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Employment = Better Collaboration

Carrie Vaughan, for HealthLeaders Magazine, June 11, 2009
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Hospitals are finding that an employment model may help change the relationship between nurses and physicians for the better.

The days of a paternalistic healthcare system are gone. "Years ago, you would walk in a room and nurses stood up and offered you their seat," says Mark J. Werner, MD, executive vice president and chief medical officer at Carilion Health System in Roanoke, VA. Today, there is a more egalitarian environment and respect between the two professions for what they each bring to the table, he says.

But the increasing complexity of medicine has also put a lot of pressure on both disciplines. "With DRG, you have a certain amount of days [Medicare] is going to pay you," says Nancy Semerdjian, chief nursing officer at Evanston, IL-based NorthShore University Health System, which has more than 600 employed physicians and about 2,000 active independent physicians. Doctors write the orders, and it's the nurses' job to facilitate that order and move patients through the system in a timely manner. When it comes to expediting procedures and diagnostics, however, so much of that depends on other departments and their resources, she says.

"When I took care of patients, a patient with a heart attack stayed six weeks. Now it's two to four days. Your window of time is much shorter, so getting to know the physician is limited."

In addition, nurses are busier than ever, says Werner. They are being pulled in different directions and are caring for sicker patients. "Nurses' ability to focus intently on the needs of physicians is less robust than it used to be—in a good way," he says. "They have moved from a focus on service to physicians to service to patients."

The goals of nurses and physicians have always been the same, says Carolyn Webster, chief nursing officer and senior vice president at Carilion. "If you talk to doctors about what's important, they say patient care. If you talk to nurses, they say patient care," she says, adding that the challenge has been getting both groups at the same table talking about patient care. Three years ago the health system began converting to a physician-led clinic model. One benefit is that both nurses and physicians are now at the same table talking about how they can impact care together, says Webster.

Conflict and resolution
Prior to converting to the clinic model, if nurses wanted to change a process or clinical practice, they would call a meeting, decide what should be done, and then try to sell the change to physicians. The physicians were invited to the meetings, Webster says, but attendance was not consistent. A private physician on an independent medical staff has no direct reason to problem solve with nursing, says Werner. If physicians didn't like a hospital system or practice, "they would tell the nurse or administrator and expect them to fix it," he says.

An employment model puts physicians and nurses on equal footing, says David Green, MD, CMO at Concord (NH) Hospital, which has 238 staffed beds. It also provides a foundation for doctors and nurses to work differently together, says Werner. When he joined Carilion about six years ago, it was inappropriate for a nurse to question a doctor. "It was a culture that suppressed nursing speaking up when physicians' care of patients needed to be challenged," he says.

But with the clinic model, there is an expectation that nurses and physicians will come together to solve problems. "We have taken politics out of the team," he says. For example, physicians complained a few years back that nurses weren't getting patients up and walking them around as often as they should, Webster says. The focus was on nurses' behavior rather than the care of the patient. Once both groups were at the same table, they realized nurses were following an old paradigm that required a physician order before they could get the patients up. Physicians didn't think an order was necessary, so the health system adjusted its protocols. "There were a lot of people coming with predisposed ideas," says Webster.

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