rethink nurses

In the last few weeks, I’ve blogged about the toxic culture found in medical institutions. It’s not that physicians intend to harm anyone. It’s that they have accepted the idea that hazing and brow beating people is acceptable at work, leading to horrible consequences. This attititude of extreme professional authority means that they resist all criticism and direction unless it comes from other physicians.

There’s no silver bullet . But I do have a suggestion, which someone suggested to me recently, for one particular issue. A common problem is that physicians, for whatever reason, often forget all the minute details needed to successfully treat patients. Young physicians may simply not have all the experience needed to competently handle all patients. They may make blunders reading charts or handling simple diagnoses. Older physicians may be doing something very complicated and forget something very simple, like washing your hands. In other words, medicine is complex and human beings are limited, even the ones who went to med school.

The solution is the division of labor. Did you forget to wash you hands in the ICU? Aren’t sure that you cleaned that site for the central line? You need someone whose job it is to enforce checklists. In other organizations, this is routine. As Atul Gawande reminds his readers, this is normal when doing something like flying a plane. Can’t remember all the safety checks? No problem – make a list and then your co-pilot will go over it with you.

The problem with toxic medical culture is that it encourages physicians to assume nearly all responsibility for everything. That encourages you to dump on people who don’t have your professional status. The people in the medical institution who have the knowledge and ability to help you double check your work – nurses – have no reason to help you. Perhaps the most common complaint among nurses about doctors is that doctors trash them whenever they assert themselves. Of course, someone has to be in charge, but nurses are now treated like clueless paralegals instead of helpful advisers.

By shifting nurses from abused OR gophers to advisers and checklist enforcers, physicians can vastly improve safety outcomes. Just making sure that you wash your hands *every single time* instead of when you remember, or care, to do it you can help patients and save millions. Nurses can also be hugely helpful to physicians in training. Do you really want young and sleep deprived interns doing doling out drugs without some double checking? If not, think about nurses. They’re here to help.


Written by fabiorojas

May 25, 2010 at 12:31 am

8 Responses

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  1. Maybe surgery is different and maybe I’m biased, but do check that nurses really are treated that poorly before assuming these strong opinions. I’m an internist and, while maybe biased by a system I benefited from, your ‘toxic culture’ feels more 1970’s “House of God” and bad TV than my experience. I never saw power-tripping over nurses you assume (the nurse’s only boss is the nurse manager) and I don’t recognize the disrespect. I hope, but also think, we’ve moved forward as a field.

    Similarly, I think you’re under-respecting the roles nurses currently play in hospitals. They are the central point of interaction for all patient care and the interface with the rest of the allied health professionals.

    Checking orders by the pharmacist who receives the order and the nurse who delivers are central job responsibilities. I’ve been corrected for bad orders dozens of times and no one acts like there’s a power-play occurring, unless we actively disagree. Turning nurses into checklist-nags is not obviously something they would consider a promotion.



    May 25, 2010 at 1:17 am

  2. In the “socialist nightmare” of the NHS, popular folklore has it that doctors weren’t even allowed on the wards without the permission of matrons who enforced hygiene with an iron fist.

    Contrary to jb, from what I hear of the today’s health service from medical school tutors, students learn quite quickly to treat nurses poorly when they start their clinicals, even if they can barely fill in a prescription.

    And, I could tell you how clinical lecturers treat non-clinical staff in my college department, and the type of management that fosters…



    May 25, 2010 at 1:38 am

  3. this is exactly the question. we accept that negative, overly hierarchal cultures which lack respect for on the ground experience of nurses and common sense will end up resulting in higher costs and poor quality of care. the million dollar question is what you are trying to get at: how to change the culture? something tells me that an added layer of formalism won’t quite do the trick… physicians as an institution have been becoming “deinstitutionalized” for some time (i.e., Dick Scott et al 2000). Still, they maintain authority over reimbursement policy and definition of practice scope at the state level; more importantly, as you point out, their status still remains largely untouchable by the lay. Perhaps the start will be the increased role in primary care (as argued in the recent article in health affairs) and incentives aligned with outcomes. As far as I am concerned, the increased autonomy of advanced practice clinicians also wouldn’t hurt.


    sean mcclellan

    May 25, 2010 at 7:19 am

  4. “This attititude of extreme professional authority means that they resist all criticism and direction unless it comes from other physicians.”

    Their attitude is that only doctors can and should talk about health and medicine. Bullshit.

    “By shifting nurses from abused OR gophers to advisers and checklist enforcers, physicians can vastly improve safety outcomes.”

    Actually the model of the professional nurse is like this and beyond in some countries. The nurses I’ve talked to seem happy with it.



    May 25, 2010 at 1:54 pm

  5. As an operations management specialist who works in health care, I strongly agree with this post. Also, there is unintended irony at the end of jb’s comment, and it reveals something important about this topic. After talking about how different things are now – how much doctors respect nurses and what they do – jb ends, “Turning nurses into checklist-nags is not obviously something they would consider a promotion.” Pilots don’t call their co-pilots “nags.” Instead, they see the checklist as a collaborative process, and they treat each other as having similar levels of status. Jb’s last sentence betrays a misunderstanding of the role of a checklist – research has shown that it can be a fundamental part of a well-run health care process rather than a bureaucratic waste of time. The word “nag” indicates hierarchy, e.g., a nurse who would consistently check a doctor’s work is treated as an inferior. The word “promotion” reinforces the focus on status. I agree with jb that, with an antagonistic doctor, nurses would not welcome the role of checklist coordinator. But when doctors understand the importance of the activity (nurses already do – they develop numerous checklists for themselves), and when doctors treat the nurses as collaborators, then most nurses would welcome the innovation.


    rob s

    May 25, 2010 at 2:01 pm

  6. I tend to agree with Fabio and rob s.

    I recently read Atul Gawande’s “Checklist Manifesto” (see: ). While reading it, I got the distinct impression that the inclusion of checklists to manage not only complexity but fellow employees would be, as rob s states, “a fundamental part of a well-run health care process rather than a bureaucratic waste of time.”

    I would also like to frame my comments on Winthereik et al.’s piece on electronic patient records (or EPRs) (see: ). Winthereik and co. suggest that there is a broad understanding that accountability comes at the cost of autonomy, especially in the sort of workplace fabio describes. However, they find that as EPRs are phased into a hospital setting they promoted both autonomy and accountability, depending on how they were used.

    Moreover, there is a lively debate in STS about the role of “scripts” built-into technological devices. The idea is that technologies have built-into them a certain way of using them that designers intend. When we use a technology, we enact that script, provided we use it as intended. If the script is to restrictive or the object becomes of little use in a new setting then the user may in situ reconfigure the script. A good sociologist then wrote about how such shifts in design (i.e., when users are contributing to the the design of a product in use) blur the boundary but also constitute the shifting boundary between “who” is the designer and who is a user — sometimes they are the same, other times the boundary is enacted and issues jurisdiction are raised. The relationship between designers and users thus is dynamic and one way to understand that dynamism is through systems design.

    I imagine that checklists might be one way to understand the dynamic relation between physicians and nurses, which would highlight all sorts of issues raised above from the autonomy/accountability dynamic to the all the power relations that seem to have already been mentioned in a variety of ways. Additionally, checklists are flexible items imbued with multiple, sometimes contradictory scripts when enacted in everyday life in organizational settings such as hospitals.

    The real question, then, is “when is a checklist?” By this, of course, I am referring to Star and Ruhleder’s 1996 paper that asks “when” not “what” is an infrastructure. They frame the question this way because They rehearse the commonplace statement that technologies, of any sort, are not just objects with static characteristics. Instead, technologies are fundamentally relational. They state, “it becomes infrastructure in relation to organized practice.”

    So, when is and when isn’t a checklist?



    May 25, 2010 at 4:54 pm

  7. Actually,Fabio, a lot of what you propose already happens, just not openly. Stein (1967, Archives of General Psychiatry) (and Stein et al [1990, NE Journal of Med]) call it “the doctor nurse game”. Nurses are expected to help out docs and step in with suggestions, just doing so within the performance of deference. Some of ways this happens are pretty convoluted and funny, such as a nurse telling the patient each step of what’s about to happen before it happens (actually making sure the doctor completes each step. See also S. Gordon _Nursing Against the Odds_, Cornell U. Press, 2005.



    May 25, 2010 at 6:23 pm

  8. This is all very interesting!

    JB’s point about the “House of God’ is an interesting one. Does anyone know if there are any studies out there on its influence on hospitals? From the stories I’ve heard (in the UK and Australia) it’s had a profound impact on the language used in hospitals. Not sure if it’s had a similar impact in the US?



    May 25, 2010 at 11:40 pm

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