Brown: The hospital 'hierarchy' needs reform

Nurses, doctors need to be taught conflict-resolution tactics

Writing in the New York Times, oncology nurse Theresa Brown argues that the clinical hierarchy in a hospital—while necessary—can create dangerous challenges when a nurse questions a doctor's order.

Brown notes that nurses serve as the "final check" on all care decisions, and at times may feel the need to push back on a doctor's decision. However, this resistance can be met with abuse, according to Brown. She describes a situation where she questioned a doctor's order, prompting him to yell and try to intimidate her; physicians also may tend to blame nurses when they are unhappy about getting middle-of-the-night pages or dealing with other inconveniences.

While hierarchies are necessary because "someone has to be ultimately responsible for clinical decisions, and MDs have that authority," hospitals need to have "an established, neutral way of resolving such clashes," she writes.

"[S]uccessful health care needs to be interdependent," Brown adds, and "the silencing of nurses inevitably creates more opportunities for error."

The solution may be in educating nurses and physicians better in the art of conflict-resolution Brown says, and a few institutions—such as the University of Virginia's School of Nursing—are mandating such education.

The university requires interprofessional education for its nursing and medical school curriculums through training modules, courses, and shared faculty across both disciplines. All students are taught what collaboration means to different health care workers and to respect each other's areas of expertise.

"Let's hope the interprofessional education model catches on; otherwise, patients will feel the lack" when nurses fail to speak up, Brown writes. She adds that research shows that preventable medical errors already kill 100,000 patients a year.

"In a system that is already error-prone and enormously complicated, where health care workers are responsible not just for people’s well-being, but their lives, behavior that in any way increases dangers to patients is intolerable," Brown concludes (Brown, "The Opinionator," Times, 3/16).

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