It wasn't that long ago when rising tensions and communication issues between physicians and nurses at Cedars-Sinai Medical Center in Los Angeles had reached a breaking point.
Mary Alice Modders, RN, BSN, staff nurse at Cedars-Sinai, remembers spending precious patient care time trying to track down physicians to review patient orders and illegible notes, only to be greeted by an angry and impatient physician on the other end of the phone.
Physicians complained they couldn't find patient charts or other supplies when they needed them. Frustrations grew over what physicians felt were too many unnecessary phone calls, and physicians questioned nurses' processes and critical-thinking skills. On the other hand, nurses expressed frustration over the lack of communication with physicians and their rude behavior and felt they had no recourse when physicians acted inappropriately.
To strengthen communication and collaboration between physicians and nurses, Cedars-Sinai created the MD-RN Collaborative. The collaborative is designed to address workplace concerns and improve nurse and physician satisfaction. Since the collaborative's inception in 2000, physician and nurse satisfaction scores have risen steadily, tensions have cooled significantly, and physicians and nurses are working as a team rather than autonomously, says Peachy Hain, RN, director of medical/surgical rehabilitation services at Cedars-Sinai and co-chairwoman of the MD-RN Collaborative.
Mary Alice Modders, RN, BSN, staff nurse at Cedars-Sinai, remembers spending precious patient care time trying to track down physicians to review patient orders and illegible notes, only to be greeted by an angry and impatient physician on the other end of the phone.
Physicians complained they couldn't find patient charts or other supplies when they needed them. Frustrations grew over what physicians felt were too many unnecessary phone calls, and physicians questioned nurses' processes and critical-thinking skills. On the other hand, nurses expressed frustration over the lack of communication with physicians and their rude behavior and felt they had no recourse when physicians acted inappropriately.
To strengthen communication and collaboration between physicians and nurses, Cedars-Sinai created the MD-RN Collaborative. The collaborative is designed to address workplace concerns and improve nurse and physician satisfaction. Since the collaborative's inception in 2000, physician and nurse satisfaction scores have risen steadily, tensions have cooled significantly, and physicians and nurses are working as a team rather than autonomously, says Peachy Hain, RN, director of medical/surgical rehabilitation services at Cedars-Sinai and co-chairwoman of the MD-RN Collaborative.
One strategy that has had the greatest impact on improving both patient care and staff relationships has been the implementation of nurse/physician rounds. Here, Chris Ng, MD, Betty Nersesian, RN, and a patient work out her care plan while coordinating care with her internist via a video rounding system.
(Courtesy of Cedars-Sinai Medical Center)
The Joint Commission recognized that strained relationships between healthcare workers can compromise patient safety and quality of care. So the organization announced in July that all hospitals must establish codes of conduct that define inappropriate behaviors and establish a formal process for managing them by January.
With nearly a nine-year jump on the new initiative, Cedars-Sinai has seen many positive benefits stem from the collaborative, including safer and more efficient care, a greater focus on patient-centered care, increased nurse retention, improved satisfaction among physicians, nurses and patients, and a more pleasant work environment, says Chris Ng, MD, physician co-chairman of the collaborative. “According to senior physicians, the interaction between doctors and nurses is like night and day,” Ng says. “The nurses are now treated with respect and as equal partners in care, and this translates into better quality of care.”
The collaborative, led by physician and nurse co-chairs Ng and Hain, includes a committee of physicians and nurses whose goal is to identify the source of physician/nurse tensions and develop solutions. In many cases, the committee has found that tensions have stemmed from three primary areas: technical issues that involve accessibility of supplies and standardization of processes and procedures; lack of communication and understanding; and deteriorating courtesy and respect.
Simple Steps
The collaborative has implemented a series of solutions that have been applied globally throughout the organization. These solutions included steps as simple as standardizing the location of charts, prescription pads, and other frequently used supplies; creating “hot” files at nursing stations for frequently used order sheets or notes; implementing pre-printed medical/surgical admission order sets; providing nurses with cell phones; holding handwriting classes for physicians; and implementing the SBAR (situation, background, assessment, and recommendation) technique for hand-offs and discharges for physicians and nurses.
Relationship education and workshops were also vital to the program's success. The hospital offered a series of staff in-services to promote more effective and respectful communication including a meet-and-greet campaign for physicians and nurses, difficult conversations training, taking-charge workshops, English proficiency classes, and cultural diversity and team-building workshops.
The collaborative also teamed with physician leadership to develop a zero-tolerance physician and staff code of conduct to provide a formal incident reporting system. Now when a complaint is filed against a physician, it follows a formal chain of command that begins with review by the quality department. The complaint is then passed on to the department's medical staff leadership, who develops an appropriate resolution with the offender.
The collaborative has implemented a series of solutions that have been applied globally throughout the organization. These solutions included steps as simple as standardizing the location of charts, prescription pads, and other frequently used supplies; creating “hot” files at nursing stations for frequently used order sheets or notes; implementing pre-printed medical/surgical admission order sets; providing nurses with cell phones; holding handwriting classes for physicians; and implementing the SBAR (situation, background, assessment, and recommendation) technique for hand-offs and discharges for physicians and nurses.
Relationship education and workshops were also vital to the program's success. The hospital offered a series of staff in-services to promote more effective and respectful communication including a meet-and-greet campaign for physicians and nurses, difficult conversations training, taking-charge workshops, English proficiency classes, and cultural diversity and team-building workshops.
The collaborative also teamed with physician leadership to develop a zero-tolerance physician and staff code of conduct to provide a formal incident reporting system. Now when a complaint is filed against a physician, it follows a formal chain of command that begins with review by the quality department. The complaint is then passed on to the department's medical staff leadership, who develops an appropriate resolution with the offender.
Nurse/Physician Rounds
One strategy that has had the greatest impact on improving both patient care and staff relationships has been the implementation of nurse/physician rounds. “In the past, doctors would slip in the patient room, write orders, and leave the unit,” Hain explains. “The problem was that no one could read their notes, resulting in numerous phone calls to the doctor throughout the day. Now nurses and doctors round together and discuss a plan of care with the patient at that time. This has eliminated unnecessary phone calls and has helped create a much more collegial relationship between our doctors and nurses.”
“It's a much more collaborative effort,” Modders agrees. “A lot of the frustrations grew out of a lack of understanding and poor communication. Now that [physicians] have better understanding of our goals of care from a nursing perspective and we have a better understanding of their goals from a surgical perspective, the doctors respect our input and role in patient care.”
Cedars-Sinai has capitalized on the collaborative's success, and more recently developed unit-based MD-RN Collaborative committees to allow staff to address unit-specific issues and personal issues one-on-one. “We found that each unit has unique issues that require unique solutions,” Hain notes. “This also allows doctors and nurses to meet each other and get to know each other on a personal level. Once you have that social interaction with someone, it's much more difficult to become angry and hostile.”
Physicians and nurses have expressed increased satisfaction in many key areas since the hospital began conducting surveys in 2003, including increased collaboration and improved communication and teamwork, Hain says. Nurses also feel physicians value their contribution and consider them an integral part of the patient care team.
“With more than 47 MD-RN Collaborative committees and a formal grievance process in place, nurses now know we are serious about improving physician/nurse relations and are taking action to do something about it,” Hain says. “This alone has been very empowering.”
One strategy that has had the greatest impact on improving both patient care and staff relationships has been the implementation of nurse/physician rounds. “In the past, doctors would slip in the patient room, write orders, and leave the unit,” Hain explains. “The problem was that no one could read their notes, resulting in numerous phone calls to the doctor throughout the day. Now nurses and doctors round together and discuss a plan of care with the patient at that time. This has eliminated unnecessary phone calls and has helped create a much more collegial relationship between our doctors and nurses.”
“It's a much more collaborative effort,” Modders agrees. “A lot of the frustrations grew out of a lack of understanding and poor communication. Now that [physicians] have better understanding of our goals of care from a nursing perspective and we have a better understanding of their goals from a surgical perspective, the doctors respect our input and role in patient care.”
Cedars-Sinai has capitalized on the collaborative's success, and more recently developed unit-based MD-RN Collaborative committees to allow staff to address unit-specific issues and personal issues one-on-one. “We found that each unit has unique issues that require unique solutions,” Hain notes. “This also allows doctors and nurses to meet each other and get to know each other on a personal level. Once you have that social interaction with someone, it's much more difficult to become angry and hostile.”
Physicians and nurses have expressed increased satisfaction in many key areas since the hospital began conducting surveys in 2003, including increased collaboration and improved communication and teamwork, Hain says. Nurses also feel physicians value their contribution and consider them an integral part of the patient care team.
“With more than 47 MD-RN Collaborative committees and a formal grievance process in place, nurses now know we are serious about improving physician/nurse relations and are taking action to do something about it,” Hain says. “This alone has been very empowering.”
Susan Meyers is a freelance writer. To comment, e-mail editorCA@nurseweek.com.
