsibilities, as well as areas of conflict and disagreement, it is only through the mutual interdependence of nurses and doctors that can pave the way to true collaborative clinical work. The nature of the medical-nursing holistic approach makes it even more vital to communicate and clarify the ways in which that relationship can be affected by dynamic interactions.
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