Challenges

and Implications of the Doctor/Nurse Relationship

The Challenges and Implications of the Doctor/Nurse Relationship

Bryan A. Aungst
Juniata College

Challenges and Implications of the Doctor/Nurse Relationship

Introduction
The health care industry is heavily regulated. Because constant strains on funds,
government regulations, and limited resources are often coupled with ample opportunity
for lawsuits and life-altering or life-threatening mistakes, the organizational structure of a
health care setting is often hierarchical in nature, and very rigid. In this healthcare setting
however, the interactions between doctors and nurses can often have implications beyond
the initial interaction.
The relationship between the superior and subordinate in any number of
organizations is fairly well studied. Each industry and each organization cannot exist
without some form of interaction between the superior and the subordinate. Individual
companies tend to have their own rules, regulations, and norms for these interactions, but
larger trends found across most health care facilities tend to emerge. These trends will be
discussed later in this paper.

Researchers report an important link between perceived openness of

communication and reciprocity (the extent to which the superior and superordinate agree
on their level of interdependence) and the important role they play on the status of a given
health care setting (Coombs, 2003; Frankel & Stein, 1999; Frankel, Krupat, & Stein, 2005;
Hughes, 2008; Lindeke & Sieckart, 2005; Lingard, Reznick, Espin, Regehr, & DeVita, 2002;
Manojlovich, 2005; Manojlovich & DeCicco, 2007; Sutcliffe, Lewton, & Rosenthal, 2004;
Svensson, 1996). Because of the harried nature of health care and the necessary hierarchy,
there are often challenges, such as limited time permitted for interactions or unclear
directions being given, that strain the superior/subordinate relationship.

Challenges and Implications of the Doctor/Nurse Relationship

In the following pages I will discuss the challenges presented by the

superior/subordinate relationship in a health care setting. Topics covered include the
importance of communication between these parties, and methods of assessment and
suggestions to improve this communication, how government regulation both protects and
puts a strain on health care, and how it attempts to reform the superior/subordinate
relationship that currently exists in most hospitals and doctors offices. I will also address
implications of these superior/subordinate relationships, and how improving
communication can improve health care on a macro level, therefore arguing that
implementing training to improve communication between doctors and nurses can benefit
hospitals and other health care settings economically.
Before I discuss the literature, it is important to define the terms I will be using.
When I talk about just health care, I am talking about the industry as a whole, and
generalized to U.S. American health care. When the term health care setting is used, I am
generally referring to hospitals, doctors offices, outpatient centers, and the like. From here
on out the abbreviation HCS is used as a generalization for health care setting.
In HCSs, due to the complex nature of the system and the rigid hierarchy, there are
many superiors and many subordinates, and often a person is both. A doctor may be a
superior to an intern, but a subordinate to the head of his or her department. For the sake
of simplifying my writing, it should be assumed that superior in this paper should be
generalized as doctor, and that subordinate should be generalized as nurse or intern
(resident).

Challenges and Implications of the Doctor/Nurse Relationship

The Doctor-Nurse Game

When it comes to working in HCSs, cases can often be life or death, but many times
they are not. The role of nursing has been changing greatly in recent years due to financial
strains on the health care system. Nurses are being asked to take on more and more
primary care roles, creating a time of uncertainty (Williams & Sibbald, 1999, pp. 737).
This phrase describes the dissonance between nurses responsibilities and place in the
hierarchy of their HCS (Williams & Sibbald, 1999). Despite the fact that nurses are being
asked to perform more duties and make more decisions, some scholars argue that doctors
often get the final say (Coombs, 2003; Svensson, 1996).
With nurses being more involved with patients interpersonally, they are more
equipped to make calls about medical decisions that are in line with patients wishes.
However, referring once again to the hierarchical structure of health care organizations, we
see that doctors have final say. From this frustrating trend over the years, we see the
emergence of a phenomenon known as the Doctor-Nurse game (Hughes, 2008).
Hughes (2008) describes the Doctor-Nurse game as an interaction or series of
interactions in which the nurse must appear to be subordinate to the doctor while offering
nonverbal cues and the like to manipulate the doctor or to affect a diagnosis. These games
are often played around decisions such as deciding whether or not a patient is in need of
hospitalization or which course of treatment should be taken for specific patients (Coombs,
2003).
Hughes (2008) and Svensson (1996) suggest however that the Doctor-Nurse game
is not a normal practice in current medicine. Svensson (1996) argues that nurses and
doctors can and do negotiate (i.e. communicate about duties, treatments, and the like) and

Challenges and Implications of the Doctor/Nurse Relationship

this causes change in the power hierarchy seen in HCSs. Hughes (2008) also states that a
trend of collaboration in forming diagnoses is emerging in industrialized health care
settings. This makes the idea of power interesting to consider, because in Hughes and
Svenssons views, more power is shifting to the nurses. Amidst the conflicting messages
floating around regarding the state Doctor-Nurse game, it could be said that the doctor is
out on this subject. There is no one clear answer, but I believe that remnants of this game
do indeed still exist, and may be found more often depending on what geographic area one
is looking in for them.
One of the first things to consider when observing how doctors and nurses interact
in HCSs is how they were trained. The type of training that doctors receive for dealing with
patients and others is somewhat different from the training that nurses receive (Lindeke &
Sieckart, 2005). Nurses often spend more one on one time with patients, and thus tend to
receive more training and practice in interpersonal communication when it comes to
dealing with patients (Hunter, 1996). According to Frankel, Krupat, and Stein (2005), when
one receives training in communication skills in one area, improvement can often be seen
in other interactions. Knowing this, it can be assumed that nurses training in interpersonal
skills with patients often help them in interacting with colleagues and superiors.
Miscommunication between doctors and nurses is often the main cause of medicine-
based and non-operational treatment mistakes (Sutcliffe, Lewton, & Rosenthal, 2004). With
that as a known fact, improving this communication should be a priority in most HCSs. A
main focus should specifically be on interpersonal communication skills. According to
Duffy et al. (1999):

Challenges and Implications of the Doctor/Nurse Relationship

While communication skills are the performance of specific tasks and behaviors by
an individual, interpersonal skills are inherently relational and process oriented.
Interpersonal skills focus on the effect of communication on another person. (p.
497)
Assessing Communication
There are a number of ways to assess communication skills of doctors and nurses.
One particularly useful method is patient questionnaires and surveys. The patient is often
the best judge of the interpersonal skills of these professionals (Duffy et al., 2004). Another
useful method is the use of checklists to guide doctor and nurse behaviors and observation
by a professional trained in communication theory can help to assess the ability of a doctor
or nurse in their interpersonal skills with patients (Duffy et al., 2004). These methods could
easily be adapted to view how doctors and nurses interact with each other.
Improving Communication

Once ample information has been gathered about communication ability (strengths
and deficiencies alike), a plan can be developed to improve communication skills. Frankel,
Krupat, and Stein (2005) suggest that the average U.S. physician conducts between 140,000
and 160,000 medical interviews in his or her life, and this can lead to burnout and lower
quality communication. Large California-based health care provider Kaiser Permanente
utilized a method known as the Four Habits Model in order to aid clinicians in learning and
improving important basic communication skills quickly and efficiently (Frankel, Krupat, &
Stein, 2005). Upon following up with patient surveys, Kaiser Permanente verified that the
use of the Four Habits Model did indeed help improve the communication skills of the
clinicians within the organization (Frankel, Krupat, & Stein, 2005). Based on their success,

Challenges and Implications of the Doctor/Nurse Relationship

the Four Habits Model has picked up a bit of steam and is being used more often to help
improve these skills.

The Four Habits Model (Table 1 in appendix) discusses the four main habits

clinicians should exhibit while conducting medical interviews. The four habits are: Invest
in the Beginning, Elicit the Patients perspective, Demonstrate Empathy, and Invest in the
End (Frankel, Krupat, & Stein, 2005). The model outlines the skills associated with each
habit, lists techniques and gives examples of them, and outlines the payoff from exhibiting
each habit. This can be beneficial especially in training new interns or residents, as
communication in everyday interactions and settings such as the Operating Room help to
socialize the novices, who may have negative opinions of them formed from unsatisfactory
communication with superiors (Lingard, Reznick, Espin, Regehr, & DeVito, 2002).
Implications
Having stronger interpersonal skills and better communication between doctors
and nurses has a number of important implications. One of the timeliest implications stems
from government pressure on the health care system. The U.S. government expectation of
health care management and real life practice are in a state of dissonance (Hunter, 1996).
The government wants a more flexible team-oriented approach to health care, but
according to Coombs (2003), this is not the common practice yet. Strengthening
interpersonal communication will aid in shifting to this more team-based system.
Another important implication of a more reciprocal relationship between doctors
and nurses, with greater perceived open communication, is the improvement of job
satisfaction for nurses (Frankel & Stein, 1999; Frankel, Krupat, & Stein, 2005; Hunter, 1996;
Manjojlovich, 2005; Manjojlovich & DeCicco, 2008; Mayfield, Mayfield, & Kopf, 1998;

Challenges and Implications of the Doctor/Nurse Relationship

Williams & Sibbald, 1999). While environment and structural empowerment play a role in
job satisfaction for nurses, nurses also highly value open communication with the doctors
they work with, and the relationship between their perceived quality of communication
and their job satisfaction is directly proportional (Manjojlovich, 2005). Adding to that, in
most settings, when nurses job satisfaction was higher, patient outcomes were better and
mortality rates were lower (Manjojlovich, 2005).
The correlation between job satisfaction and patient outcomes holds true in all
medical environments other than Intensive Care Units (ICU). Job satisfaction does not
necessarily affect patient mortality in ICUs (Manjojlovich & DeCicco, 2007). This is perhaps
due to the nature of the patients that come through the ICU. There is a higher chance for
these patients to die in general than for patients in other floors of hospitals. Another
important trend did emerge however. In the ICUs, a correlation was found between nurses
job satisfaction and a lower risk of nurse-assessed medication errors (Manjojlovich &
DeCicco, 2007). When nurses were happier with their jobs, they made less medication-
centered errors. This again, is linked back to perceived reciprocity and openness of
communication that nurses have with doctors.
Other studies had similar findings. Between 44,000 and 98,000 people die in
hospitals in the U.S. annually due to errors, and these errors often are results of
miscommunication (Sutcliffe, Lewton, & Rosenthal, 2004). In one study, Sutcliffe, Lewton,
and Rosenthal (2004) stated:
The occurrence of everyday medical mishaps in this study is associated with faulty
communication; but, poor communication is not simply the result of poor
transmission or exchange of information. Communication failures are far more

Challenges and Implications of the Doctor/Nurse Relationship

complex and relate to hierarchical differences, concerns with upward influence,

conflicting roles and role ambiguity, and interpersonal power and conflict. (p. 186)

Lowering the number of patient mortalities and creating better patient outcomes

have greater benefits than those received by the individual patients. Patients who are
treated for their condition and treated well in the process are less likely to pursue lawsuits
(Manjojlovich, 2005). Along with that, nurses that are satisfied with their jobs and making
fewer errors tend to use resources (including time) more efficiently (Sutclifee, Lewton, and
Rosenthal, 2004). Both of these are substantial economic benefits to HCSs.
Conclusion
The relationship between doctors and nurses, superiors and subordinates is
complex. A number of organizational barriers and government pressure can put strain on
this relationship, as outlined earlier. Open, reciprocal communication that utilizes strong
interpersonal skills can help to bypass these barriers. When nurses feel unable to openly
communicate with doctors, they may resort to methods of manipulation in order to get
doctors to see their point of view.

However, if HCSs, and the health care industry in general, are willing to step back

and observe the ways in which communication between superiors and subordinates take
place, they can implement programs and training that can improve interpersonal skills. The
benefits of improving these skills are many, as Ive shown here. Not only do patients fare
better, but also there are economic benefits to be had, and a feasible decrease in lawsuits.

In the literature, scholars speculate about the direction that the health care industry

was headed. In the U.S., the government is pushing for a teams approach to health care,
which in some ways could be very beneficial. However, with nurses and doctors working

Challenges and Implications of the Doctor/Nurse Relationship

10

together on teams, the importance of interpersonal communication skills becomes even

greater.

The challenges of the doctor/nurse relationship in the current health care

atmosphere are great, but still navigable. If health care in the U.S. truly is in a time of
uncertainty, than the challenges of this relationship will become greater as we transition
into a new way of doing things. And yet it is the implications of these relationships that
should receive the most focus. When the involved parties perceive the relationship as
healthy, everyone benefits.

Challenges and Implications of the Doctor/Nurse Relationship

11

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Challenges and Implications of the Doctor/Nurse Relationship

Appendix
Table 1

13

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