Study: Constant conflicts

cause nurses to leave

If you were asked to name a reason why nurses choose to leave their workplace,
you’d probably think of benefits, salary, or work schedule. However, according to a
recent study, a significant factor is something you may not immediately suspect: conflict
with physicians.
The study, which was conducted by VHA West Coast, one of 18 regional
divisions of VHA Inc., a network of community-owned health care systems, and
surveyed 1200 nurses, physicians and hospital administrators, found that 92% had
witnessed disruptive behavior by a physician, while 30% knew a nurse who had left the
facility as a result. (REFERENCE 1)
Continual conflict between nurses and physicians can have a profoundly negative
impact, stresses Tracy Sanson, MD, FACEP, assistant medical director for the
department of emergency medicine at Brandon (FL) Regional Medical Center. “Bad
behavior undermines the effectiveness of the medical team, and negatively impacts the
reputation of the ED,” she says.
Morale of individual nurses is also adversely affected, she stresses. “This leads to
absenteeism, frequent staff turnover, and low recruitment,” she says. “In turn, this
impacts both patient safety and our bottom line.”
Here are recommendations to avoid conflicts between nurses and physicians:
Instruct staff to be clear about their needs.
An “expectation mismatch” occurs when one person expects something to be
done and the other does not do it, says Louise Andrew, MD, JD, FACEP.
The best way to avoid this is to be explicit in what you expect.  “This is not easy
for doctors, who don't like to ask for things, although we certainly do like having it all
done for us.” she says.
It’s also not easy for nurses, who often don't expect their needs to be valued or
met, and have limited recourse when they are not, adds Andrew. “This is true even of ED
nurses, although they are among the most assertive of all nurses,” she says.
The nurses who are most successful in being explicit bear constantly in mind that
their needs requests are thefor things which will mean the best care for patients. It is
always easier to ask for something for someone else than for ourselves.
Don’t delay a confrontation.
It may be tempting to postpone addressing an unpleasant problem in the hopes
that it will resolve itself, but this is a mistake, says Sanson. If you need to take action, she
recommends doing so immediately, as delaying a confrontation only allows anger and
resentment to build between staff members, she says.
“The resolution of the conflict should take precedence over considerations of
staffing, finances, and other personal or professional obligations,” Sanson underscores.
Confront behavior, but give the individual an “out.”
According to Andrew, the best way to stop disruptive behavior is to confront it
directly when it occurs. She recommends naming the behavior and asking requesting
firmly but politely that it stop, while providing an "out" for the individual who is being
confronted, says Andrew.
 She gives the following example: EP: “I notice that you have not checked the
vitals on Mr. J for some time. Perhaps I have not been clear that it is important that we
keep track of his progress this way.  Is there somethingWhat can I can do to help you to
be sure that this is done? ED Manager to EP: “Bob, the nurses have complained that you
are being “curt” with them this week. I know you understand that doesn’t help our
efforts in the area of teamwork or good patient care. Is there something going on right
now which is stressing you more than usual? Can I do anything to help What can I do so
that you will be more available to our staff? “
Make it easy for nurses to report problems.
Almost half of the study’s respondents reported barriers to reporting physician’s
disruptive behavior. This can be for a variety of reasons. Nurses legitimately fear
retribution from physicians whom they report. Some hospitals have a tradition of firing
nurses who are whistleblowers on physician behavior. If the reporting chain requires
going to a physician leader, the problem is compounded and the leader might of course be
the problem him or herself. There should be a safe reporting mechanism which allows
for anonymity in reporting disruptive behavior, especially if there is any suspicion of
possible impairment. The key to open reporting of lesser concerns is having a receptive
environment and a manager who is known to have authority and good rapport with both
nurses and physician staff. There should be education of all staff about the importance of
reporting behavior which is not conducive to good patient care and clearly delineated
guidelines for reporting, including alternate routes where the reportee is felt to be part of
the problem. All of these mechanisms can be modified from but modeled after sexual
harassment reporting mechanisms which are required by law.

Staff should be given inservices.

Andrew recommends providing training for both physicians and nurses on
effective and assertive communication skills. The goal is to enable staff to nip problems
in the bud as soon as they begin, she explains. “If the ED manager has to intervene, it has
gone on too long unchecked,” says Andrew.
Sanson says that as an ED leader, you should do the following:
* establish departmental expectations of behavior;
* implement coaching and mentoring;
* develop role playing educational opportunities;
* provide informal and formal feedback;
* create opportunities to share and review lessons learned from specific episodes.
“Feedback that is shared and integrated into the ED practices improves the whole
system processes and enhances the safe delivery of care to patients,” she says.
If you have to intervene, involve both parties.
Sanson advises taking the following steps when addressing a conflict: Conduct a
thorough and fair investigation, arrange a private meeting to discuss the behavior and its
impact, and set specific goals to change the behavior.
NOTE TO DR. SANSON: CAN YOU GIVE EXAMPLES OF GOALS TO SET?
ALSO, CAN YOU SUGGEST HOW TO CONDUCT A THOROUGH AND FAIR
INVESTIGATION—FOR INSTANCE, SHOULD AN ED MANAGER INTERVIEW
OTHER STAFF MEMBERS TO SEE IF THEY HAVE WITNESSED THE BEHAVIOR
IN QUESTION?
 “The meeting should allow sufficient time to address the problem, and
specifically focus on the behavior,” she says.
Andrew recommends involving both parties, and allowing each to ventilate
without fear of retribution. “Make it clear that it is the PROBLEM, not the PEOPLE who
are the concern,” she says.
Ask each person what they think can be done to address the present problem and
avoid its happening again, she advises. “Amazing creativity can be generated in this way
if it is done effectively,” says Andrew.
For example, if a physician is experiencing frustration because written orders are not
being taken off the chart promptly, while verbal orders are prohibited, a creative and
mutually acceptable solution developed by brainstorming might be a system of colored
flags to signal the presence of written orders that are critical, moderate urgency, or
routine.

For more information on management of conflicts, contact:

 Louise Andrew, MD, JD, FACEP, Associate Director, Center for Professional
Well-Being, Durham, N.C. and Victoria, BC.; lbandrew@cpwb.org.*

 Tracy Sanson, MD, FACEP, Assistant Medical Director, Department of

Emergency Medicine, Brandon Regional Medical Center, 119 Oakfield Drive,
Brandon, FL 33511. Telephone: (813) 681-0503. Fax: (813) 948-8477. E-mail:
oaks61596@aol.com
* A variety of resources and training in effective communications and creative conflict
resolution, individual behavioral assessment and disruptive professional policy
development are available from the Center for Professional Well-Being, a nonprofit
educational organization. . For more information, contact the Center for Professional
Well-Being: 21 West Colony Place, Suite 150, Durham, North Carolina; 27705. Tel:
(919) 489-9167. Fax: (919) 419-0011. E-mail: CPWB@mindspring.com. Web:
www.cpwb.org.