Framing the Discussion Around What’s Best for the Patient

There’s been some discussion around here and in other places about what nurses ought to do when they disagree with the physician. The general consensus among nurses, is that we are professional obligated to advocate — even aggressively — for the best possible care and treatment for our patients. Theresa Brown’s recent article in the New York Times about her own conflicts with physicians articulates this point of view well. But what to do when that discussion fails, as it often does? The traditional answer, as all good nurses were taught in school, is to advocate up the food chain, either on the nursing side or the medical side. But sometimes this is not an effective approach nor is it realistic. Nurses are constrained by power structures and institutional culture which devalue the opinion of the front-line — a chief of medicine once told me three nurses witnessing a physician error was insufficient for him to do anything about it, because the physician herself denied the error — or perhaps managerial indifference; there are constraints of time (the problem must be dealt with immediately) or timing (going up the food chain in the middle of the night is difficult). The system, in general, can make it difficult for nurses’ voices to be heard.

So when all attempts fail at persuasion, we resort to other tactics and stratagems . Some nurses, like Maha at Call Bells Make Me Nervous, exceed their scope of practice and put their licences at risk trying to do right by the patient. Another example: we have all heard of nurses who will give a “generous” 5 mg dose of morphine (or whatever) if the patient has insufficient pain control, rather than fight the physician to up the amount. Or you can be like me, the crusty old charge nurse who gets tired of confronting physicians, and does end-runs to get desired results. Trust me, it’s tiresome and demoralizing for us to act this, and in the end, it’s bad for nurses and nursing.

Nurses, being nurses, tend to put the blame squarely on the physicians for not listening or for failing to engage in more collaborative practice. I am not sure this is completely fair. To be sure, some physicians will insist that theirs is the absolute final word when it comes to patient care, which is patently false theoretically, and impossible in practice; I’ve had more than one physician insist I was practising nursing “under his licence” and should therefore shut up. However, it is equally true these physicians are a small minority. And I will say, I have worked with many physicians, even in the emergency department setting, who represent the ideal in collaborative practice, who will discuss treatment plans in a manner in which nursing input and perspective is essential for good patient outcomes.

Obviously, the key here is good communication, and if we’re going to be honest — and I’m as guilty of this as anyone — nurses don’t communicate their concerns as well as we might. We can be adversarial, blaming, or judgemental, or worse, passive aggressive. We tend to forget that we possess a unique body of knowledge related to nursing and to our patients. This should empower us greatly, to advocate effectively, but often it doesn’t.

I want to back up a bit to the point where the nurse disagrees with the physician about the treatment plan, and bring in a recent interview in the New York Times with Dr. Peter Pronovost, the medical director of the Quality and Safety Research Group at Johns Hopkins Hospital in Baltimore. He speaks about flattening hierarchy and egos to maintain good patient care, about creating an institutional culture where patient safety is paramount and where management empowers and (more importantly) tangibly supports nurses to speak up. “In every hospital,” he says, “patients die because of hierarchy. The way doctors are trained, the experiential domain is seen as threatening and unimportant.”

He spoke about a situation where he knew a patient was going into anaphylaxis  from a latex allergy, and having to confront the surgeon (even physicians have this problem!) to get him to remove his latex gloves:

“I said to the surgeon, “I think this is a latex allergy, please go change your gloves.” “It’s not!” he insisted, refusing. So I said, “Help me understand how you’re seeing this. If I’m wrong, all I am is wrong. But if you’re wrong, you’ll kill the patient.”

This, I think, is exactly the way to approach it. Show me how I’m wrong, because if I’m wrong, than all I am is wrong,and I hope so, because being right about this may harm the patient. Suddenly it isn’t about externalities. It isn’t about nursing judgement, or physician qualifications or ego. All of that is off the table. It’s about patient safety and about providing the best possible care.  The next time I disagree with a physician, I promise to ask this: when disagreeing with physicians, nurses must be prepared to be wrong in order to best advocate for their patients. But then, so must physicians.

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  1. #1 by Dr Dean on Monday 25 October 2010 - 1311

    Hey, I don’t have many answers. I see it at my institution-docs who are bullies, and the admins don’t support the nurses.

    But, and this is a big but, the situation has improved over the last 5 years.

    Most of us do work well with nurses, and listen to their input. The turkeys though make it seem as if no physician can play nice.

    And your passive aggressive comment is noted. I am one of the Docs that nurses talk to. And many times I say-why didn’t you take it up the chain? And usually there is no good answer.

    More discussion like this should help.

  2. #2 by Maha on Monday 25 October 2010 - 1628

    Well said TorontoEmerg. Maybe I’m getting a little bit more jaded but sometimes you can do all the right things and you’re still stuck with nothing to show for your efforts. I don’t want to be ‘one of those nurses’ that just stews in the back and blames everything on doctors being jerks while not taking responsibility for the role I play. At the same time its totally demoralizing when you’re told that your opinion is unnecessary. The us vs them mentality is draining for everyone involved.

  3. #3 by wisdomovertime on Monday 25 October 2010 - 1726

    In Ct. 50% of all enforcement actions taken by the dept. of of public health are against nurses. While they seem to chase the nurses, they let many other professional off without so much as a “slap on the wrist” See my blog for a posting called “Nurses disciplined more often than other professionals”
    http://wisdomovertime.wordpress.com/2010/10/24/202/

  4. #4 by Susan Eller on Tuesday 26 October 2010 - 1711

    TorontoEmerg – enjoyed reading this blog. In my simulation job, I do a lot of training and practice with nurses on how to speak assertively with physicians. Your point about passive communication struck such a nerve with me. So many times I hear nurses ask the MD “are you sure…?” The MDs have told me, if I nurse asks if I am sure, I know that I am doing something wrong – but I may or may not know what. How much better for everyone, including the patient, to understand the concerns or potential hazards. “Doctor I am concerned about you using latex since this patient is allergic”. “Doctor, I am uncomfortable giving naloxone to this neonate, since his mother was addicted to narcotics and I am afraid the baby will seize.”

    Yes, borrowing the CUP (or CUS) words from TeamSTEPPS – but they work.

    Our nurses especially like the opportunity to practice and learn with actual physicians and ask the MDs many questions about how to phrase or frame things so that the nurse, the doctor, and especially the patient is respected during the communication.

    My recent favorite was the nurse who had an MD give her a very hard time about coming to reassess a patient who was anemic and becoming slightly hypotensive – “Doctor, it is important for this patient’s condition that you make it a priority to get here.”

  5. #5 by agingsociety on Tuesday 26 October 2010 - 2017

    Your writing is increasingly becoming stronger and worthy of publication. I think you could consider this, if you are not already doing so.

  6. #6 by wilomis on Tuesday 26 October 2010 - 2055

    this post deserves a “BOOOYAH!”

    This is a major issue, especially because many of the positions I have applied for are 7PM-7AM when no one will be available. I agree totally with the “show me how I am wrong because my ego can be damaged” if it means saving a life. I enjoyed this post.

  7. #7 by Cartoon Character on Wednesday 27 October 2010 - 0942

    In the L&D field I find that most of the docs will listen……I can remember one occasion where the doc wouldn’t get the pediatrician there for what I was predicting to be a very traumatic delivery and subsequent resus for the baby…..and I told him that I would be charting his refusal to get the peds there…..he thought twice and then he aquiesced for the consult …. I have used the “are you sure…” several times…. good posting.

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