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Dear Director,
I received a complaint from an ED triage nurse that one of our emergency physicians yelled at her for getting an ECG on a patient that he didn’t think needed one. She told me she’s now afraid to order ECGs on anyone but a straight forward chest pain patient. How can I improve the communication in my department between the physicians and the nurses?

The ED is a high stress environment which, whether we like it or not, operates as an interdependent team and requires excellent communication. The kind of disruptive physician behavior described above undermines a culture of safety and will have a significant impact on your ED. For nurses, morale and job satisfaction go down. The hospital loses out as more nurses call in sick and even resign. The ED is negatively impacted even when the problem doc is off duty as nurses worry about trying to guess what each individual physician on duty may or may not want.

In the specific example above, a nurse is afraid to approach a doctor because she fears getting yelled at. Now I’ll admit, I don’t love hearing a nurse say, “Doc, just so you know . . .” But that’s because I know it will be followed by the chart note of “MD Aware” in which all blame for bad outcomes is shifted to my shoulders. You know what is even worse? Not being told about a dropping blood pressure until the systolic is 70 or that my asthma patient isn’t improving, all because the nurse was afraid of my response. I’ve seen both of these situations occur, with interventions coming just moments before it was too late.

To the specific case, triage ECGs are typically protocol-driven to capture the unusual presentation of a STEMI or ACS. Physicians need to recognize this and take responsibility for designing the protocol rather than criticize the nurse who implements it. When we’re presented with an ECG we didn’t think was needed or with an elevated blood pressure that we wouldn’t act on, we need to treat it as a chance to educate our fellow healthcare professionals. It’s a golden opportunity to acknowledge and address the nurse’s concerns and then explain your thinking. This can be done in a respectful, professional manner that improves – rather than erodes – the nurse-physician relationship.

Communication barriers in the ED
Historically there has been tension between ED physicians and nurses on a variety of levels, from hierarchy to disruptive behaviors to dismissive attitudes. If you’ve been yelling at nurses for years (and it only takes throwing charts once), you’ve built up a large wall around you that nurses will have a hard time working around. Additionally, nurses and doctors tend to have fairly different communication styles. Generally, RNs give narratives while docs use more precise or abridged language. Nurses are more patient-centered while docs tend to be diagnosis focused. The size of your ED can even play a role. If your docs and nurses aren’t in close proximity to each other, it can be that much more challenging to have a conversation. Many EDs have resorted to using electronic devices to communicate and we all know that texts are no substitute for a face-to-face chat. Finally, staff turnover, whether it’s docs or nurses, means that there’s always a new person to get to know and understand. 

There are several ways to improve communication among your team. First and foremost, make sure that each physician understands that there is no excuse for disruptive behavior. Every ED probably has a doc who has yelled at the triage nurse for obtaining or not obtaining an ECG. This is completely unacceptable. It wasn’t until our department started a doc-in-triage program years ago that I became fully aware of the challenges that these triage nurses face.

Because many communication clashes occur over questions of protocol, the next step is explaining to docs and nurses how protocols developed and how they exist for the department’s greater good. A doc may even be saved on an atypical STEMI presentation because of these protocols. The medical director should welcome the team’s desire to review them and give input.

Consider instituting 360 degree evaluations of your doctors, completed by the nursing staff, in order to learn more about undesirable physician behavior. This is not a witch hunt; rather, use this information to mentor and coach your team.

Depending on the size of your ED, think about the technological tools needed for better communication. The piece of paper left on my desk noting that a patient wants pain meds is OK, but not if I’m running a code down the hall for 30 minutes. In that case, calling my Spectralink phone is likely better for getting a pain med ordered.

If your department is struggling with poor communication and deteriorating doctor-nurse relationships, consider having a morning huddle with nursing or teaching a “medical minute” on the white board at change of shift.

Finally, make sure that doctors and nurses are speaking the same language. Nursing has been using SBAR for years and it’s essentially how we communicate when we call the hospitalist for an admission. Situation (I have a patient with chest pain), Background (history of HTN, DM), Assessment (negative enzymes and ECG, so not a STEMI), Recommendation (admit for stress test). Work with your nursing leadership so that as patient situations arise, the docs know what to listen for and the nurses are doing more than passing the buck.

The nurses and techs are doing their jobs when they bring ECGs ordered by protocol for the doc to review and sign off that there is no STEMI. The heat of a busy ED shift is not the time or place to change that behavior or protocol. I try to keep in mind what General Colin Powell once said: “The day soldiers stop bringing you their problems is the day you have stopped leading them.” As the medical director, you need to listen to your staff when they bring you operational concerns and then communicate the hows and whys that make something important or discuss how it can be improved.


Michael Silverman, MD, is a partner at  Emergency Medicine Associates and is chairman of emergency medicine at the Virginia Hospital Center. 

 

Comments   

# The magic word still is magicAdan Atriham 2013-10-23 19:13
If the first thing a doctor says when interacting with another health care provider is "thank you" that sets the tone for a more cordial an beneficial interaction. When the nurse brings that EKG, I say "thank you" followed by whatever else I need to say; the nurse hears "I appreciate what you do" then she will be more receptive to whatever I will say next. Same applies to techs, secretaries, EMS, house keeping, etc. Try it, it works!
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# It goes both ways...EMR 2013-11-06 11:12
As easy and stereotypical as it is to assume that it's the big, old, mean doctor that's disrespecting the innocent nurse, I think it's important to acknowledge that communication goes both ways before automatically assuming the doctor is at fault. There is plenty of "disruptive behavior" that goes on with nurses and techs that negatively effects patient care and communication. 360 degree evaluations is fine, assuming that nurses also receive similar feedback from physicians...ot herwise it just seems like a threat and further empowers malignant behavior against physicians.

Just food for thought.
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