ConflictAmong and Between Doctors, Nurses, and Residents

Communication scholars often study health communication in the context of conflict among or between doctors and nurses. The sources of conflict are similar to those dis­cussed above, such as status inequities, com­peting discourses, and ambiguity; yet the level of interdependence required makes it even more challenging for these health care providers to balance competing tensions of autonomy and connection.

Status Inequity and Role Ambiguity. As described above, doctors and nurses often find themselves in situations where status distinc­tions are ambiguous. Apker, Propp, and Ford (2005) found that even though nurses are typi­cally seen as subordinate in their communica­tion with doctors, they are the de facto leaders in patient care teams with patient care assis­tants. In these team settings, nurses are given higher status compared with other team mem­bers, while they are expected to act as equals. Similar to the experiences of nurses in teams with doctors, patient care assistants reported that nurses delegated tasks that they could often do themselves and did not communicate with them as peers, causing them to feel devalued.

Nurses commonly experience role ambigu­ity in that they are expected to be nurturing and supportive but are also relied on to be patient advocates and keepers of the rules. Apker et al. (2005) found that nurses needed to distance themselves from their patients to be perceived as legitimate by doctors while simultaneously feeling pressured to make eye contact, listen with empathy, and show con­cern for patients. Similarly, Gardezi et al. (2009) found that operating room nurses experienced role conflict in their performance of the preoperative checklist. Using a checklist met the nurses’ needs to enforce the rules, yet it contradicted their role as supporting the surgeon and challenged the doctor’s authority.

Role ambiguity has also been found to create conflict in doctor-resident interaction. Atkinson (1999) found that medical students in the United States and the United Kingdom wanted to be seen as knowledgeable and be treated as equals by doctors but were chal­lenged when the doctor asked questions and even quizzed the medical students in front of patients. Atkinson pointed out that this conflict is exacerbated by the fact that doctors typically spend less time with the patient than other providers do, yet they are ultimately held accountable for patient care (e.g., physi­cians are most likely to be named in medical malpractice lawsuits because they have the greatest financial capacity to offer monetary damages). This contradiction between the amount of time spent with patients and ulti­mate responsibility for their care also creates a tension between autonomy and connection in interactions between doctors and nurses.

Tensions Between Autonomy and Connection. The practice of providing anesthetics in much of the United States provides another exam­ple of a structure in which providers feel compelled to protect their autonomy and status while simultaneously relying on the other. The typical model is that one anes­thesiologist supervises two to four patients simultaneously, while the certified registered nurse anesthetist (CRNA) remains with the same patient throughout a surgical procedure (Jameson, 2004).

Competing Discourses. As was found in doc­tor-patient communication, conflict among nurses, administrators, and other health care providers is also caused or exacerbated by differ­ent expectations. Nicotera, Mahon, and Zhao (2010) described a phenomenon they called “structurational divergence” that occurred when nurses were unable to prioritize one set of rules over another. Nicotera et al. (2010) pro­vided an example of structurational divergence in a hospital geriatric care unit. In this case, the relational leadership style of the unit director and the task leadership style of the assistant director created a contradiction that made it dif­ficult to coordinate even mundane tasks such as scheduling. While the director needed the assis­tant director to take a task-focused approach to balance her relational style, the nurses resented what they perceived to be the assistant director’s autocratic leadership. When nurses complained to the director, she expected them to be able to work it out collaboratively and referred them back to the assistant director. This situation led to continued frustration among the nursing staff, low morale, and high turnover. This is an example of a negative spiral caused by structur- ational divergence that could only be resolved by creating a new discourse that merged the task and relational leadership styles rather than seeing them as competing.