An Unexpected Opening to Teach the Impact of Interactions Between Healthcare Personnel

Abstract

Goold and Stern (2006) offer a much needed dose of insight into the weakness of medical education from the perspective of resident and nonresident physicians. One of their findings pertains not to insufficiencies in existing coverage of particular topics, but to absence of coverage of particular topics, including “the learning environment and resident-attending interactions” (Goold and Stern 2006, 9). Although medical ethics education has long attended to the interactions between patient and physician, this finding indicates an unexpected awareness of the significance of interactions between at least some medical personnel. Despite the fact that residents specifically target only the resident–attending physician interaction, this is an excellent opportunity to initiate ongoing physician education about the impact of physician interactions with nursing and administrative personnel. Such interactions can greatly impact patient care as well as organizational welfare; they do not always proceed in perfect harmony and can only do so if all parties are aware of the nature and import of their interactions. A critical interaction for organizational welfare, professional satisfaction, and patient outcomes is that between physicians and nurses. In 1985, Prescott and Bowen conducted a survey of physicians and nurses that indicated that 70% of the physicians and 69% of the nurses described relationships as mostly positive; however, the greatest number of disagreements reported were related to the patient’s plan of care. Resolutions of these disagreements were described as “competitive in nature” according to 65% of physicians and 53% of nurses. Few examples of joint problem-solving (collaboration) were seen. Physician– nurse relationships all too frequently follow this course even today (Rosenstein 2002; Schmalenberg et al. 2005), and have a substantive impact on patient outcomes. A comparison of intensive care unit patient outcomes with reported unit-level collaboration between attending physicians, resident physicians, and nurses indicated a rank order correlation between unit-level collaboration and outcomes. In other words, as competition decreases and joint problemsolving increases, patients are less likely to die and more likely to be released from the intensive care unit to an area of less-intensive care without subsequent readmission to intensive care (Baggs et al. 1999). More recent studies have further confirmed that so-called “collegial and collaborative” nurse–physician relationships demonstrably improve patient outcomes (Schmalenberg et al. 2005). However, patient welfare is not just affected by clinical personnel relationships. Patient welfare and, indeed, organizational welfare, can also be affected by personnel retention. A survey of 1,200 nurses, physicians, and hospital executives conducted by VHA West Coast, Inc. (Pleasanton, CA) suggested that physician–nurse interactions strongly determine working morale of nursing staff, which in turn affects staff retention. Both physician and nurse respondents indicated mutual concern over the impact of physician–nurse relationships. In the face of the current nursing shortage, neither organizations nor patients can afford preventable loss of nursing personnel. This is especially important because both sets of respondents identified “disruptive” physician behavior as the key impediment to productive interactions between nurses and physicians. When asked whether nurses had ever observed “abusive” behavior by a physician towards a nurse, 97% said yes. Of the respondents, 30.7% said they knew a nurse who had left the system because of such behavior (Rosenstein 2002). However, nurses are not the only clinical personnel whose retention is damaged because of poor physician-nursing relationships. Rural clinics often have high physician turnover resulting from untenable workloads (Mainous, Ramsbottom-Lucier, and Rich 1994). Such high workloads have been traced in part to the degree to which physicians take on work which can be collaboratively done by – and with – others. Given that recent models of demographic trends, economic trends, and healthcare needs have indicated that the United States may face a modest shortage of physicians as soon as 2010 and a major shortage by 2020 (Cooper et al. 2002), physician retention may soon be a concern for rural and urban healthcare. Again, it is apparent that neither organizations nor patients can afford preventable loss of personnel—in this case, physicians. The effects of personnel interactions on patient outcomes and organizational welfare have drawn attention to the need for systemic changes which can improve relationships between individuals. Colorado Permanente Medical Group has instituted a “Preferred Clinical Partner” program that includes training in constructive relationships between physicians and nursing staff. This has improved not only retention of nurses but also the perception by nurses that nurses and physicians work as a team to provide improved patient care (Cochran, Fahy, and Bansek 2004). In a separate example, rural Marathon, Canada (population 5,500) had seen a physician turnover of 75 physicians between 1988 and 1998. With only one physician persistently in place, residents had little reliable long-term care. Thanks to measures which included “training nurses in effective triage