Practice Matters

Physician and nurse engagement: From concept to collaboration

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In today’s complex healthcare environment, it’s crucial for all members of the healthcare team to work together in a collaborative, collegial manner in an effort to provide the best patient care. Physicians and nurses play a prominent role in this process. On the surface, the idea of physicians and nurses working well together seems straightforward, but in reality, things are not quite so simple.

In a profession often plagued by hierarchy, silo-based thinking, and discipline-specific roles and responsibilities, there are differing perspectives, pressures, incentives, priorities, and objectives as to what constitutes best practices in health care. The problem is further compounded by the changes brought about by healthcare reform and other healthcare initiatives that have emphasized efficiency, value, and accountability to the point of restructuring healthcare delivery. With the focus on performance metrics, patient satisfaction, and full-spectrum care, all members of the healthcare team need to be engaged and must work together to coordinate efforts to achieve the desired goals.

Full engagement starts with harnessing the spirit and motivation of the workforce, followed by employing strategies designed to help team members work more effectively together. Healthcare organizations must recognize that to enhance engagement they must first address discipline-specific needs and concerns and provide appropriate support services to enable providers to better adjust to the pressures of the work environment.

The first, crucial step toward engaging multidisciplinary collaboration between physicians and nurses involves engaging discipline-specific needs. Gaining a better understanding of individual priorities and concerns, rallying around the mutual goal and importance of making combined efforts resulting in the best patient care, and providing needed support can set the stage for developing a positive work culture and environment. We explore a multistep approach to improving physician and nurse engagement that nurse leaders can use as a starting point to bring physicians and nurses together in today’s healthcare environment.

Improving physician engagement

The first step in improving physician engagement begins with educating the physicians themselves, providing them with better insight as to the rationale and reality of today’s healthcare environment so they can better understanding what is happening and why. Appropriate administrative, clinical, and behavioral supports are needed to enhance physician well-being. These programs can be provided through physician wellness committees, physician employee assistance programs (EAPs), coaching and counseling services, and other resources available through human resources or medical staff services.

Physicians also need training that focuses on the importance of developing positive staff and patient relationships, including such relevant topics as customer satisfaction training, diversity management, communication skills, team collaboration skills, and conflict management.


The second step in the physician engagement process is to provide relevant and appropriate education and training for nurses and other colleagues to help them gain a better understanding of the physician’s primary concerns and priorities and how physicians perceive their role in medical care. Physicians are proud of what they have accomplished and just want to practice good medical care; they can, however, regard everything that gets in their way as an unnecessary intrusion on their medical practice.

Physician discontent, stress, and burnout

For physicians, the landscape of medical care has changed significantly over the past several years. With the growing focus on performance accountability, the restructuring of how care is delivered, productivity requirements, utilization and reimbursement controls, electronic documentation, and other restrictions and requirements, there is a growing amount of frustration and discontent among physicians. A 2015 study by Tait Shanafelt, MD, and colleagues suggests that 50% of physicians are experiencing stress and burnout. As a result, many physicians have decided to either change their practice structure, move into salaried positions, change professions, or retire from practice.

For physicians who continue to practice, the growing pressures and demands have had had a significant negative impact on their attitudes and behaviors, which can in turn have a negative impact on relationships that affect patient care. If we are to improve physician engagement, we must look for ways to help physicians better adjust to the changing environment of health care.

Leaders in healthcare organizations must recognize that they need to take a proactive role in trying to help physicians address issues of stress and burnout rather than leaving it up to physicians themselves to take action. Although specialized courses in stress management may help physicians experiencing stress and burnout, individualized coaching or counseling services may be required to achieve maximum benefit. Unfortunately, physicians frequently do not realize that they are working under stress and are unaware of how it is affecting their behavior. If they do realize it, they believe they have always worked under stress and can handle it themselves. Those recognizing that they may need help can be reluctant to seek outside help for reasons related to ego, perceptions of competency, or concerns about confidentiality. Needed services can be provided through the organization’s Human Resources department, physician wellness committees, or a designated physician EAP (Employee Assistance Program). More difficult cases may require other specialized behavioral interventions. Focus also on the importance of promoting a positive work-life balance by providing a variety of health enhancement programs and offering appropriate coaching and counseling services.

Ensuring input

A critical part of the process of improving physician engagement is ensuring physicians have input into the processes they are involved in. Physician input can be fostered through town hall meetings, discussions at department meetings, specialized committees or task forces, or though one-on-one meetings with clinical and administrative leaders. Listening and responding, encouraging more involvement, and fostering physician leadership and championship will go a long way in enhancing overall physician engagement.

Assistance running a practice

Another important issue to address is helping physicians adjust to the pressures of running a practice. Be sensitive to the demands of a hectic physician routine and consider making adjustments in scheduling, committee responsibilities, and time spent on nonclinical duties. For physicians having difficulty managing electronic documentation, provide additional technical support and training or provide scribes to help with data input. Consider using physician assistants, nurse practitioners, or care coordinators for situations that don’t involve the care of medically complex patients.

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Promoting nurse engagement

Like physicians, nurses have many challenges.

Task overload

For nurses, the standard for delivering basic quality care has changed dramatically over the last decade as well. Although length of stay has decreased, associated comorbidities and the complexity of care have increased. As Ebrite and colleagues have noted, nurses care for more patients who are severely ill and require a more compressed and intensive workload, which requires new roles and responsibilities characterized by multiple goals, unpredictability, and constant change.

This situation explains why the chief complaint of physicians is that they cannot find the nurse, and why the chief complaint of nurses is that they can’t find the physician. These are both valid points, as nurses perform more than 160 tasks in an 8-hour shift, with each specific task taking just under 3 minutes to complete. As Krichbaum and colleagues documented, nurses report being in a constant state of task overload, with seven to eight stacking items on their “to do” list at any given time. In order to accomplish the variety of tasks assigned, nurses must focus intently; unfortunately, this myopia decreases peripheral vision and unconsciously shifts the focus from the relationship with the patient or physician to the tasks at hand.

With computerized charting, staffing requirements, 12-hour shifts, and staying up-to-date on the latest pharmaceuticals, products, technologies, and best practices added to this workload, it is easy to understand why up to 40% of a nurse’s work is not related directly to patient care. No wonder patients complain of not seeing their nurses. Task overload can lead to a growing amount of moral distress and compassion fatigue, as demonstrated in a 2014 study by Mason and co-workers.

Patient safety

Developing collegial working relationships with physician partners may appear optional in a world where each day nurses are asked to do more with less. There is a well-documented direct relationship between the supportive and collaborative relationships nurses have with physicians and the ultimate safety of their patients that has been known for decades, discussed in the 2008 study by Rosenstein and O’Daniel in the Joint Commission Journal on Quality and Patient Safety. Yet not all relationships feel equal and collegial despite the attention paid over the last decade to the damage caused by disruptive physician-nurse interactions. Research published by Lyndon and colleagues found that a clinician’s perception of risk is an important predictor of speaking up about safety concerns. If nurses do not feel at ease approaching a physician with a question or concern, the patient can suffer. Ineffective communication and silence undermine quality and safety. Positive, collegial physician-nurse partnerships increase morale and job satisfaction for both groups and improve patient safety.

Overcoming barriers

The greatest barriers to encouraging collegial nurse-physician teamwork are

  • going with the status-quo: a subjective, untested belief by both physicians and nurses that they already have great working relationships
  • a lack of time
  • lack of role clarification
  • an unrecognized power differential that blocks communication

A good starting point for discussion is helping both physicians and nurses understand that both groups are under tremendous pressure. Nurses will never be engaged if they do not perceive a need to change, or recognize the subtle or overt power differences that have silenced them in past experiences. Engagement can be bolstered by surveying staff on the quality of their working relationships with their physician partners and hardwiring feedback.

Nurses could evaluate the professionalism and ease of their working relationships with physicians knowing that this greatly affects communication and safety. Physicians could then give feedback to nurses as to their readiness, knowledge, and critical thinking skills. The bottom line is that unless leadership creates the time and opportunity for physicians and nurses simply to be together as professionals who are both dedicated to healing humanity, establish a feedback structure, and set the standard for seamless, professional communication, the status quo will continue to reign. (See Examples of successful physician-nurse collaboration.)

Examples of successful physician-nurse collaboration

There are many excellent examples of how hospitals and clinics have dramatically improved physician-nurse collaboration by creating a structure that acted as a forcing function.

  • Every year the Intensive Care Unit of a large metropolitan hospital hosts a conference in which topics are selected by a physician and nurse who pair off to research best practice. Each team then speaks for 20 minutes, with the physician talking about his or her role in managing the disease, and then the nurse speaking specifically to nursing interventions. The conference is a sell-out every year.
  • Another hospital hosts an annual Nurse-Physician Summit in each department. Prior to the summit, physicians get together and discuss the top five things they would like nurses to change in order to deliver the most optimal quality care. At the same time, nurses meet and list their top five issues involving physicians. At a luncheon attended by both groups, a facilitator reveals the results of these surveys. The survey results are always a surprise and bridge a critical communication gap in understanding each other’s roles.
  • After returning from the annual Nurse-Physician Summit, four orthopedic physicians avidly discussed their newly perceived role in creating a supportive climate. They composed a survey they asked every nurse to fill out regarding each surgeon, with ratings on a 1-to-5 Likert scale on approachability, patient complaints, and professionalism. The results were eye-opening for both groups. Neither realized how subliminal attitudes and beliefs were affecting their everyday behaviors.
  • Both physicians and nurses in a department survey each other annually by asking the person they work with the most frequently for specific feedback: “What do you like that I do well?” and “What would you like to see more of?”

 

Engagement strategies for both physicians and nurses are essentially the same. (See Engagement strategies.)

 

Engagement strategies

Here are some ideas for engaging physicians and nurses.

  • Every year the Intensive Care Unit of a large metropolitan hospital hosts a conference in which topics are selected by a physician and nurse who pair off to research best practice. Each team then speaks for 20 minutes, with the physician talking about his or her role in managing the disease, and then the nurse speaking specifically to nursing interventions. The conference is a sell-out every year.
  • Another hospital hosts an annual Nurse-Physician Summit in each department. Prior to the summit, physicians get together and discuss the top five things they would like nurses to change in order to deliver the most optimal quality care. At the same time, nurses meet and list their top five issues involving physicians. At a luncheon attended by both groups, a facilitator reveals the results of these surveys. The survey results are always a surprise and bridge a critical communication gap in understanding each other’s roles.
  • After returning from the annual Nurse-Physician Summit, four orthopedic physicians avidly discussed their newly perceived role in creating a supportive climate. They composed a survey they asked every nurse to fill out regarding each surgeon, with ratings on a 1-to-5 Likert scale on approachability, patient complaints, and professionalism. The results were eye-opening for both groups. Neither realized how subliminal attitudes and beliefs were affecting their everyday behaviors.
  • Both physicians and nurses in a department survey each other annually by asking the person they work with the most frequently for specific feedback: “What do you like that I do well?” and “What would you like to see more of?”

Common goals

As long as we remain siloed within our own perceptions and realities, nothing changes. To be truly successful, organizations need to do a better job of engaging their staff. Leadership must acknowledge and articulate that the individual pressures and incentives faced by both physicians and nurses impede true multidisciplinary teamwork. Leaders must create the structure for physicians and nurses to discuss, evaluate, and share both challenges and success stories. Within the changing landscape of health care, with both physicians and nurses facing high levels of pressure, there is an unprecedented opportunity to create seamless physician-nurse partnerships in a patient-centric culture, with the goal of delivering the best health care that medical science can provide.

As a final step in the engagement process, always take the time to say thank you. Showing respect and appreciation will go a long way toward improving satisfaction and motivation.

Alan H. Rosenstein is a practicing Internist in San Francisco, California, and a consultant in healthcare management specializing in physician behaviors and organizational engagement. Kathleen Bartholomew is a nurse leader, author, and international expert on the health care culture, who lives in Friday Harbor, Washington. She is the author of Speak Your Truth: Proven Strategies for Effective Nurse-Physician Communication.

Selected references

Baggs J, Schmitt M, Mushin A, et al. Association between nurse-physician collaboration and patient outcomes in three intensive care units. Crit Care Med. 1999;27:991-998.

Ebright PR, Patterson ES, Chalko BA, Render ML. Understanding the complexity of registered nurse work in acute care settings. J Nurs Admin. 2003;33:630-638.

Krichbaum K, Diemert C, Jacox L, et al. Complexity compression: nurses under fire. Nursing Forum. 2007;42:86-94.

Lyndon A, Sexton JB, Simpson KR, et al. Predictors of likelihood of speaking up about safety concerns in labour and delivery. Quality and Safety in Healthcare. BMJ Qual Saf. 2012;21:791-799.

Mason VM, Leslie G, Clark K, et al. Compassion fatigue, moral distress, and work engagement in surgical intensive care unit trauma nurses: a pilot study. Dimens Crit Care Nurs. 2014;33:215-225.

O’Donnell J, Ungar L. “Disruptive” doctors rattle nurses, increase safety risks. USA Today September 20, 1015.

Rosenstein AH. Meeting the physician’s needs: the road to organizational-physician engagement. Trustee. June 2015:19-22.

Rosenstein AH. Strategies to enhance physician engagement. J Med Pract Manage. 2015;31:113-116.

Rosenstein AH, O’Daniel, M. A survey of the impact of disruptive behaviors and communication defects on patient safety. Joint Commission J Qual Patient Safety. 2008;34:464-471.

Shanafelt T, Hasan O, Dyrbye L, Sinsky C, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc. 2015;90(12):1600-1613.

Thew J. Interprofessional collaboration: the impact of eliminating individual silos and meeting industry goals. HealthLeaders. 2015;18:19-22.

 

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One thought on “Physician and nurse engagement: From concept to collaboration”

  1. Meagan Salmon, RN says:

    Dear Editor:

    I am writing to address “Physician and Nurse Engagement: From Concept to Collaboration” by Alan Rosenstein and Kathleen Bartholomew from August, 2016, Volume 11, No. 8 of American Nurse Today. I felt a strong connection to the need for improved communication among nurses and providers. I have been working as a nurse at a teaching hospital on an oncology unit for just under 3 years. Good communication with the providers is something the nurses on my unit are continuously striving to improve, but difficulties arise when we are meeting and working with new residents on a monthly basis. There are strategies the authors explain that we have not implemented as a unit, such as training each role to understand the opposing role and engaging each other to provide feedback on the relationship that I believe would be helpful, but in addition to the strategies mentioned in the article, I would like to bring up another approach. Nurse and physician rounding for a unit like mine where training would indeed be beneficial, but feedback would be difficult due to our short time together. Responsibility falls on both nurses and providers to close the gap that causes miscommunication and decreased patient safety and I appreciate the articles acknowledgement of that duty.

    As mentioned by the authors, I agree that it is imperative for the nurse and physician to understand each others roles in order to better understand where the other is coming from. As Bartholomew and Rosenstein (2016) discuss, physicians should be more aware of task overload that nurses face each shift and nurses should be more aware of the role of the physician in order to improve collaboration. In addition to the strategies in the article, I have read research that has been summarized in the article, “What Works: Physician and Nurse Rounding Improves Patient Satisfaction” by Brian Conner and Boone Johnson that can be found in December, 2014 Volume 9 Number 12 issue of American Nurse Today.

    The authors discuss a project that began in 2012 collecting data that reflected patient satisfaction related to nurse communication and physician communication measured by HCHAPS scores. The data showed significant improvement in scores after implementing physician and nurse rounding (Conner & Johnson, 2014). Having the nurse, the physician, and the patient all in the same room to discuss the patient’s care puts all members of the team on the same page and decreases the risk for miscommunication. Mean HCHAPS scores improved related to nursing communication and physician communication after this rounding was put into practice (Conner & Johnson, 2014).

    I appreciate Bartholomew and Rosenstein for portraying strategies that can improve physician and nurse engagement such as training and feedback. The improvement of patient satisfaction is something all health care settings are striving to advance. I also urge the authors to consider the collaboration of nurse and physician rounding as an option for units that do not continuously work with the same physicians, and therefore may not have as much success with the more long term alternatives mentioned in the article. In any scenario, by acknowledging the roles of each other, nurses and physicians can better understand the opposing point of view and hopefully show more appreciation, leading to better collaboration and increased patient safety.

    Regards,

    Meagan Salmon, RN

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