The Real World: Should I apologize to my nurse?

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“Apparently I offended a nurse the other day when she questioned my orders. Even though I overheard her badmouthing me to others, I’ve been asked to apologize. I feel she should apologize to me— after all I’m the doctor. What should I do?”
JB, California

Given all the obstacles to wade through during a shift in the average ER, it is not surprising that you will occasionally become testy. A good practice to have is to clean it up the mess as soon as possible. That means getting in communication and acknowledging to the other person that you are not committed to that style of communication. Because you’re not, right?
I hope you’re not because it doesn’t take too many negative encounters with nurses to be branded a jerk and then your shifts will become that much harder. Your ability to be an effective ER doc depends on your relationships with your teammates—nurses and clerks. They are your hands, eyes, and ears. If you offend them, they will do as little as possible for you. They can choose not to put in a good word for you when a patient or family member is less than satisfied. They can use language in a way that puts a big question about you in the mind of a patient. And that can cost you.
Consider giving up your position of being right. Think more strategically about your communications.  Ultimately it is about what is effective in the ER.
You may favor the command and control style of leadership, but if it has a disempowering impact on others…dispense with it. Teams can accomplish so much more than individuals and while the command and control style may work in a code, there is no evidence that it is the most effective style to use on a regular basis. This style and the resultant environment it creates may be the reason why patients wait so long in the ER.
For example, instead of a nurse setting up a suture tray with everything you need, prepping a wound, and then letting you know the patient is ready for stitches, they may just wait for you to do it all, complain about what a mess you made, and then ask you exactly how would like to them to dress the wound…and then, when you start to answer, tell you to write it down.
If you want to work in an effective ER environment, then you must help fully empower nurses and clerks. For the sake of efficiency, you want them to do as much problem solving as possible on their own. They will feel like the valued team members they are and enjoy their jobs more. And to make for a safer environment for patients, you want nurses and clerks to be thinking about what they are doing and why. Not just following your orders.
There are a number of practices you can adopt that empower nurses.
1. Use prn orders liberally.
2. Give a range of dosages for a nurse to choose from.
3. Post simple protocols so that nurses can start workups and give meds.
4. Be a teacher.
5. Acknowledge them frequently…and sincerely. 
For clerks, here a few simple practices:
1. Say, “when you get a chance, can you….”
2. Avoid pointing out what they didn’t do right.
3. If a communication is missed, take responsibility for causing it. Imagine creating an environment in which people took responsibility for what didn’t work, instead of pointing fingers at others.
4. Acknowledge them frequently…and sincerely.

Let’s say a nurse has a practice of coming to you and saying, “My patient is vomiting” and then standing there waiting for you to come up with a solution—a solution that may or may not be the one desired or most appropriate. What then often ensues is an exchange of information about what the patient wants, what worked in the past, what the patient is allergic to or had a reaction to in the past, what medication you want to give, how much you want to give, and what route.


You can do a number of things to streamline this conversation and make things easier both for you and the nurse. In the above example, wouldn’t it be better if the nurse came to you and just said, “Can I give my patient 4 mg of Zofran IV?” to which you just say, “Good idea.” To get to this point, just make it a practice to ask them what they would like to do. And then when they tell you, heartily agree.
Eventually, people will come to you to report solutions, not present problems. And then not only will they be happier, but so will you and your patients…and your ER will be a step more effective.
So should you apologize? Yes.
John Frey, MD is the author of Secret Ingredients of the Ultimate ER (about an ER team with a waiting list for nurses and press ganey scores of 97%) and the developer of the SmartNotes documentation system.

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