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.