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Creating & Sustaining Healthy Relationships

“I’m OK, You're A Doctor- The RN/MD Game”

Kathleen Bartholomew, RN, RC, MN Seattle, Washington

“Our core challenge is to create a mechanism by which we can have a meaningful sense of community, a discovery and iteration of core

values and a behavior change based on shared values”.

-Larson

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Significance

• Moral Distress • Work Environment • Patient Safety • Retention/Recruitment • Job Satisfaction

“…a murky and omnipresent problem that has a strangle hold

on the heart of the nursing profession”

-Chancey, Staff Nurse

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What is the problem?

•  90% of nurses witnessed conflict –  Average 6-12 incidents per year

•  Survey of 1200 nurses, physicians and administrators confirmed

– 92.5% witnessed disruptive behavior

2004 Survey

“…less than 15% of physicians and nurses perceived that they had an “excellent”

relationship with each other,

…less than 25% were “very good”

(Buerhaus)

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Where Did This Conflict Begin?

•  Socio-economic Origins •  Gender Roles •  Nature of the Profession •  Education •  Stein’s doctor/nurse game

Theoretical Framework

• Oppression Theory – Major characteristics of oppressed behavior stem from the ability of dominant groups to identify the “right” norms and values and from their power to enforce them.

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OBJECTIVE

SUBJECTIVE

SCIENCE

ART

CURE

CARE

MD

RN

In a nutshell...

•  Collaboration alone does not work •  Enhancing opportunities for

communication does not work •  Units with good relations have

decreased mortality rates (Knaus 1986, Baggs 1992)

•  Poor MD/RN relations effect morale, satisfaction, retention

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•  Physicians and nurses do not agree on:

–  Beliefs about responsibility –  Barriers to progress –  Potential solutions

The Current Situation • Physician Pressures

–  decreasing reimbursement –  increasing workload –  rising malpractice costs –  loss of autonomy –  decreasing morale

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The Current Situation

• Nursing Pressures –  higher acuity –  heavier patient load –  physically heavier patients –  nursing shortage –  less time with patients

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“Every system is perfectly designed to exactly achieve the results it consistently produces”

Don Berwick

What is our goal?

Nurses and physicians working together cooperatively, sharing responsibility for problem solving, conflict management, decisions, communication and coordination to improve outcomes

Baggs 1992

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HOW?

One relationship at a time…...

Evasive Action?

•  30.7% leave the hospital •  24% refused to work or changed schedule

(Advisory Board)

>30% of administrators, nurses and MD’s could name a nurse who left in the last year specifically because of a poor interaction (Rosenstein)

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Conflict Styles

•  Collaborative – value relationship & goal •  Compromise – give a little to get a little •  Accommodation – relinquish goals for

relationship •  Forcing – task is most important •  Avoidance – nothings worth the conflict;

efforts to resolve conflict are useless

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Shared pool of meaning

Crucial Conversations

P P

A A

C C

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“The responsibility falls on nurse managers to develop, nurture, and support equal power relationships between nurses and physicians.”

Kramer/Schmalenberg

New Nurse Training

Kathleen Bartholomew, RN, RC, BS Nurse Manager, Orthopedics and Spine

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Mobility

• Posterior Precautions – Avoid 90 degrees of hip flexion

(Dr Toomey prefers 70 degrees) Avoid bringing knees together Avoid internal rotation of affected leg

Anterior Precautions

•  No hip hyper-extension •  No hip external rotation > 45 degrees (avoid these movements together)

No limitations on hip flexion Pillow between knees while in bed and sitting No crossing knees or tailor sit Encourage short steps, walk through gait ok.

Dr. Phillips

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Anterior/Precautions (con’d)

• No crossing legs. • No tailor sitting • No active extension with external rotation • (If good leg is in neutral, extension of operated leg is ok -Golfer’s lift)

Dr. Pritchett

Anterior Precautions (con’d) Dr. Toomey

• Do not bend hip greater than 80 degrees • Keep legs apart with pillows in bed/sitting • Keep hip slightly bent at all times, using a pillow under the thigh when in bed and for exercises • Don’t let the leg roll outward

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Dressings

•  Dr. Crutcher - 1/2” steri-strips cut in 1/2 closely spaced after applying tincture of benzoin

•  Dr. Peterson - 6” ace wrap over knee with ted hose •  Dr. Wilson - full length 1” steri-strips •  Dr. Zorn - DSD change 1st day POD •  Dr. Phillips - Don’t even think of pulling the drain

Blood Dr. Winquist - gives auto blood in PACU Dr. Crutcher - give 1 unit auto if drain> 500cc call if Hct < 26 Dr. Pritchett - call if Hct < 27 Drs. Toomey, Downer, Zorn - Hct < 30 Family member of any physician - Hct <20

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Breaking the cycle:

1. Unveil the problem 2. Raise individual and collective self esteem

-Susan Roberts

To be engaged in the solution

we must understand the problem

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Breakdowns For nurses 1. Discharge Disagreements 2. Treatment Conflicts 3.  Disruptive Behavior

-In private, eye contact, just the facts 4. Telephone Trouble

Conflict

1.  Collaborative – value relationship and goal

2.  Compromise – give a little to get a little

3.  Accommodation – relinquish goals to maintain a relationship

4.  Forcing – task at hand/goal is most important

5.  Avoidance - neither goal or relationship is worth the conflict

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Collegial Collaborative Teacher-Student Neutral Negative

Kramer-Schmalenberg Scale

Changing the Culture of Medicine

Negative -Neutral-Teacher-Collaborative-Collegial

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Strategies…

•  Collegial - Personally thank the MD - Send a thank you note to the physician - Send a note to the medical director and copy to the CEO stating specific examples of great teamwork

Strategies…

•  Collaborative or Teacher/Student - Takes time to develop trust - Show “your stuff” – use progress

notes - Ask questions - Tease out the human being

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Strategies…

•  Neutral - Most difficult to reach because of lack

of vested interested - Don’t play the game; engage anyway - Look for the common goal: best

patient care possible - Look for common interests

Strategies…

•  Negative - Confront in private using good eye

contact - State the facts: behavior and effect and that the behavior will not be

tolerated - Go up the chain of command if

necessary - Fill out an incident report if unresolved

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Exercise

•  Physician •  Feeling •  MD behavior •  My conflict style •  My typical response •  New response

Exercise

•  Physician •  Feeling •  MD behavior •  My conflict style •  My typical response •  New response

- Dr. Rude - Hurt and angry - Obnoxious and loud - Avoidance - Leave – ASAP! -Ask to speak to him

alone, or ask manager to come along

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Case Studies

•  Yelling and shouting •  Intimidation •  Telephone etiquette •  Ignoring •  Devaluing

Opportunities 1. Administrative Support

-Zero Tolerance Policy -Formalized Collaborative Models

2. Education -Assertiveness Training -Role of the nurse -Joint education events

3. Powerful Equalizers - name/clothes 4.  Building Community – connecting human to

human

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Opportunities

5. Role model collaboration/collegiality 6.  Hold the vision – daily communication 7.  Use Formalized collaborative models 8. Acknowledge excellent relationships 9. Attend medical rounds 10. Support joint celebratory events

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“Never doubt that a small group of individuals can

change the world, Indeed, it’s the only thing

that ever has.”

Margaret Mead

Thank you.

•  Kathleen Bartholomew •  kathleenbart@msn.com •  206-356-2599 •  www.kathleenbartholomew.com