An American College of Physician Executives survey found that three-quarters of doctors are concerned about “disruptive physician behavior”; virtually all of the respondents said that it affects patient care. Yet “despite the best efforts of many, our profession is still plagued by doctors acting in a way that is disrespectful, unprofessional, and toxic to the workplace,” ACPE CEO Barry Silbaugh observed.
Ultimately, these issues can be attributed to a fundamental lack of respect between doctors and nurses, who should be considered separate but equal, yet too often are treated as master and handmaiden. To wit: When an attractive, young female East Coast ER doctor didn’t even try to save a man who coded in the ambulance on the way to the hospital, the nurses in the room complained to the hospital’s medical director. The director dismissed the nurses’ complaints patronizingly: “You’re just saying that because she’s young and pretty.”
In Arkansas, an anesthesiologist told a Certified Registered Nurse Anesthetist, “I could teach a monkey to do your job.” CRNAs are advanced-practice nurses with master’s degrees who provide anesthesia either autonomously or under a physician’s supervision. They are “the sole anesthesia providers in nearly all rural hospitals, and the main provider of anesthesia to the men and women serving in the U.S. Armed Forces,” according to the American Association of Nurse Anesthetists. CRNAs told me they are stuck between doctors and nurses. “The medical profession perceives you as a glorified nurse and the nursing profession perceives you as a nurse trying to be a doctor,” said the Arkansas CRNA. “The general public is not aware of what a nurse anesthetist is or that we provide seventy to eighty percent of all anesthesia in the United States.”
The doctor–nurse hierarchy is rooted in the past, in traditionally ingrained remembrances of outdated roles. Up until the mid-twentieth century, nurses were expected to stand when a doctor entered the room, offer him their chair, and open the door so that he could walk through first, in chivalric reverse. Nurses were expected to await instructions passively without questioning the physician. By the 1960s, nursing schools were still teaching that, as one nurse described it, “He’s God almighty and your job is to wait on him.”
In 1967, psychiatrist Leonard Stein described the nurse’s role in an essay entitled “The Doctor–Nurse Game.” The object of the game, he said, was for a nurse to “make her recommendations appear to be initiated by the physician. . . . The nurse who does see herself as a consultant but refuses to follow the rules of the game in making her recommendations, has hell to pay. The outspoken nurse is labeled a ‘bitch’ by the surgeon. The psychiatrist describes her as unconsciously suffering from penis envy.”
Since then, “Nurses have spent the last half century fighting to overcome the stereotype that they are defanged doctors. It’s a division rooted in education, income, and gender. Doctors—men, affluent, with a professional education—reigned supreme in the hospital,” pediatrician Rahul Parikh wrote in a Salon article: “Do doctors and nurses hate each other?” In present-day North Carolina, a physician still expected the medical/ surgical nurses to rise from their seats when he entered the unit. “A couple of the nurses staged a sit-in,” a nurse from that unit told me. “He eventually got the point.”
The current doctor–nurse divide cannot be strongly attributed to gender, however, because some female physicians, like Dr. Baron, can be just as disrespectful as the men. “Female doctors are working in a predominantly male-centered world,” said a Washington State ER nurse. “They want to be respected and heard, but aggressiveness can be confused with assertiveness. They seem to not like to be questioned. A married doctor couple in town is known by the nurses as ‘Bitch and Bitchier.’”
Nurses have continued to battle the stereotypes even as their profession has evolved. They developed specialties and expanded their scope to include more medical tasks. Nursing schools shifted from hospitals, where doctors oversaw the students, to universities, where the instructors are nurses. “Nursing school was now independent of doctors,” New York Times nurse columnist and author Theresa Brown told Parikh in a dialogue for his Salon article. “Yes, we are taught to be patient advocates, but we are also taught to be a check on the doctor. The problem with that is we’re only taught to see docs as adversaries.” Nurses “never get a good understanding of the stresses and strains of what it’s like to be a physician.” If nursing schools don’t share doctors’ perspectives and medical schools don’t teach nurses’ perspectives, then “how do doctors and nurses learn to behave and negotiate with each other?” she asked.
Many physicians trace doctor bullying to behavior they learned in medical school. Kevin Pho, the physician who runs the popular medical blog KevinMD.com, has argued, “Blame should be directed toward the physician education system, rather than doctors themselves. The hierarchical culture that perpetuates bullying goes back as far as medical school, when as students, future doctors are trained in a pecking order not unlike the military. It’s no wonder that some carry that attitude into the workplace.”
In a 2011 survey, doctor bullies blamed a heavy workload and behavior they had learned in medical school and residency. Indeed, Rosenstein has written, “Surgeons have learned that disruptive behavior can intimidate others into doing what they want, and surgical residents seem to learn this behavior by observation.”
If medical school helps to ignite what the ISMP calls a “culture of disrespect among healthcare providers,” then some hospitals and health officials help to perpetuate that hierarchy. In October 2014, when Texas Health Presbyterian Hospital nurse Nina Pham contracted Ebola from a patient, Dr. Thomas Frieden, the head of the Centers for Disease Control and Prevention, seemed quick to appear to blame the victim. “Clearly there was a breach in protocol,” Frieden told Face the Nation. “Infections only occur when there’s a breach in protocol.”
But Pham’s colleagues said that was not the case. National Nurses United, the country’s largest nurses’ union, spoke to the nurses and issued a statement asserting that the hospital neither trained the nurses nor established protocols to begin with. Supervisors told nurses that certain protective masks were unnecessary, hospital authorities resisted a nurse supervisor who demanded that the patient be moved from a non-quarantined zone to an isolation unit, and the nurses’ protective gear left their necks exposed, according to the NNU.
While, amid an uproar from nursing communities, Frieden later said his remarks were misconstrued. “There’s a lot of outrage about Frieden’s comments,” American Academy of Nursing president Diana Mason told NPR. “It’s blame the nurses again.”
Some health organizations place nurses on the front lines, and then fail to protect them, let alone treat them like the heroes they truly are. On a lesser scale, many hospitals develop policies that blatantly set nurses apart from other staff members. WSMV-TV Nashville reported that at Vanderbilt Medical Center in 2013, administrators cut costs and risked cross-contamination by forcing nurses to perform housekeeping duties, including emptying garbage cans, changing linens, sweeping, and mopping patient rooms and bathrooms. At other hospitals, nurses were the only employees who were charged for parking. A lighter but still legitimately irritating example occurred at a northern California hospital, where administrators announced that they would no longer provide half-and-half for nurses and other staff, but would continue to have it available for doctors and administrators. The staff responded by planting a “Will Work for Half-and-Half” jar in a break room, in which coworkers deposited donations of half-and-half containers.
These administrators’ message is clear: They value doctors more than they value nurses and treat them accordingly. They might also prioritize some doctors over others. In one study, nearly 40 percent of doctors said that administrators are more lenient with the physicians who generate large amounts of money for their organization. Hierarchies like these do not promote patient care; rather, they enmesh doctors and nurses in territorial fights that can make
them lose sight of what matters.
The controversy over the doctorate of nursing practice degree (DNP) is emblematic of the professions’ crossed signals. As of 2015, nurses wishing to become nurse practitioners—who are able to diagnose and treat patients in ways similar to a general practitioner—must go beyond master’s level training to earn a doctorate, and can therefore add “doctor” to their title. Nurse leaders say the additional education is important to expand nurses’ expertise, enhance their qualifications for hospital administrative jobs, and gain more respect in the medical field.
But physicians have turned the debate into a turf battle over the “doctor” title that some NPs, as they are known, would use, claiming that the degree threatens the medical doctors’ position as healthcare leaders. They argued that nurses calling themselves “doctor” will confuse patients and is an attempt to equate their status with physicians, who have thousands more hours of medical training. The American Medical Association loudly protested the Doctor of Nursing Practice designation, calling it “title encroachment,” and proposed a resolution to restrict the “doctor” title in medical settings to physicians, dentists, and podiatrists. Eventually, the AMA instead adopted a resolution to “advocate that professionals in a clinical healthcare setting clearly and accurately identify to patients their qualifications and degrees attain(ed)” and to “support state legislation that would make it a felony to misrepresent one’s self as a physician.”
Nurse practitioners say they are looking to develop their knowledge, not to take over the field. In general, they have more time than physicians to spend with patients and charge less for their services. A major study found that nurse practitioners’ patients have “essentially the same” health as physicians’ patients. At the time of this writing, nineteen states and the District of Columbia allow nurse practitioners to practice independently. Nurse-owned practices are a growing component of healthcare; in 2011 (the most recent year for which data is available), 100,585 advanced practice registered nurses billed $2.4 billion in services to 10.4 million Medicare patients—32 percent of the Medicare fee-for-service population. Those numbers are expected to grow. With a looming physician shortage in the United States by 2020, nurses with advanced degrees offer an additional option to patients, particularly in rural areas where access to doctors is scarce.
Effective 2009, The Joint Commission required hospitals to have a “code of conduct that defines acceptable and disruptive and inappropriate behaviors” and a process for managing those behaviors. Since then, studies have shown “moderate improvement” in doctor bullying and nurse reporting of this behavior. In 2005, only about 10 percent of critical care and OR nurses spoke up if they were bullied by a doctor or if they felt patient care was compromised; by 2010, this number had increased to about one-quarter of these nurses. TJC continues to receive reports of intimidation, and medical researchers say “there are still large, disconcerting gaps between what we have been able to achieve and where we need to go.”
Some healthcare providers have devised helpful strategies to handle intimidation. In one surgical department, when any staff member in the room feels that tensions are rising, he or she can call out, “Tempo!” as a reminder for everyone to calm down. (That safe-word strategy would not work in all hospitals.) A Southern hospital keeps red phones at each nurses station; if a physician is berating a nurse, she picks up the phone and an administrator quickly arrives to assist her. Similarly, nurses in a New Brunswick, Canada, hospital began a practice known as “Code Pink” when they got fed up with a particular doctor bully. When the doctor lambasts a nurse, other nurses spread the “Code Pink” alarm and stand beside her in support. The practice has expanded; at another hospital, a mistreated nurse can page a “Code White” to the same effect.
Still, these codes go more toward treating a symptom rather than preventing problems in the first place—perhaps fitting in an American healthcare model. Rather than collaborating with each other, too many groups of healthcare providers view their roles as practically adversarial. Some doctors equate “nurse-friendly” hospitals with “doctor-unfriendly,” as if what’s good for the nurse can’t possibly also be good for the doctor.
Nurses have earned their place at the table. Is it possible to have a chain of command without implied levels of superiority? To view the various scopes of practice as complementary rather than hierarchical? One strategy is to rework administrators’ perspectives and doctor–nurse relationships so that all staff members view each other as part of a team. Obviously, this won’t work for every pairing. As one ER pediatrician told me, “If I have a shitty nurse, it affects my entire day.” But it is imperative that the professions acknowledge that every member of the team deserves a voice.
In his 2011 commencement address at Harvard Medical School, surgeon Atul Gawande said, “We train, hire, and pay doctors to be cowboys. But it’s pit crews people need.” He explained to the graduates that the hospitals that achieve the best medical performance results are not the most expensive, but rather, the places where “diverse people actually work together to direct their specialized capabilities toward common goals for patients. They are coordinated by design. They are pit crews.”
To get there, healthcare organizations are going to have to force stakeholders to agree on the most effective role for a twenty-first-century nurse. As a Canadian ER nurse posted on KevinMD.com, “The issue boils down to whether the healthcare industry can tolerate highly educated, vocal, critically thinking, engaged nurse-collaborators who, in the interest of their patients, will constructively work with—and challenge, if necessary— physicians and established treatment plans. Or does the industry just want robots with limited analytical skills, who blindly and unthinkingly collect vital signs and carry out physician orders? More importantly, which model presents the best opportunity for excellent patient care?”
SAM CITYCENTER HOSPITAL, September
Before Sam’s first night shift, she guzzled a grande nonfat mocha from the hospital’s twenty-four-hour coffee shop. As a morning person, she wasn’t sure how to handle her sleep logistics to remain alert for a 7:00 p.m. to 7:00 a.m. shift. She had awakened at ten that morning, unable to sleep later. She was scheduled to work three night shifts in a row.
Sam arrived early, wiped down her glasses, tied her long hair back in its usual ponytail, then went to the outgoing day-shift nurse for report. She had heard that the beginning of night shifts were the craziest part of the twelve-hour period. She expected to have several patients initially, and then taper down to two or three. She didn’t expect the outgoing nurse to list six patients immediately, more than a full load. Sam rushed around the department, taking each patient’s vitals. Her ER cell phone buzzed. “Your drip is here,” the secretary said.
“What drip?” Sam asked.
When she got to the nurses station, she looked at the patient’s name on the bag of Cardizem, a heart and blood pressure medication that the pharmacy had premixed. It was unfamiliar. She looked at the computer, and there he was, a seventh patient—and the sickest one—whom the other nurse had forgotten to mention. Sam rushed to the room. The patient, who had come into the ER with an irregular heart rhythm, was in danger of a blood clot traveling to his lungs or brain. Sam hung the drip and prepared the patient for the Cardiac Care Unit, where he would be monitored closely.
By 2:00 a.m., the ER was quieter, but Sam felt like she was going to keel over. She was distracted from her vaguely unsettled stomach only by the piercing headache behind her gray eyes. All she wanted to do was lie down on a stretcher to nap. As she slugged down the hallway, her eyelids drooping, the charge nurse called out to her. “You just gotta keep moving, sweetheart, you just gotta keep moving.” Sam revisited the coffee shop and drank another mocha.
Still, she did not regret her decision to work nights. During the following weeks, she learned that the night staff was more laid back, less harried. By day, the ER was loud; it was hard
for Sam to hear herself think. At night, under the fluorescent glow of emptier hallways, it was more peaceful. Only the people who truly needed to be at the hospital were present at night. If a chief resident came down to the ER during the day, he would be accompanied by a fellow and four medical students. At night, the resident visited the patients alone. The ER felt like more of a team that had to pull together to get things done. The night shift was better for introverts, too. In this smaller community, it was easier for Sam to get what she needed for her patients. Gradually she began to learn how and when she needed to be assertive to get something done.
The only drawback to night shifts was that they wreaked havoc on Sam’s social life. As a new nurse, she was given the least desirable schedules, which rendered her entire week useless for nonwork matters because she slept until 5:00 p.m. She wasn’t a party girl to begin with; she spent much of her free time babysitting her brother’s young daughters. But when she did date, she found that people outside the field of medicine usually didn’t understand her. She would tell a guy about seeing a rare disorder or amputation, and his response would be, “That’s nice, but did you see the basketball game?”
A week after a date that seemed to go well, Sam hadn’t heard from the guy and was debating whether to text him. Working a slow night, Sam ran into William, her attractive former preceptor. “Hey, how’s it going?” he asked.
Sam unleashed on him. “Guys suck!” she growled. “I had a date last week. I had a good time and he didn’t seem like he was having a terrible time, either. But I haven’t heard a word. If you say you’re going to call, call. If you don’t want to call, tell me.”
William smiled, his kind eyes crinkling. “Yeah, I’ve never understood that. That’s not my M.O.,” he said. “But most girls aren’t like you, so guys might not be used to someone with no pretense. You’re not one of those girls who acts dumb or creates drama. You’re quiet, but if someone says something stupid, you let them know.”
The Nurses: A Year of Secrets, Drama, and Miracles with the Heroes of the Hospital Page 8
