Dear Broca,
I’m the chief of a small ED group and have a new female grad working in our department. Overall she is quite talented and well liked but she seems to be having difficulties with a group of nurses on a particular shift, specifically they report she gets overly defensive when they question a work up and they often feel dismissed. Ironically we have several men who appear to get away with this same behavior unscathed so I am a little wary of making this any bigger than it is. Do you have any suggestions?                              
Caught in the Gap 

altDear Gap,
At first glance this appears to be a bit of gender hazing. You have a new grad trying to transition into the role of attending and attempting to find a new niche. But as she is experimenting with leadership styles (some of which she may have picked up from fellow male colleagues apparently) she is learning the hard way that women have much less patience of an authoritarian style when it comes from another woman. She then feels singled out as she perceives that only her orders are being unreasonably questioned and she gets overly defensive. Hopefully spotlighting this dysfunctional circuit out to the young attending and encouraging a more collaborative effort will be helpful. One suggestion would be that she consciously approach the nurses before they see the orders so that she is able to explain herself up front.

At second glance, however, there appears to be a bigger storm brewing. You describe several men using this same approach of “dismissing” nurses. My question would be, do they really walk away “unscathed?” More important, do your patients? A published study (Thomas EJ- Crit Care Med 2003) on the interaction between ICU nurses and physicians suggested that physicians routinely felt that they had strong communicative and collaborative interactions with their nurses whereas only 1/3 of the nurses believed the same. Undoubtedly some of this is gender based with different gender based expectations and communication styles, but if we don’t learn how to communicate effectively we set ourselves and our patients up for medical errors. For example, a male attending may swear loudly at the computer because the EMR crashed. In his perspective his anger is isolated to the computer problem. But the young female nurse next to him senses a different vibe and may now be less likely to approach him for clarification on an incorrect order.

I think you need to do more research with the nurses. If there is any suggestion that your doctors – regardless of their gender – are not perceived as approachable and available for nursing questions I would dedicate your next departmental meeting to address this issue. The stakes truly are huge: if the nurses feel dismissed, out of the loop, or unappreciated it will greatly impact their morale and their delivery of patient care.

The Advisor:
Jeannette Wolfe, MD, is active in AAWEP and will be giving a talk on gender-based conflict resolution at the ACEP Scientific Assembly in Chicago

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