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    Nurse physician relationship articles Nurse physician relationship articles Document Transcript

    • November-December 2012 • Vol. 21/No. 6 343 Sherita Johnson, MSN, RN, is Staff Nurse, Coronary Care Unit, Forsyth Medical Center, Winston-Salem, NC. Daria Kring, PhD, RN, is Director, Nursing Research, Forsyth Medical Center, Winston-Salem, NC. Nurses’ Perceptions of Nurse-Physician Relationships: Medical-Surgical vs. Intensive Care Sherita Johnson Daria Kring “C ollaboration has been described as a process that allows the inter- action of colleagues within a flat hierarchy to make deci- sions both independently and as part of a team” (Burchell, Thomas, & Smith, as cited in Taylor-Seehafer, 1998, p. 387). It is a complex process that requires intentional knowledge sharing and joint responsibility for patient care. “Interprofessional col- laboration refers to collaboration of two or more professionals working jointly toward mutual goals with shared responsibility” (Johanson, 2008, p. 29). In the current, complex health care environment, the collaboration of professionals affected by complex health care issues warrants attention as a strategy for the problem-solving team (Stein-Parbury & Liaschenko, 2007). Collaboration between nurses and physicians is essential in facili- tating improved patient care out- comes and patient care satisfaction. The benefits of effective nurse/physi- cian relationships include decreased cost, better patient care, and decreased patient morbidity and mortality (Nelson, King, & Brodine, 2008). Additional benefits are improved communication among health care workers, improved effi- ciency, improved understanding of the nursing role, and decreased patient length of stay (Dailey, Loeb, & Peterman, 2007). Implications Historically, the doctor-nurse rela- tionship has been an unequal one characterized by the dominance of the doctor, with the nurse assuming a position of lower status and depend- ence on the physician (Qolhole, Research for PracticeResearch for Practice Effective collaboration between nurses and physicians (RN-MD) is essential in facilitating improved patient care outcomes. A pilot study was conducted among nurses on medical-surgical and inten- sive care units to identify differences in nurses’ perceptions of RN- MD collaborative efforts. Introduction Collaboration between nurses and physicians is essential in fostering interdisci- plinary relationships. Specialty practice may influence the quality of this collabora- tion. Effective communication and collegial RN-MD relationships are critical to improved patient outcomes. Purpose The purpose of this study was to identify differences in nurses’ perceptions of collaborative efforts between nurses and physicians in medical-surgical (MSUs) units versus intensive care units (ICUs). Results A descriptive survey methodology was employed. Nurses in three ICUs and eight MSUs within a 975-bed Magnet® hospital completed a 25-item Nurse- Physician Relationship survey, used in previous studies on RN-MD communication. The sample (N=170) consisted of 54% medical-surgical nurses and 46% ICU nurses. No statistically significant differences were found in the demographic vari- ables between the MSU and ICU nurses except for educational degree. A greater percentage of ICU nurses held a bachelor’s degree. This study found that although some differences existed in ICU and MSU nurses’ perceptions of RN-MD collabo- ration, there are more similarities between the two areas. Overall, nurses were sat- isfied with RN-MD relationships, with 75% of ICU and 65% of MSU nurses report- ing satisfaction (p=0.110). MSU nurses were less likely to participate in interdisci- plinary rounds than ICU nurses (p<0.001). ICU nurses were more likely than MSU nurses to report that physicians treat nurses as handmaidens (p=0.056) and that physicians displayed unprofessional behavior (p=0.019). Conclusions Certain nursing specialty areas are not immune to problems with RN-MD rela- tionships. Rather, all clinical service lines should be concerned with fostering colle- giality between nurses and their physician partners.
    • November-December 2012 • Vol. 21/No. 6344 Conradie, Ogunbanjo, & Malete, 2006). Nurses who work closely with physicians and participate in shared decision making experience less burnout and decreased turnover. Conversely, disruptive physician behavior has been cited as a contribu- tor to the nursing shortage (Nelson et al., 2008). However, additional research cites the benefits of mutual respect and collaboration (Dailey et al., 2007). A great deal of progress remains to be made. A study by Sirota (2008) found 43% of nurses were dissatis- fied with their overall relationships with physicians and 68% doubted physicians understood nursing responsibilities. Respondents in this study indicated a belief physicians are more likely to respect and appre- ciate nurses’ knowledge and skills when they work closely with nurses and get to know them. Interestingly, over 57% indicated they had better working relationships with younger physicians than older ones. Although evidence supports col- laborative nurse/physician relation- ships, true partnership rarely exists in acute care facilities. Power dis- tance and ineffective communica- tion remain huge barriers to achiev- ing collaboration. Factors contribut- ing to ineffective collaboration must be identified if real progress is to be made. One factor yet to be explored is clinical specialty. Different special- ties often require different levels of interaction between nurses and physicians (Sirota, 2008). Intensive care unit (ICU) nurses have limited patient assignments due to high acuity and often work closely with one or two intensivists. Medical-surgical nurses often care for more patients and have shorter interactions with many different physicians. These two specialties may experience differences in the level of nurse/physician collabora- tions (Sirota, 2008). Understanding these possible differences may assist nurses and physicians to focus efforts on collaboration and team- work according to specialty area. The purpose of this study was to explore perceived nurse/physician collabora- tion between ICU and medical-surgi- cal nurses. Methods A quasi-experimental design was used to measure the perceptions of nurse-physician collaboration with- in a convenience sample of nurses working either in an intensive care unit or medical-surgical setting. This study was conducted in an urban 975-bed hospital in the southeast region of the United States. The study population consisted of regis- tered nurses who work on eight medical-surgical units and three intensive care units randomly select- ed to participate. To participate in this study, ICUs had to contain at least eight beds and medical-surgical units contained at least 12 beds. Prior to data collection, the study was approved by the hospital’s insti- tutional review board and the nurs- ing research council. A convenience sample of all nurses working in those units were invited to participate in the study. Potential nurse partici- pants had to meet the following requirements: employment on a medical-surgical unit or intensive care unit for at least 6 months, and work at least one 8-hour shift per week. Nurses were informed about the study in writing, and face-to-face data collection sessions were con- ducted with the principal investiga- tor. Light refreshments were served during the data collection sessions. No incentives for participating were offered. Return of the surveys served as implied consent. No identifying information, such as name, employ- ee identification number, or date of birth, was collected. All surveys were kept in a locked cabinet in the office of nursing research. Computer files were password protected. Instrument A 25-item survey used by Sirota (2007) which uses a varying response scale (Likert response as well as “yes/no” response) was selected to collect information regarding nurse/ physician collaboration. Computer files were password protected. Per- mission was obtained to use Lippincott Williams & Wilkins Nurse- Physician Relationships Survey Tool. Questions for this tool, which has been used in national studies regard- ing nurse-physician relationships, were similar to those posted in a nurse-physician survey that drew 1,100 respondents in 1990 and near- ly 900 in 2007 (Sirota, 2008). The sur- vey evaluates collaborative efforts between nurses and physicians, pro- fessionalism and disruptive behavior, and managerial and administrative support. Sample questions include, “Do you think physicians under- stand the nursing profession and your role as a nurse?” “Do physicians speak to you in an unprofessional tone?” “Do nurses routinely make rounds with physicians?” Data Collection A trained research nurse adminis- tered the surveys and ensured requirements for participation were enforced strictly. Recruitment fliers were posted on the selected units and nurses were notified 2 weeks prior to the study initiation that a nurse researcher would be conduct- ing information data collection ses- sions in the unit. Participants had 1 week to complete the survey. Results The sample was analyzed by descriptive statistics (SPSS 16). The t- test was used to compare means, and findings with a p value less than 0.05 were deemed statistically significant. Study participants included 170 nurs- es, with 54% (n=89) of respondents being medical-surgical nurses and 46% (n=77) ICU nurses. Approxi- mately half the participants held a bachelor’s degree in nursing (n=83), had 5 or less years of nursing experi- ence (n=80), and worked day shift (n=85). Most participants were direct-care nurses (n=138, 86%) and worked full time (n=151, 93%). No statistically significant differences existed in the demographic variables between the medical-surgical and intensive care nurses except for edu- cational degree. A greater percentage of ICU nurses held a bachelor’s degree compared to the medical-sur- gical nurses (p=0.015) (see Table 1). Each of the items on the survey was Research for Practice
    • November-December 2012 • Vol. 21/No. 6 345 Nurses’ Perceptions of Nurse-Physician Relationships: Medical-Surgical vs. Intensive Care analyzed collectively, as well as according to work area (ICU or med- ical-surgical) (see Table 2). Of the 21 questions with defined response sets, only three showed a statistically sig- nificant difference between the groups (p≤0.05). In general, nurses were satisfied with RN-MD relationships. As many as 75% (n=74) of ICU nurses and 65% (n=84) of medical-surgical nurs- es reported satisfaction with the nurse-physician relationships. In addition, 78% (n=87) of medical-sur- gical nurses and 76% (n=75) of ICU nurses believed physicians respected nurses’ decisions. However, one par- ticipant stated, “Most physicians are professional, but a few are rude and disrespectful.” Another participant noted, “Overall, I am satisfied with nurse-physician relationships; on the contrary, some physicians are hateful and don’t return pages.” While both ICU and medical-sur- gical nurses indicated they had wit- nessed disruptive behavior by physi- cians (57%, n=94), only a minority noted they had reported disruptive behavior (26%, n=43). ICU nurses were more likely to report physicians displayed unprofessional behavior than their medical-surgical counter- parts (p=0.019); 80% (n=41) of ICU nurses reported unprofessional phy- sician behavior compared to 58% (n=50) of medical-surgical nurses. Similarly, ICU nurses were more like- ly than medical-surgical nurses to report physicians treat nurses as handmaidens (p=0.056). One partic- ipant stated, “Some physicians won’t listen to what I say, but will give orders in an exasperated tone.” Another participant commented, “Some physicians don’t take the time to listen to what we are asking or listen to our concerns.” A statistically significant differ- ence was detected between ICU and medical-surgical nurses regarding interdisciplinary rounds, with 75% (n=71) of intensive care nurses and 33% (n=80) of medical-surgical nurs- es reporting they participate in inter- disciplinary rounds with physicians (p<0.001). One participant indicated she needed to make a greater attempt to talk with physicians during inter- disciplinary rounds. Another partici- pant stated physicians do not include nurses in the patient’s plan of care. Only 53% (n=80) of nurses at the study hospital reported they partici- pate in interdisciplinary rounds. Regardless of whether nurses were satisfied with their RN-MD relation- ships, very few ICU and medical-sur- gical nurses reported having collegial relationships with their physician counterparts (32%, n=51). One par- ticipant stated, “I think it depends on the nurse and the physician and how much knowledge the nurse displays regarding the patient.” Another participant suggested colle- giality varies according to the physi- cian service line. A majority 62% (n=100) of the nurses perceived they were subordi- nate to physicians. In addition, about half the respondents perceived physi- cians do not really understand what nurses do. Interestingly, half the respondents reported having a better relationship with younger physi- cians. How nurses and physicians addressed each other also may con- tribute to perceptions of collegiality. The majority of nurses 62% (n=97) reported physicians addressed nurses by their first names. However, nurses almost never 2% (n=160) addressed physicians by their first names. Discussion This study found that although TABLE 1. Demographic Information Medical-Surgical ICU Total Job Title (p=0.152) Staff RN 83% 89% 86% Team leader 1% 0 1% Advanced practice nurse 0 1% 0.6% Charge nurse 10% 9% 9% Nurse manager 5% 0 3% Employment (p=0.144) Part time 2% 9% 6% Full time 95% 89% 93% PRN 2% 1% 2% Shift (p=0.418) 7 a.m. – 7 p.m. 49% 56% 53% 7 p.m. – 7 a.m. 44% 42% 44% 7 a.m. – 3 p.m. 1% 0 0.6% Other 5% 1% 3% Education (p=0.015) Diploma 16% 3% 10% Associate’s Degree 34% 28% 32% Bachelor’s Degree 43% 61% 51% Master’s Degree 7% 8% 7% Experience (p=0.099) 6 months-2 years 22% 36% 28% 3-5 years 17% 25% 21% 6-10 years 21% 12% 17% 11-15 years 11% 8% 10% More than 15 years 26% 20% 24% Note: p value is statistically significant if p<0.05.
    • November-December 2012 • Vol. 21/No. 6346 some differences exist between ICU and medical-surgical nurses’ percep- tions of RN-MD collaboration, in general there are more similarities. Overall, nurses were satisfied with RN-MD relationships. Nevertheless, both ICU and medical-surgical nurs- es had witnessed disruptive behavior by physicians. Surprisingly, only a small minority of nurses had report- ed disruptive behavior. Nurses may not be aware of processes in place for dealing with disruptive physician behavior, or they may not believe the process is effective. Additionally, nurses may not know how to use their chain of command effectively, or they may feel uncomfortable ini- tiating the process. ICU nurses were more likely to report disruptive behavior by physi- cians than were medical-surgical nurses, and ICU nurses were more likely to perceive physicians treated them as handmaidens. This finding was worthy of note, particularly because 75% (n=71) of ICU nurses participated in interdisciplinary rounds with physicians. Perhaps medical-surgical nurses have a more distant relationship with their physi- cian colleagues and are less invested in the quality of that relationship. Medical-surgical nurses may be unable to participate in interdiscipli- nary rounds due to their patient care assignments and higher nurse-to- patient ratios. In this study, some nurses stated physicians do not understand the role of a nurse. This may explain why some nurses, particularly ICU nurses, perceived they were treated as handmaidens. As for collegiality, most nurses perceived they were sub- ordinate to physicians and very few nurses reported having collegial rela- tionships with their physician coun- terparts. A possible influence on this perception is the belief by a majority of nurse respondents that physicians do not understand the significance of a nurse’s job role and responsibility. A great deal of work remains to promote and facilitate better colle- gial relationships between nurses and physicians. One way to establish collegiality between nurses and physicians is to facilitate a mentor- ing relationship. For instance, nurses and physicians could follow each other to get a better understanding of the other’s role and responsibili- ties. Participating in joint activities is another way to promote collegial relationships. For example, quarterly luncheons or an annual field day between nurses and physicians may facilitate teamwork and relationship building. Nurses and physicians need posi- tive, respectful relationships to ensure quality patient care. In- creasing opportunities for nurses and physicians to interact with each other also increases the likelihood of developing collaborative, interactive relationships. Likewise, nurses and Research for Practice TABLE 2. Lippincott Williams & Wilkins Nurse-Physician Relationships Survey by Nursing Unit Question Medical-Surgical ICU Total p Nurses are satisfied with professional relationships. 65% 75% 70% 0.110 Physicians understand what nurses do. 50% 57% 54% 0.701 Physicians respect nurses’ decisions. 78% 76% 77 0.550 Nurses have better relationships with younger MDs. 50% 50% 51% 0.561 Physicians address nurses by first name. 60% 64% 62% 0.465 Nurses address physicians by first name. 3% 1% 2% 0.358 Nurses perceive they are subordinate to physicians. 62% 61% 62% 0.963 Nurses have a collegial relationship with physicians. 30% 32% 32% 0.963 Nurses make rounds with physicians. 25% 34% 30% 0.330 Nurses have seen disruptive behavior by physicians. 56% 57% 57% 0.513 Nurses are aware of process for disruptive behavior. 88% 78% 84% 0.231 Nurses report disruptive physician behavior. 31% 19% 26% 0.140 Physicians display unprofessional behavior. 58% 80% 68% 0.019* Physicians don’t understand the nurses’ role. 34% 51% 42% 0.074 Physicians don’t listen to nurses about patients. 42% 48% 42% 0.332 Physicians don’t communicate with nurses. 54% 43% 50% 0.227 Physicians treat nurses like handmaidens. 21% 39% 30% 0.056 Nurses participate in team conferences. 25% 32% 29% 0.189 Nurses participate in interdisciplinary rounds. 33% 75% 53% 0.000* Nurses use practice protocols. 33% 42% 38% 0.182 Nurses use communication tools, like SBAR. 91% 84% 88% 0.161 * p value <0.05
    • November-December 2012 • Vol. 21/No. 6 347 physicians must engage with each other away from the bedside. With increased exposure comes the associ- ation of names with faces rather than just room numbers with scrub colors (Dailey et al., 2007). Concerning interdisciplinary rounds, although unforeseen cir- cumstances can occur, having rounds on specific days and times can help ensure members of each discipline can be available. This would be very helpful on medical- surgical units, where only 33% (n=80) of nurses reported participa- tion in interdisciplinary rounds with physicians. Moreover, nurses would have a better understanding of the patient’s medical plan of care and physicians could discuss aspects of patient care with nurses. One interesting finding in this study was more ICU nurses held a bachelor’s degree (61%, n=76) com- pared to medical-surgical nurses (43%, n=87). Within the study set- ting, 40% (n=788) of staff nurses held a bachelor’s degree in nursing. According to the North Carolina Board of Nursing (2010), 32% of nurses in the state have a bachelor’s degree. The ICU nurses in this study not only had more education than their medical-surgical colleagues, but also more than many nurses in the state. This educational differ- ence may have contributed to a greater desire by ICU nurses to be equals with their physician col- leagues; they may have been more concerned when they were treated disrespectfully, or felt less appreciat- ed for what they contributed to patient plans of care. Future Research A great deal of research still is needed on the topic of RN and MD collegiality. This study should be replicated in other settings with greater numbers of nurses. While this study was undertaken using an established survey for understanding RN-MD relationships, it was not based on a conceptual model of these relationships. Thus, the instru- ment’s questions only could be ana- lyzed individually. Creating an instrument built on subscales of the concept of RN-MD collegiality would provide researchers with a stronger tool. Such an instrument would allow creation of a conceptu- al framework delineating antecedent and causal relationships impacting collegiality, as well as testing of inter- ventions to improve collegial rela- tionships. How nurses and physicians ad- dress each other needs to be ex- plored. Using last names to address colleagues is a sign of formality and respect, whereas using first names among colleagues is a sign of famil- iarity and comfort. However, a mis- matched form of address often sig- nals power distance and inequality (Hofstede, Hofstede, & Minkov, 2010). This mismatch often is seen with children and adults, students and teachers, and as evidenced here, nurses and physicians. Using first names may be a future development as collegial relationships mature, or it may be that using first names at the onset of a relationship fosters collegiality more quickly. Given many of the findings of concern in this study, it is interesting that nurses are satisfied with RN-MD relationships overall. This result is quite encouraging and provides a firm foundation for making further improvements. It may be that a few disruptive physicians drive the nega- tive perceptions held by some nurses toward their physician colleagues. Because the study site was a Magnet- designated hospital, these results may be higher than what might be seen at non-Magnet hospitals, as one of the Forces of Magnetism is posi- tive interdisciplinary relationships (American Nurses Credentialing Center, 2008). Conclusion Faulty communication between nurses and physicians can affect patient outcomes adversely. Nurses promote patient safety in part by communicating with physicians (Monojlovich, Antonakos, & Ronis, 2009). Effective collaborative efforts and clear communication improves the quality of patient care in the work environment (Nelson et al., 2008). Poor communication between physicians and nurses leads to mis- understandings, errors, and ongoing conflict between nurses and physi- cians (Sirota, 2007). Ultimately, qual- ity patient care is jeopardized. For these reasons, collaborative efforts and positive relationships between physicians and nurses must be assessed and improved continuously. This study found certain nursing spe- cialty areas are not immune to prob- lems with RN-MD relationships. Rather, all clinical service lines should be concerned with fostering collegiality between nurses and their physician partners. REFERENCES American Nurses Credentialing Center. (2008). Magnet recognition program application manual. Silver Springs, MD: Author. Dailey, M.S., Loeb, B.B., & Peterman, C. (2007). Communication, collaboration, and critical thinking quality outcomes. Patient Safety and Quality Healthcare, 4(6), 22-30. Hofstede, G., Hofstede, G.H., & Minkov, M. (2010). Cultures and organizations: Software of the mind (3rd ed.). New York, NY: McGraw-Hill. Johanson, L.S. (2008). Interprofessional col- laboration: Nurses on the team. MED- SURG Nursing, 17(2), 29. Monojlovich, M., Antonakos, C., & Ronis, D. (2009). Intensive care units: Com- munication between nurses and physi- cians, and patients’ care outcomes. American Journal of Critical Care Nurses, 18(1), 21-33. Nelson, G.A, King, M.L., & Brodine, S. (2008). Nurse-physician collaboration on med- ical-surgical units. MEDSURG Nursing, 17(1), 35-40. North Carolina Board of Nursing. (2010). Currently licensed RNs, 2010 [Data File]. Raleigh, NC: Author. Qolhole, M., Conradie, H., Ogunbanjo, G., & Malete, N. (2006). A qualitative study on the relationship between doctors and nurs- es offering primary health at KwaNobuhle (Uitenhage). South African Academy of Family Practice, 48(1), 17a-17d. Sirota, T. (2008). Nurse/physician relationships survey report. Nursing2008, 38(7), 28-31. Sirota, T. (2007). Nurse physician relation- ships: Improving or not. Nursing2007, 37(1), 52-55. Stein-Parbury, L., & Liaschenko, J. (2007). Understanding collaboration between nurses and physicians as knowledge at work. American Journal of Critical Care, 16(5), 470-477. Taylor-Seehafer, M. (1998). Nurse-physician collaboration. Journal of the American Academy of Nurse Practitioners, 10(9), 387-391. Nurses’ Perceptions of Nurse-Physician Relationships: Medical-Surgical vs. Intensive Care