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Can you hear me now? Mending physician-nurse communication

Posted Sep 15 2011 9:12am

by Dr. Joseph S. Bujak and Kathleen Bartholomew

Humans have a tendency to sensationalize and focus on the negative. But research tells us that less than 5 percent of physician-nurse relationships are disruptive. What's the rest of the story? Sadly, only 15 percent of both physicians and nurses rated their relationships as collegial; and only 25 percent were "very good" (Rosenstein). Considering that the most important factor in a study of 13 ICU's patient mortality was the relationship between the nurse and physician, this is reason for alarm (Knaus, et al.).

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.

Several changes have contributed to the distancing of the traditional physician-nurse relationship over the past 20 years. In fact, you will find both physicians and nurses lamenting that it was "better in the old days." Why?

Structurally, physicians have become progressively 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 is often unreachable. Rounding in the morning is hurried and often done before the patient even wakes up. There is no time to locate the primary nurse. Sadly, physicians too 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.

Structural changes have impacted nursing as well. Twelve-hour shifts make continuity of care difficult. Only 40 percent of a nurse's work is actually nursing--the rest of the time they are performing clerical duties, locating missing medications, trying to find equipment or on the telephone on hold. One nurse admits, another gives care, and yet another nurse discharges in 48 hours--another example of why failed communication is the number one cause of medical error.

How can this system of relating to each other be professionally or personally satisfying for physicians and nurses? How can it possibly be deemed "safe"?

Some structural changes have the potential to reverse this trend. The advent of intensivist and hospitalist physicians is reducing the number of doctors involved in complex patient care. Team rounding is becoming more prevalent, and physician availability for an entire shift improves opportunities for communication. SBAR (Situation-Background-Assessment- Recommendation/Request) communication is improving the nurses' understanding, supporting their professionalism, and helping prevent the entrapment of physicians when a lack of necessary information precludes good decision making.

Most of all, it is essential to personalize the nurse-physician relationship. Physicians must commit to knowing the nurses' names. Leadership on this commitment must come from the top. Nurses must insist on identifying themselves before each encounter. When you know someone, and know something about them outside of their work role, it becomes much more difficult to communicate in a disruptive manner and communication flows more freely.

One important improvement would be to have a physician present a brief teaching experience to nurses weekly or, at least monthly. Another example would be to have the charge nurse present a case scenario at weekly physician rounds--unheard of at most institutions.

Executives must lead this cultural change by insisting on daily communication, physicians knowing nurses names, creating informal structures such as joint educational and celebratory venues and bedside rounding, and actually living the values of the institution by zero tolerance on all disruptive behavior--same rules for all roles.

Until the two most critical professionals in patient care can work together for the benefit of the patient, we will continue to send subtle, covert warnings to the general public just under the radar--bring someone with you, ask your caregivers to wash, call Rapid Response if you need to--because the two most important people in your care, physicians and nurses, don't have the relationship that you need to be safe.

Kathleen Bartholomew, RN, MN, ( is an author, international speaker, and national expert on healthcare culture.

Joseph S. Bujak, MD, FACP, ( is an author, veteran speaker, and expert on healthcare organization--physician relationships, clinical quality and patient safety, and leading and managing transformational change.

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