Tipping the Balance: Nurses Take Responsibility for Collaborative Nurse-Surgeon Relationships

OR Today Magazine | January 2013 | Cover Story Tipping the Balance“We’re just now starting to realize that there’s often a disconnect in perceptions of teamwork and cooperation across the hierarchy of the OR.” Marty Makary.

“Providing safe and effective care increasingly depends on nurses and physicians working closely together to achieve optimum patient outcomes,” says Maureen Habel, RN, MA, a health care consultant and author from Seal Beach, Calif. “Today, a wide range of health care agencies — including the Centers for Medicare & Medicaid Services, The Joint Commission and the Institute for Healthcare Improvement — emphasize the critical need for health care professionals to communicate in a way that prevents errors and improves quality.”

Marty Makary MD, Associate Professor of Surgery and Public Health at Johns Hopkins University School of Medicine, is the author of “Unaccountable,” which examines the need to make the nation’s health care system more transparent and democratic. While researching for the book, Makary saw first-hand the importance of solid working relationships between nurses and surgeons.

“We’re just now starting to realize that there’s often a disconnect in perceptions of teamwork and cooperation across the hierarchy of the OR,” says Makary. “A surgeon may think his or her relationships with nurses are excellent, while the nurses think the relationships are poor. In my book, I argue that we need better teamwork and cooperation in the OR between surgeons and nurses as part of an increased focus on a culture of patient safety.”

A caste-like relationship

Habel notes that nursing originally developed during a time when men were widely viewed as superior to women, and that despite drastic changes in health care, this attitude sometimes still persists. “The traditional cultural assignment of power roles to males contributed to the caste-like relationship between primarily male surgeons and predominately female nurses,” she explains.

During her 46-year nursing career, Roxanne Tweedy, RN, MSN, CDR, NC, USN, RET, has watched the evolution of the health care industry and, along with it, the changing nature of the nurse-surgeon relationship. “These relationships today are generally much better than they were years ago, when surgeons could actually get away with cursing and throwing fits in the OR.”

Makary says some nurses feel they can’t speak up in the OR when they think there is some kind of problem. He believes that perception is one of the biggest hindrances to strengthening nurse-surgeon relationships.

“Fortunately, some physician groups are now speaking honestly about this for the first time. Also, the surgical checklist and the surgical time out have empowered nurses to speak up and voice their safety concerns with less fear of recrimination.”

Tweedy agrees: “Many surgeons I work with have said that they like the way I perform the surgical time out. I remind them that the time out is strictly Joint Commission protocol. If I see that someone is not paying attention, I get their attention and then proceed. The surgeon stops, looks at me and then either agrees or disagrees out loud. Sometimes people in the OR try to hurry me, but that isn’t going to happen with me. I’m all about patient safety.”

“Increasingly, patient safety literature emphasizes the importance of creating a culture of safety in which all OR staff are expected to speak up when a patient may be harmed,” adds Habel. “A wide variety of studies has found that communication between physicians and nurses is one of the most significant factors associated with patient mortality. Negative nurse-physician relationships jeopardize the ability of nurses to provide optimum patient care.”

Habel cites a survey of 14 Magnet hospitals that identified power as the most important factor driving nurse-physician relationships. This survey described five different types of nurse-physician relationships:

Collegial — These “different but equal” relationships represent a true partnership.

Collaborative — Mutual trust and respect in these relationships produce willing cooperation.

Student-teacher — Here, physicians and nurses teach and explain to each other, although the physician retains the power.

Neutral — This is a near absence of any relationship at all.

Negative — Here, communication is avoided whenever possible, resulting in compromised patient outcomes.

“The ‘different but equal’ style characterizing collegial relationships benefits everyone—physicians, nurses and, most importantly, patients,” says Habel. “Working as colleagues, nurses and physicians plan the most appropriate care for individual patients. Collegial relationships represent a true partnership in which nurses feel equal to physicians in caring for patients, and both value the positive effect that medical expertise and nursing expertise combined have on patient care.”

She also points to the Jefferson Scale of Attitudes Toward Nurse-Physician Collaboration, which makes the following statements about the appropriate roles for nurses and physicians:

Physicians should be the dominant authority in all health care matters.

A nurse should be viewed as a collaborator and colleague with a physician, rather than as an assistant.

Interpersonal relationships between physicians and nurses should be included in their educational programs.

Nurses are qualified to assess and respond to the psychological aspects of patient’s needs.

Take responsibility for collaboration

Habel encourages nurses to take responsibility for improving nurse-physician collaboration and initiating strategies that free nurses from the subservient role that persists in some organizations. Strategies she suggests include being assertive, approaching conflict directly rather than avoiding it, and using a clear and persistent approach when communicating with physicians.

Tweedy tells the story of one run-in she had with a surgeon and how she stood her ground: “The surgeon had just made an incision on the patient when the RN from the room across the sub-sterile came in and asked if he could consult with an orthopedic surgeon doing a hip replacement. I reminded him that he needed to take off his gown and gloves as he was now contaminated. He yelled back at me that he was not contaminated and told me to open the door. I tried explaining again as I gently pulled the gown off his shoulders, then he jerked the gown and gloves off and told me to get the hell out of his OR.

“Several days later, our director called me in to discuss the incident because the surgeon had omplained about me. I explained what happened and stated that I had followed appropriate infection control policy. She hemmed and hawed so I asked her how I should have handled it, but she didn’t really answer. I then stated, ‘You were not there. I made the best decision in the interest of both patients and would do the same thing again.’ The surgeon and I worked together again two months later and acted like nothing happened. He has continued to be friendly and professional.”

Makary encourages surgeons not to criticize or lose their temper with nurses who raise concerns, even if the concerns are not legitimate. “If you yell or lose your temper with a nurse just once, every future interaction with that nurse is tainted, and the nurse is less likely to speak up in the future.”

Meanwhile, Tweedy encourages nurses to respect themselves and their knowledge of patient safety and proper procedures. “Be the patient advocate — don’t back down if you know you’re right. On the other hand, sincerely apologize if you make a mistake and it truly is your fault. Neither nurses nor surgeons should ever use foul language or tell off-color jokes in the OR — this is not funny and it doesn’t make anyone look cool.”