Can nurses communicate direct I y with physicians? A critical care nurse was describing what she does in caring for acutely ill patients. She re- lated how she observed the patient, assessed his condition, provided nursing care, and then evaluated that care. She emphasized these activities represented a cycle of care based on knowledge and judgment.

Then she explained how she communicated with the physician. “I can tell him what the vital signs are - the blood pressure, respira- tion, pulse, and skin condition and color-but I don’t say, ‘The patient is in shock.’ ”

She gave another example. A resident wanted to prescribe a diuretic for a patient who was in critical condition. She asked him, “Do you know what the patient’s potassium is?” She explained that she would not say outright, “The patient has a low potassium.” The admin- istration of the diuretic would have put the pa- tient in serious jeopardy, yet the nurse did not feel that she could say this directly. Fortunately for the patient, the resident was able to calcu- late all this and prescribe another medication.

This critical care nurse was testifying as a witness for the plaintiffs in the suit nurses employed by Denver brought against the City and County of Denver.’ The nurses were trying to show that nurses’ pay should be compara- ble to that of other professional and adminis- trative groups. The critical care nurse’s tes- timony was to demonstrate the importance of her job and the knowledge and judgment it required. For these patients in crisis, it was clear that her abilities were critical to their well-being.

Editorial 1 U

Yet, at the same time, she was saying she did not believe she could communicate directly with the physician. After I left the courtroom and attempted to sort out all the testimony I had heard, I found myself thinking about what she had said. The incidents she related were classic examples of the doctor-nurse game. Is this doctor-nurse game still a predominant method of communication? Is it necessary? Who perpetuates it? Do physicians demand it, or are nurses continuing to play it?

These questions seemed relative to the arti- cles we were editing for this issue on self- assertion. To a large extent, self-assertion is an effective method of communication. In her article, Pamela E Butler defines assertion as the ability to express feelings and opinions unhindered by anxiety or embarrassment. She discusses the difficulty women experience in expressing themselves directly and honestly. M Dianne Elliott takes Butler’s theories and applies them to uncomfortable OR situations you will probably find familiar. Both articles should help OR nurses gain insight into their own ways of handling difficult interpersonal situations.

The testimony of the critical care nurse dramatizes that nurses need to examine their methods of communication. Perhaps they are having difficulty in even transmitting informa- tion in a straightforward manner.

At one time, nurses were taught in school to use indirect strategies in communicating with physicians. For example, after observing a pa- tient’s blood-soaked dressings, they were in- structed to write in the chart a statement such as “The patient appears to be bleeding.” But in the last 15 years, nurses have learned to use nursing diagnosis-making observations, drawing conclusions, and, I would hope, stat- ing them. I trust nursing educators have aban-

AORN Journal, August 1978, Vol28, N o 2 193

doned the policy of teaching nursing students to communicate with physicians in an indirect, oblique manner. Please let me know if I am wrong.

This kind of dialogue perpetuates the nurse’s subordinate role to the physician. If nurses want to be considered colleagues and recognized as professionals, they should take the first steps in stopping the game. They can start by communicating with medical students and interns, who are not already accustomed to doctor-nurse games, in a direct manner with factual statements. This could help to develop nurses’ confidence in their own knowledge and skills.

I would be interested in hearing from you about how you see this problem. How do you communicate with physicians? Directly or indi- rectly? Do you get different reactions from older physicians and younger physicians? Are medical students and interns, who may be less sure of themselves, more or less receptive to direct communication? Traditional social pat- terns are changing. Is this reflected in nurse- physician communication?

I think it takes two to play a game, and if nurses stop playing, there won’t be a game. What do you think? I would be interested in hearing from nurses and physicians alike.

rn Regular readers of the AORN Journal will note the addition of a new feature column this month. This new column, entitled “Test your knowledge,” has been added to assist you in assessing your knowledge of a specific area of operating room practice. Each month the column will address some aspect of OR nursing-technique, procedure, nursing pro- cess, or interpersonal relationships within the OR environment. Material for this feature will be contributed by members of the Editorial Committee.

Elinor S Schrader Editor

Notes 1. Elinor S Schrader, “Denver nurses lose dis-

crimination suit against city,”AORNJourna/28 (July 1978) 13-14.

How to sponsor public smoking laws Do you want to sponsor an ordinance curbing smoking in public places in your neighborhood?

Be factual and objective in gathering and organizing your testimony on behalf of a proposed clean air act, and do not criticize either tobacco smokers or their habit. Some of the members of the city council are probably smokers and will not appreciate your criticism, says Geoffrey E Greene, MD, in the May 19 Journal of the American Medical Association.

In describing experiences in seeking such an ordinance in Howard County, Md, Dr Greene pointed out, “It was useful to stress that although smokers have the right to smoke, the right of the nonsmoking majority to breathe comfortably should take precedence. It was unnecessary to discuss the harmful effects of smoking on the smoker, as those facts are not germane to the issue of the health rights of nonsmokers.”

Physicians should testify as to the health effects of smoking, but laymen also should be included in the presentation, Dr Greene adds. Tobacco smoke presents health problems to allergic and asthmatic people, infants and children, people with chronic heart or lung disease, and contact-lens wearers, he says.

In describing testimony given at the Howard County hearing, Dr Greene reported that ”the council, although appreciative of well-prepared medical and scientific facts, listened even more attentively and sympathetically to lay citizens who described the illnesses and discomforts they suffered when exposed to sidestream tobacco smoke.” Dr Greene points out that the proportion of adults who smoke had decreased to 34% in 1975 and says that “recently the nonsmoking majority has been asserting its right to breathe smoke-free air. This has resulted in numerous laws to restrict smoking in public places.”

The percentage of physicians, dentists, and pharmacists who smoke has also decreased.

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