This document discusses strategies for enhancing nurse-physician collaboration. It defines collaboration as nurses and physicians working cooperatively together to solve problems and make care decisions, rather than competing or asserting power over one another. The benefits of collaboration include improved patient and staff outcomes. Key aspects of collaboration include effective communication, managing disruptive behaviors, and developing competence and confidence. Communication tools like SBAR are recommended to structure nurse-physician discussions. Addressing disruptive behaviors respectfully by focusing on facts and impacts is advised. With practice over time using strategies like these, nurses can develop skills to confidently enhance collaboration.

1. Enhancing Nurse-Physician
Collaboration
An Evidenced-Based Project
By Barbara Malebranche, RN, BSN

2. Objectives
• Discuss the foundations for establishing
nurse-physician collaboration
• Describe effective communication and tools
to optimize communication
• Explore strategies to manage disruptive
physician behavior
• Briefly review developing confidence in
mastering new skills

3. Nurse-Physician Collaboration Defined
• Nurse-physician collaboration is:
– Nurses & physicians working cooperatively together
– Sharing responsibility for problem solving
– Making care planning decisions together
• Collaboration is not:
– Competition between roles
– Power struggles
Petri, 2010, p. 74-76

4. Benefits of Nurse-Physician
Collaboration
– Healthy Work Environment (Cornette & O’Rourke, 2009)
– Improved patient outcomes
– Improved employee performance and satisfaction
– Better nurse retention
• Better communication
– Improved efficiency
• Collaboration is a critical element in a healthy work
environment (AACN, 2005)

5. Building blocks for collaboration
• Foundations for collaboration:
– Competence, confidence, and expertise in one’s role
– Interpersonal skills that focus on mutual respect and trust
– Well-developed communication skills
• Effective Communication skills and tools:
• Managing Barriers
• Got Chart? and SBAR tools
• Managing disruptive physician behavior that
contributes to ineffective communication
(Rosenstein & O’Daniel, 2008, p. 1565)

6. Communication
• Effective communication minimizes
misunderstandings (Griffin, n.d. p. 427)
• Ineffective communication contributes to preventable
errors in hospitals:
– Errors in intensive care units (Manojlovich & DeCicco,
2007, p. 537)
– The main cause of sentinel events (Raica, 2009, p. 343)
• Barriers to effective communication (Sirota, 2007, p.
53):
– Lack of nurses’ confidence with communication
– Disruptive physician behavior

7. Communication Preparation
• A few minutes preparation can improve effectiveness
by assuring accuracy and increasing efficiency which
conveys competence and credibility
• Consider using tools such as Got Chart?
– Are you calling the correct physician?
– Are there already standing orders that apply?
– Review physician contact instructions and preferences
– Consolidate calls to a physician by calling with several
requests at one time
– Have you personally assessed the patient first?
– Have you read the progress notes prior to calling?
Studer, 2007

8. Contacting the Physician
– Have the chart ready, latest vital signs, diagnostic tests,
medication information, and code status
– Clearly introduce yourself, identify your unit, the patient
and the diagnosis in a professional manner
– Be clear and concise about the purpose for the call –
Consider using SBAR – Situation, Background, Assessment,
Recommendation
– Document the conversation completely, including the
physician’s name, time of the call, and a summary

9. SBAR promotes accuracy and
efficiency
– Situation – present the patient’s name, pertinent
information, and reason for your call including urgency
level
– Background – present a succinct clinical history relevant to
the problem for which you are calling
– Assessment – provide latest clinical findings, labs, vital
signs, risks, needs, nursing and medical assessments
– Recommendation – clearly state your request, confirm
timeline for actions, agree on when the next follow-up
should be done
Using a structured format assures consistency and accuracy
Curtis, Tzannes, and Rudge, 2011, p. 18

10. Keep your focus!
• Remember to focus on
– the patient
– your concern for the patient
• If you aren’t sure of the problem or cannot offer
recommendations, begin by clearly stating your
concern
• Provide specific evidence that supports your
concern such as vital signs, test results, trends,
changes from baseline, and timeframes
• Consider the physicians’ stand point – they are
intensely focused on their patients

11. Manage Communication Barriers with
graded assertiveness
• Be assertive but not aggressive – use graded
assertiveness
• Level I states your concern
• Level II inquires or offers a solution
• Level III asks for an explanation to better
understand
• Level IV is a definitive statement requiring a
response
Curtis, Tzannes, and Rudge, 2011, p. 18

12. Disruptive Behavior
Disruptive physician behavior – “any inappropriate behavior,
confrontation, or conflict ranging from verbal abuse to physical or sexual
harassment”
Examples include:
• Abusive anger
• Public and private berating
• Condescending behavior
• Disrespectful treatment
The impact of disruptive physician behavior is that
it discourages nurses from communicating with
physicians
Rosenstein and O’Daniel, 2008, p. 1564

13. Successfully managing Disruptive
behavior
• A crucial concept: The fundamental attribution
error – problematic behaviors are not an
inherent part of one’s personality or done for
personal enjoyment
• Are due to lack of communication skill or
problem-solving abilities
• Behavior must be addressed - failure to address
the behavior “approves” it…what you permit
you promote
Patterson, et. al., 2005, p. 60-64

14. Addressing Disruptive behavior
• Be clear about what your personal motives are, plan
thoughtfully, and have the right conversation
• Convey respect, explain the gap
– Consider your tone of voice, facial expressions, body language
– Safety is achieved when mutual respect and concern for their
interests are conveyed
– Stick to the facts
• Establish mutual purpose (example: you both care about
the patient’s welfare)
• Describe the problematic behavior and its impact to what
you both want
• End with a question to validate your understanding, ask
for agreement.
Patterson, et. al., 2005, p. 91-110

15. Inspiring motivation, establishing
commitment
• People are motivated by consequences of their choices or
actions, either good or bad
• Explain natural consequences that will occur:
– Positive consequences of a change
– Negative consequences without a change
– Impact on those affected
• Link consequences to the person’s values or interests,
identify consequences that are important to the person
• Conclude the conversation with an agreement that clearly
identifies who does what by when
Patterson, et. al., 2005, p. 119-139

16. Managing Extreme Behavior
• Assure your own safety first
– Most people resort to silence rather than violence but…
– If you are in actual danger, call security or other
appropriate authority
• If you are not in danger, deal with the behavior first,
then the issue you are trying to discuss
– Don’t get caught up in the emotion and respond in kind
– Don’t attempt to “out-do” the person with another of
your problems…the other person is only focused on his
issue
– Do not patronize the other person
Patterson, et. al., 2005, p. 187-197

17. There is more to the story
• Look beyond the behavior to identify the cause, i.e.,
feelings, emotions, the “story”
• Ask the other person about his distress
– Describe what you see vs. what he states (if applicable)
– Summarize his responses to build a picture of his
concern, validate your understanding of his position
– Encourage deeper discussion
• Encouraging the other to talk about his distress can
de-escalate his state and, subsequently, the behavior
Patterson, et. al., 2005, p. 218

18. Think Strategically
• There are occasions when leaving the
situation temporarily is the better choice
• If either or both of you are irretrievably
upset, defer until later
• Be sure you return to that conversation at the
next opportunity
Patterson, et. al., 2005, p. 218-227

19. Proceed confidently
• People often avoid difficult situations or conversations when they
feel unable to deal with that situation
• Research shows that past experiences influence nurses’ decisions
when faced with similar situations (Curtis, Tzannes, & Rudge,
2011, p. 16)
• As with any skill development, mastering
effective communication and promoting
collaboration require practice and sustained
effort

20. Social Cognitive Theory & Skill
Mastery
• Individuals can effect their own change
• Beliefs about one’s abilities will predict the degree of effort,
perseverance, and success in skill mastery
• Successful skill mastery requires perseverance in the face of
difficulties
• It is the perseverance through adversity while practicing skill
mastery that results in success
Bandura, 1989, p. 1175-1179

21. Summary and The Code of Ethics for
Nurses
Provision One:
“The nurse, in all professional relationships,
practices with compassion and respect for the
inherent dignity, worth, and uniqueness of
every individual, unrestricted by
considerations of social or economic status,
personal attributes, or the nature of health
problems”
American Nurses Association, 2010, p. 1

22. References
AACN (2005). AACN standards for establishing and sustaining
healthy work environments. Retrieved August 10, 2012, from
http://www.aacn.org/WD/HWe/Docs/ExecSum.pdf.
American Nurses Association, (2008). Guide to the Code of Ethics
for Nurses. Silver Springs, MD: American Nurses Association.
Bandura, A. (1989). Human agency in social cognitive theory.
American Psychologist, 44 (9), 1175-1184.
Coronett, P. & O’Rourke, M. (2009). Building organizational
capacity for a healthy work environment through role-based
professional practice. Critical Care Nursing Quarterly, 32 (3), 208-
220.

23. References
Curtis, K., Tzannes, A., & Rudge, T. (2011). How to talk to doctors – a
guide for effective communication. International Nursing Review, 58 (1),
13-20.
Griffin, E. (n.d.). A first look at communication theory. Retrieved
September 12, 2012, from
http://www.afirstlook.com/docs/anxietyuncertainty.pdf.
Manojlovich, M. & DeCicco, B. (2007). Healthy work environments,
nurse-physician communication and patients’ outcomes. American
Journal of Critical Care, 16 (6), 536-543.
Patterson, K., Grenny, J., McMillan, R., & Switzler, A. (2005). Crucial
Confrontations. New York: McGraw-Hill.

24. References
Petri, L. (2010). Concept analysis of interdisciplinary collaboration. Nursing Forum, 45
(2), 73-82.
Rosenstein, A. & O’Daniel, M. (2008). Managing disruptive
physician behavior. Neurology 70 (17), 1564-1570.
Sirota, T. (2007). Nurse/physician relationships: Improving
or not? Nursing 2007, 37 (1), p. 52-55.
Studer Group. (2004). Save physicians time: Got chart?
Retrieved August 23, 2012, from
http://www.studergroup.com/newsletter/Vol1_Issue4/vol1
_i4_sec4.htm