Enhancing Nurse-Physician Collaboration

An Evidenced-Based Project

By Barbara Malebranche, RN, BSN

Objectives

• Discuss the foundations for establishing nurse-physician collaboration

• Describe effective communication and tools to optimize communication

• Explore strategies to manage disruptive physician behavior

• Briefly review developing confidence in mastering new skills

Nurse-Physician Collaboration Defined

• Nurse-physician collaboration is:

– Nurses & physicians working cooperatively together

– Sharing responsibility for problem solving

– Making care planning decisions together

• Collaboration is not:

– Competition between roles

– Power struggles

Petri, 2010, p. 74-76

Benefits of Nurse-Physician Collaboration

– Healthy Work Environment (Cornette & O’Rourke, 2009)

– Improved patient outcomes

– Improved employee performance and satisfaction

– Better nurse retention

• Better communication

– Improved efficiency

• Collaboration is a critical element in a healthy work environment (AACN, 2005)

Building blocks for collaboration

• Foundations for collaboration:– Competence, confidence, and expertise in one’s role– Interpersonal skills that focus on mutual respect and trust– Well-developed communication skills

• Effective Communication skills and tools: • Managing Barriers• Got Chart? and SBAR tools

• Managing disruptive physician behavior that contributes to ineffective communication (Rosenstein & O’Daniel, 2008, p. 1565)

Communication

• Effective communication minimizes misunderstandings (Griffin, n.d. p. 427)

• Ineffective communication contributes to preventable errors in hospitals:– Errors in intensive care units (Manojlovich & DeCicco,

2007, p. 537)

– The main cause of sentinel events (Raica, 2009, p. 343)

• Barriers to effective communication (Sirota, 2007, p. 53):– Lack of nurses’ confidence with communication

– Disruptive physician behavior

Communication Preparation

• A few minutes preparation can improve effectiveness by assuring accuracy and increasing efficiency which conveys competence and credibility

• Consider using tools such as Got Chart? – Are you calling the correct physician?– Are there already standing orders that apply?– Review physician contact instructions and preferences– Consolidate calls to a physician by calling with several

requests at one time– Have you personally assessed the patient first?– Have you read the progress notes prior to calling?

Studer, 2007

Contacting the Physician

– Have the chart ready, latest vital signs, diagnostic tests, medication information, and code status

– Clearly introduce yourself, identify your unit, the patient and the diagnosis in a professional manner

– Be clear and concise about the purpose for the call –Consider using SBAR – Situation, Background, Assessment, Recommendation

– Document the conversation completely, including the physician’s name, time of the call, and a summary

SBAR promotes accuracy and efficiency

– Situation – present the patient’s name, pertinent information, and reason for your call including urgency level

– Background – present a succinct clinical history relevant to the problem for which you are calling

– Assessment – provide latest clinical findings, labs, vital signs, risks, needs, nursing and medical assessments

– Recommendation – clearly state your request, confirm timeline for actions, agree on when the next follow-up should be done

Using a structured format assures consistency and accuracy

Curtis, Tzannes, and Rudge, 2011, p. 18

Keep your focus!

• Remember to focus on– the patient – your concern for the patient

• If you aren’t sure of the problem or cannot offerrecommendations, begin by clearly stating your concern

• Provide specific evidence that supports your concern such as vital signs, test results, trends, changes from baseline, and timeframes

• Consider the physicians’ stand point – they are intensely focused on their patients

Manage Communication Barriers with graded assertiveness

• Be assertive but not aggressive – use graded assertiveness

• Level I states your concern

• Level II inquires or offers a solution

• Level III asks for an explanation to better understand

• Level IV is a definitive statement requiring a response

Curtis, Tzannes, and Rudge, 2011, p. 18

Disruptive Behavior

Disruptive physician behavior – “any inappropriate behavior, confrontation, or conflict ranging from verbal abuse to physical or sexual harassment”

Examples include:• Abusive anger

• Public and private berating

• Condescending behavior

• Disrespectful treatment

The impact of disruptive physician behavior is that it discourages nurses from communicating with physicians

Rosenstein and O’Daniel, 2008, p. 1564

Successfully managing Disruptive behavior

• A crucial concept: The fundamental attribution error – problematic behaviors are not an inherent part of one’s personality or done for personal enjoyment

• Are due to lack of communication skill or problem-solving abilities

• Behavior must be addressed - failure to address the behavior “approves” it…what you permit you promote

Patterson, et. al., 2005, p. 60-64

Addressing Disruptive behavior

• Be clear about what your personal motives are, plan thoughtfully, and have the right conversation

• Convey respect, explain the gap– Consider your tone of voice, facial expressions, body language– Safety is achieved when mutual respect and concern for their

interests are conveyed– Stick to the facts

• Establish mutual purpose (example: you both care about the patient’s welfare)

• Describe the problematic behavior and its impact to what you both want

• End with a question to validate your understanding, ask for agreement.

Patterson, et. al., 2005, p. 91-110

Inspiring motivation, establishing commitment

• People are motivated by consequences of their choices or actions, either good or bad

• Explain natural consequences that will occur: – Positive consequences of a change– Negative consequences without a change– Impact on those affected

• Link consequences to the person’s values or interests, identify consequences that are important to the person

• Conclude the conversation with an agreement that clearly identifies who does what by when

Patterson, et. al., 2005, p. 119-139

Managing Extreme Behavior

• Assure your own safety first– Most people resort to silence rather than violence but…– If you are in actual danger, call security or other

appropriate authority

• If you are not in danger, deal with the behavior first, then the issue you are trying to discuss– Don’t get caught up in the emotion and respond in kind– Don’t attempt to “out-do” the person with another of

your problems…the other person is only focused on his issue

– Do not patronize the other person

Patterson, et. al., 2005, p. 187-197

There is more to the story

• Look beyond the behavior to identify the cause, i.e., feelings, emotions, the “story”

• Ask the other person about his distress– Describe what you see vs. what he states (if applicable)

– Summarize his responses to build a picture of his concern, validate your understanding of his position

– Encourage deeper discussion

• Encouraging the other to talk about his distress can de-escalate his state and, subsequently, the behavior

Patterson, et. al., 2005, p. 218

Think Strategically

• There are occasions when leaving the situation temporarily is the better choice

• If either or both of you are irretrievably upset, defer until later

• Be sure you return to that conversation at the next opportunity

Patterson, et. al., 2005, p. 218-227

Proceed confidently

• People often avoid difficult situations or conversations when they feel unable to deal with that situation

• Research shows that past experiences influence nurses’ decisions when faced with similar situations (Curtis, Tzannes, & Rudge, 2011, p. 16)

• As with any skill development, mastering effective communication and promoting collaboration require practice and sustained effort

Social Cognitive Theory & Skill Mastery

• Individuals can effect their own change

• Beliefs about one’s abilities will predict the degree of effort, perseverance, and success in skill mastery

• Successful skill mastery requires perseverance in the face of difficulties

• It is the perseverance through adversity while practicing skill mastery that results in success

Bandura, 1989, p. 1175-1179

Summary and The Code of Ethics for Nurses

Provision One:

“The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems”

American Nurses Association, 2010, p. 1

References

AACN (2005). AACN standards for establishing and sustaining healthy work environments. Retrieved August 10, 2012, from http://www.aacn.org/WD/HWe/Docs/ExecSum.pdf.

American Nurses Association, (2008). Guide to the Code of Ethics for Nurses. Silver Springs, MD: American Nurses Association.

Bandura, A. (1989). Human agency in social cognitive theory. American Psychologist, 44 (9), 1175-1184.

Coronett, P. & O’Rourke, M. (2009). Building organizational capacity for a healthy work environment through role-based professional practice. Critical Care Nursing Quarterly, 32 (3), 208-220.

References

Curtis, K., Tzannes, A., & Rudge, T. (2011). How to talk to doctors – a guide for effective communication. International Nursing Review, 58 (1), 13-20.

Griffin, E. (n.d.). A first look at communication theory. Retrieved September 12, 2012, from http://www.afirstlook.com/docs/anxietyuncertainty.pdf.

Manojlovich, M. & DeCicco, B. (2007). Healthy work environments, nurse-physician communication and patients’ outcomes. American Journal of Critical Care, 16 (6), 536-543.

Patterson, K., Grenny, J., McMillan, R., & Switzler, A. (2005). Crucial Confrontations. New York: McGraw-Hill.

References

Petri, L. (2010). Concept analysis of interdisciplinary collaboration. Nursing Forum, 45 (2), 73-82.

Rosenstein, A. & O’Daniel, M. (2008). Managing disruptive physician behavior. Neurology 70 (17), 1564-1570.

Sirota, T. (2007). Nurse/physician relationships: Improving or not? Nursing 2007, 37 (1), p. 52-55.

Studer Group. (2004). Save physicians time: Got chart? Retrieved August 23, 2012, from http://www.studergroup.com/newsletter/Vol1_Issue4/vol1_i4_sec4.htm