The man on the examination table had a recurrent hip dislocation, and the orthopedist wanted to perform a procedure in the X-ray department. The patient insisted he wanted it done in the operating room under anesthesia, even though the physician said he'd administer a muscle relaxer and pain medication.

Tom Trimble, RN, an emergency room nurse for 16 years at the University of California, San Francisco Medical Center, told the physician that the procedure couldn't be done without the patient's consent.

"I don't want to argue about this," the physician said.

Trimble didn't want to argue either, but he firmly told the physician that he'd have to talk with the administrator and the medical director, because the patient refused to give his consent. After Trimble's intervention, the patient had the procedure under anesthesia.

It's not easy for nurses to disagree with a physician, yet most nurses at some time end up in a situation similar to Trimble's. One of the most stressful workplace situations for nurses arises when they have to confront a physician, co-worker or even a patient, and conflict is something many nurses don't like.

"Conflict avoidant" is the term Phyllis Beck Kritek, Ph.D., RN, FAAN, uses for her fellow nurses.

"Nurses tend to want to smooth over a conflict-we're known for that," Kritek said. "But that doesn't solve it."

Kritek, a professor of nursing at Virginia Commonwealth University, travels the United States giving conflict resolution seminars for nurses. She's written a book, Negotiating at an Uneven Table: Developing Moral Courage in Resolving Our Conflicts, to bring conflict resolution skills to people who don't share the same power as the other negotiators. Traditionally, nurses are treated like second-class citizens, with physicians and administrators holding the upper hand, Kritek said.

Most workplace conflicts revolve around quality care issues, she said, not the nurses' own working conditions, as many people assume. Yet speaking out-even on behalf of patients-can be difficult.

"It feels dangerous to speak out," Kritek said. "Should they speak out, they may feel in jeopardy without hope of making a significant change."

It doesn't have to be that way. Nurses have exceptional communication skills, she said, and they make great conflict resolution negotiators. But this skill isn't taught in nursing school.

Practice run

That shortcoming hit home with Shelly Malin, Ph.D., RN, when she recently conducted a focus group with nurse residents at Children's Hospital of Wisconsin, where she is director of practice. In June, the hospital started a 12-month pilot residency program for pediatric nurses that has four participants.

After their first month at the hospital, Malin asked the nurses about their interactions with the physicians. She wanted to know if their experiences were different from what they thought they would be or from their student experiences. When the nurses told her how few opportunities they had had to interact with physicians during their schooling, she realized the new residency program would have to work on building the physician-nurse relationship.

"You have contact with physicians maybe three times in school. Then we expect you to come into a really complex health system and advocate for your patients," Malin said.

Through the nurse residency program, the hospital is trying to integrate training of medical residents and nursing residents to foster greater collaboration. The nurses are joining medical residents on rounds, and Malin would like to have a nursing professor team with a medical school professor for joint case study lectures.

The collaboration between nurses and physicians is so important; it affects mortality rates, she said, but this relationship needs improvement on both sides. Nurses have to find out about the system they are working in and learn where they can go with conflicts they can't solve directly.

"It would be awful for a nurse to think there's no place to turn," Malin said. "There usually is a place to go. You have to know where it is."

When Malin encountered conflicts during her own career, it helped to remember that she was speaking out for the patient.

"If a patient had a need, I'd never hesitate," she said. "It's not something I was doing for me."

Sometimes, it can be the patient who's at the root of a conflict.

"In emergency departments, this happens all the time and is a hallmark of our flexibility that at one moment we are confronting a loud and belligerent intoxicated sociopath, and the next moment be consoling a child or frail elder and deflecting questions about an incident," said Trimble, the independent publisher of Emergency Nursing World! [www.enw.org], a nonprofit Web site not associated with UCSF, and Em-Nsg-L [www.enw.org/Em-Nsg-L.htm], an Internet discussion list.

Often, an ER nurse has to set limits on behaviors for patients or family members in emotionally charged situations, he said, so offering to buy a stressed family member a cup of coffee or suggesting they go outside for fresh air can deflect a tense situation.

"I've been fired by patients,' said Alan Redick, RN, a nurse at Contra Costa Regional Medical Center in Martinez, Calif.

Redick believes patients should have the right to "fire" a nurse by asking for a different RN to be assigned to them. When a patient cringes every time you walk into a room, Redick said, you can't be useful.

In those cases, it's better to let someone else work with that person. That hasn't happened often to Redick, who has been a preceptor for most of the 20 years he's worked at the county hospital.

When students come into the hospital, they are so worried about getting procedures correct and not making mistakes that they don't think much about co-worker relationships. But they have to learn their place with the physicians and the patients, Redick said. He has trained many of the RNs now on staff at the hospital and said he believes his longevity earns him respect.

"I like to think I'm a barometer of behavior," he said. "You have to maintain an even keel. It's very difficult to work here alone. You have to work as a team."

When conflicts arise with team members, Redick advises new nurses to try to work it out one-on-one. But he also lets them know he is there as a resource.

"Most people try to do things by themselves," he said. "But you can't do this job by yourself."

Every culture is different, and experienced nurses say the best advice is to find a work environment where physicians and administrators want nurses to speak up and advocate for their patients.

No one expects a nurse to develop that sense of self-confidence immediately. Kay McVay, RN, president of the California Nurses Association, said that she was halfway into her 40-year career before she learned to speak up with confidence. It takes a lot of courage for nurses to do that, she said.

"We were brought up in an age where women weren't suppose to question anything," she said about the nurses of her generation. "It's amazing that it's us (veteran nurses) who have learned to question. If you don't speak up, your patient is going to suffer."

Contact Donna Hemmila at dhemmila@prodigy.net.