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Page 35
Gina Aya Nelson
Major L. King
Stephanie Brodine
Nurse-Physician Collaboration
On Medical-Surgical Units
Interdisciplinary collaboration is viewed as a critical
factor in delivering quality
patient care. The purpose of
this study was to describe
nurse-physician perceptions
of collaboration relationship
on general medical-surgical
units.
A
lthough many factors contribute to the current nursing shortage, one of
the primary reasons nurses leave the profession is dissatisfaction with
their practice environment (Joint Commission on Accreditation of
Healthcare Organizations, 2001; U.S. General Accounting Office, 2001).
Integrated structure and processes (collaboration) that allow nurses and
physicians to resolve their differences (conflict) are likely to increase nurse
satisfaction, recruitment, and retention (Rosenstein, 2002; Schmalenberg et
al., 2005). Achieving this goal requires significant commitment and support
by nursing administrators.
Conflict with physicians has been identified as one stressor in the nurse
work environment (Greenfield, 1999). Nurses may face both verbal and
physical abuse when conflict arises with physicians (Rosenstein, 2002).
Conflict may arise from differences in opinion regarding patient care
requirements, or from the longstanding hierarchical relationship of physician dominance and nursing subservience (Greenfield, 1999). Nevertheless,
some degree of conflict exists. The goal should be to produce positive
results through conflict resolution.
Literature Review
Gina Aya Nelson, MSN, RN, is Intern
Manager, Nursing Support, Resources
Pool, Scripps Hospital, La Jolla, CA.
Major L. King, PhD, RN, CNS, is a
Professor, School of Nursing, Azusa
Pacific University, Azusa, CA.
Stephanie Brodine, MD, is Division
Head, Epidemiology and Biostatistics,
Graduate School of Public Health, San
Diego State University, San Diego, CA.
Note: A related article on this topic
“Bridging the Professional Chasm: Tools
for Collaborative Communication” can
be found in the January/February 2008
issue of Medsurg Matters, the official
newsletter of the Academy of MedicalSurgical Nurses (www.medsurgnurse.
org).
MEDSURG Nursing—February 2008—Vol. 17/No. 1
Interdisciplinary collaboration is viewed as a critical factor in delivering
quality patient care (Institute of Medicine [IOM], 2004; Rosenstein &
O’Daniel, 2005). The benefits of positive nurse-physician relationships are
well documented in the literature. Interdisciplinary collaboration benefits
the organization in terms of decreased costs, better patient care, and economy of decision making (National Joint Practice Commission, 1981;
Schmalenberg et al., 2005), and decrease patient morbidity and mortality
(Aiken, Clark, Sloane, Sochalski, & Huber, 2002). Moreover, a strong link
exists between effective interactions (collaboration) among team members
and risk-adjusted patient length of stay (Aiken, 2001). The nursing profession faces a critical nursing shortage with the nursing workforce expected
to decrease by 20% in 2020 (Buerhaus et al., 2005), making collaboration
between nurses and physicians a high priority for nurse administrators.
Studies show that nurses who practice collaboratively with physicians
experienced less “burnout,” and recruitment and retention rates are higher
than nurses who practice in non-collaborative environments (Aiken, Clarke,
Sloane, Sochalski, & Weber, 1999; Buchan, 1999).
One focus of Nursing’s Agenda for the Future was the development of a
nurse practice environment that supported shared decision making and collaboration (American Nurses Association, 2002). The IOM (2004) also recommended that organizations adapt a structure that supports collaboration
by encouraging interdisciplinary patient care rounds and providing ongoing
education in the collaborative process and training for all staff.
Many studies have explored nurse-physician collaboration, but most
have been limited to intensive care units and emergency departments
(Rosenstein & O’Daniel, 2005; Schmalenberg et al., 2005). Several studies
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(King & Lee, 1994; Rosenstein &
O’Daniel, 2005; Schmalenberg et al.,
2005) showed significant differences
in nurses’ and physicians’ perceptions of collaborative relationship,
with physicians perceiving greater
collaborative behaviors than nurses. Alternately, nurses in critical
care units are likely to have better
working relationships with physicians when compared to nurses on
medical-surgical units because of
their clinical expertise and the
opportunity to work closely with
physicians (Greenfield, 1999; King &
Lee, 1994).
Definition of Collaborative
Practice
Collaborative practice has
been defined in many ways. Weiss
and Davis (1985) offered a useful
definition that supports the theoretical framework for this study.
The researchers defined collaborative practice as “the interactions
between nurse and physician that
enable the knowledge and skills of
both professions to synergistically
influence the patient care provided” (p. 299).
Study purpose. Efforts to increase collaboration between nurses and physicians are notable
because of their impact on patient
outcomes such as decreased morbidity and mortality (Kramer &
Schmalenberg, 2003; Rosenstein &
O’Daniel, 2005). It is important to
evaluate nurses’ and physicians’
perception of their interaction patterns in medical-surgical units,
where physicians spend little time
interacting with nurses (Greenfield,
1999). The purpose of this study
was to describe medical-surgical
nurses’ and physicians’ perceptions of their collaborative behaviors on medical-surgical units.
Theoretical Framework
Styles of conflict management
have evolved from several dimensions. Deutsch (1949) and Ruble
and Thomas (1976) conceptualized
conflict management in one and
two dimensions respectively.
However, the concept of conflict
resolution has evolved to five
dimensions in other sources (Blake
& Mouton, 1970; Kilmann &
Thomas, 1977; Rahim, 1983).
Kilmann and Thomas (1977)
36
Page 36
provided the theoretical framework
for this study. They suggested that
individuals use one of five modes in
conflict resolutions: competing, collaborating, compromising, avoiding, and accommodating. These five
modes reflect independent dimensions of interpersonal conflict
behavior and build on earlier work
by Ruble and Thomas (1976), who
proposed a classification scheme
based on a two-dimensional model
of cooperativeness and assertiveness. The dimensions of cooperation and assertiveness have independent connotations for individuals. Cooperation is attempting to
satisfy the other person’s concerns,
while assertiveness is attempting to
satisfy one’s own concerns. The
combination of these two dimensions yields five types of conflict
behaviors that identify conflict as
competing (assertive and uncooperative), collaborating (assertive
and cooperative), avoiding (unassertive and uncooperative),
accommodating (unassertive and
cooperative), and compromising
(intermediate in both cooperativeness and assertiveness).
Most nurse-physician conflicts
occur in the areas of general plan of
care (Rosenstein, 2002), specific
orders, and patient disposition.
Conflict is natural and part of interactions with others (Zerwekh &
Claborn, 2006); therefore, the goal
should focus on conflict resolution.
Noted industrialist Mary Parker
Follett (1977) was one of the first to
study organization conflict, suggesting that conflict be viewed as
differences of opinions and differences of interest. Follet noted that
conflict is neither “good” nor “bad,”
and that it should be used to identify the source of differences. Dealing
with conflict involves domination,
compromise, or integration. In
domination, one party wins over
the other. In compromise, each
party gives up a little to keep the
peace. Compromise is ineffective
because it means giving up a desire.
According to Follett (1977),
integration is an effective mode of
conflict resolution; “when two
desires are integrated, it means that
a solution has been found in which
both desires have a place that neither side has had to sacrifice anything” (p. 245). Integration involves
inventing new ways of solving differences. The key to this process is
open and effective communication.
Differences cannot be resolved unless nurses and physicians acknowledge that differences exist in
their practice. These differences
may be due to culture, gender, and
to some extent, perceived differences in power base (for example,
clinical expertise) (Kramer &
Schmalenberg, 2003). Integration is
an effective mode of conflict resolution because it creates win-win situations. In integration, solutions
have been found in which both
desires have a place, and neither
side needs to sacrifice anything
(Follett, 1977).
Obstacles to integration include undue influence of leaders
and lack of training for using it
(Follett, 1977). For example, Greenfield (1999) noted that nursing leaders (managers) may not be receptive to establishing collaborative
relationships with physicians because this may be seen as reinforcing the subservient role. He recommended that nurses and physicians
receive training that recognizes the
unique contributions of each in providing quality patient care. Leadership support and education are key
to improving relationships between
individuals with different worldviews (Follett, 1977). A recent study
by Rosenstein and O’Daniel (2005)
supported this strategy. Kilmann
and Thomas (1977), Rubel and
Thomas (1976), and Follett (1977)
suggested that it is the manner in
which nurses and physicians resolve their differences that determines whether collaborative practice exists in their relationships.
Cooperation, assertiveness, and
open communication are healthy
conflict resolution strategies in
resolving conflict and are necessary
for collaboration to occur in the
organization (King & Lee, 1994).
Methodology
Design and sample. A convenience sample of registered nurses
and physicians was recruited from
medical-surgical units in a hospital
in San Diego, CA. A total of 120 surveys were distributed to both nurses and physicians respectively.
Power analysis was used to determine the sample size with an alpha
MEDSURG Nursing—February 2008—Vol. 17/No. 1
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of 0.05, power of 0.80, and a moderate effect size of 0.40. These parameters required a sample size of 196
(98 nurses and 98 physicians).
However, the available population
for this study was less than that
required to meet this parameter;
however, the effect size was large
enough to detect differences in
means scores between nurses and
physicians in this study (Polit &
Beck, 2004). The response rate was
84% (101 surveys) for nurses, and
43% for physicians (51 surveys).
Eight questionnaires were discarded because they failed to meet the
cut-off guidelines of answering at
least 50% of the questions. Data
analysis was performed using
responses from 95 nurses and 49
physicians. It was large enough to
detect a difference in mean scores
between groups with a partial η2
(effect size) of 0.11, which according to Cohen’s taxonomy is a medium to large effect size.
Page 37
Figure 1.
Collaborative Practice Scale – Nurses
Data Collection Procedures
Instrumentation. The Collaborative Practice Scale (CPS) was used
to measure perceptions of collaboration between nurses and physicians (Weiss & Davis, 1985). The
CPS has two scales, one for nurses
(see Figure 1) and one for physicians (see Figure 2). The CPS for
nurses has 9 items with a possible
score of 54. Each item is scored on
6-point scale, ranging from never (1)
to always (6).
The nurse CPS has two factors,
with one factor having a maximum
score of 30 and the other 24. The
first factor (five items) measures
the degree to which a nurse directly asserts professional expertise
and opinions when interacting
with physicians about patient care.
The second factor (four items)
measures the degree to which a
nurse clarifies with the physician
mutual expectations regarding the
nature of shared responsibilities in
patient care.
The CPS for physicians has 10
items that are divided into two factors of five items each. Each item
is scored on the same 6-point
scale. Each of the two factors has
a maximum score of 30 (total maximum score 60). The first factor
(five items) measures the degree
to which a physician acknowl-
MEDSURG Nursing—February 2008—Vol. 17/No. 1
Figure 2.
Collaborative Practice Scale – Physicians
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edges the importance of nurses’
unique contribution to different
responsibilities in patient care.
The second factor (five items)
measures the degree to which a
physician seeks consensus with
nurses regarding mutual responsibilities and patient care goals.
Higher scores on the instrument
imply greater use of collaborative
behaviors by the nurse or physician (Weiss & Davis, 1985).
This instrument is reliable and
valid. Cronbach’s alpha coefficients
of 0.80 and 0.84 were reported for
nurses and physicians respectively
(Weiss & Davis, 1985). Another
study reported Cronbach’s alpha
coefficients of 0.83 for the nurse
CPS total scales and 0.86 for the
physician CPS total scales (King &
Lee, 1994). In the current study, the
CPS demonstrated acceptable internal consistency reliability with
Cronbach’s alpha coefficients of
0.87 for the nurse CPS and 0.88 for
the physician CPS. Factor analysis
was used to determine construct
validity for the nurse and physician
CPS, which was similar to that
reported by Weiss and Davis (1985)
and King and Lee (1994).
This study was approved by
the institutional review boards
(IRB) at San Diego State University
and a southern California hospital,
and IRB protocols were followed in
this study. A cover letter explaining
the purpose of the study, a consent
form, the CPS, and a demographic
record (see Table 1) were included
in the packet that was distributed
to the sample via unit mail boxes.
No identifying markers were placed
on the surveys. The directions on
each survey noted whether it was a
nurse or physician survey.
Page 38
Table 1.
Demographics for Nurses and Physicians
Mean ± SD
N (%)
Nurse
36±12
22-63
Physician
50±9.4
29-70
Gender
Nurse
Female
Male
90
(95)
5
(5)
Physician
Female
Male
7 (13.7)*
44 (86.3)
Ethnicity
Nurse
Caucasian
71
(77)
Others
24
(23)
Physician
Caucasian
41 (80.4)*
Others
10 (19.6)
Years Experience
Nurse
0-10 years
66 (69.5)
11-20 years
10 (10.5)
>20 years
19
(20)
7
(7.8)
Physician
2-10 years
11-20 years
17 (33.3)
>20 years
27 (58.9)
Shift Worked (Nurses)
0700-1930
53 (55.8)
1930-0730
34 (35.8)
Others
8
(8.4)
6
(6.4)
Degree (Nurses)
Diploma
Data Analysis
ADN
40 (42.6)
Data were analyzed using
Statistical Package for the Social
Sciences (SPSS, Version 14) applications software (2005). Univariate
analysis was used to test the differences in mean scores between
nurses’ CPS and the adjusted mean
scores on the physicians’ CPS.
Univariate analysis also was used to
test group differences for selected
demographics (age, gender, education, experience, and certifications).
BSN
46 (48.9)
38
Range
Age
MSN
2
(2.1)
Yes
24
(25)
No
71
(75)
Yes
49
(96)
No
2
(4)
Certification
Nurses
Physicians
* Missing data
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Results
Sample demographics are
shown in Table 1. Univariate analysis showed that physicians had
higher total mean scores on the
CPS than nurses (F [(1, 142] = 18.16,
p<0.05, partial η2 = 0.113). The partial η2 suggested that 11% of the
variability was due to group membership. Item mean scores for nurses and physicians are shown in
Tables 2 and 3. Nurses’ and physicians’ mean scores (± SD) on the
CPS were 3.5 ± 1.04 and 4.3 ± 1.06
respectively. Nurses and physicians
with more education [F (4, 84) =
3.59, p=0.010) and experience ([F=
(5, 78] = 5.25, p=0.0001) were likely
to perceive collaborative relationships, as were nurses with a job
title ([F (1, 42] = 4.33, p=0.044), and
advanced certification (F [1, 82] =
17.4, p=0.0001). King and Lee (1994)
demonstrated that those with
advanced clinical expertise are likely to perceive collaborative relations exist.
Page 39
Table 2.
Item Means for the Nurse CPS
(N = 95)
Mean (± SD)
Item 1
2.4 (1.5)
Item 2
2.8 (1.4)
Item 3
3.7 (1.7)
Item 4
3.3 (1.6)
Item 5
4.6 (1.1)
Item 6
3.2 (1.4)
Item 7
3.8 (1.4)
Item 8
4.6 (1.2)
Item 9
3.3 (1.5)
Note: Scale range from 1 to 6.
Table 3.
Item Means for the Physician CPS
(N = 49)
Mean (± SD)
Item 1
4.9 (1.14)
Item 2
4.7 (1.11)
Discussion
Item 3
3.2 (1.36)
This study showed significant
differences in perceptions of collaborative behaviors between nurses
and physicians on general-medical
surgical units. Findings were consistent with other studies that evaluated the concept of collaboration
(King & Lee, 1994; Schmalenberg et
al., 2005). Decades of research
show that increased collaborative
practice between nurses and physicians results in better patient outcomes. However, this mode of conflict resolution remains elusive
between the two professions (King
& Lee, 1994). In this study, communication between nurses and physicians was distant as suggested by
the differences in mean scores on
the CPS between the two groups.
Nurses’ mean scores on the
CPS suggested they lacked assertiveness skills in communicating
their unique contribution to patient
care requirements when interacting
with physicians. Findings are consistent with published reports by
Timmins and McCabe (2005a,
2005b). Gender, education preparation, and the nursing culture may
play an important part in nurses’
lack of assertive behaviors when
communicating with physicians.
Nurses had mean scores less than 3
Item 4
4.9 (.26)
Item 5
4.5 (1.26)
Item 6
3.9 (1.48)
Item 7
4.7 (1.03)
Item 8
3.5 (1.39)
Item 9
5.1 (1.20)
Item 10
3.7 (1.45)
MEDSURG Nursing—February 2008—Vol. 17/No. 1
Note: Scale range from 1 to 6.
and physician) recognizes and values the contributions of the other;
thus power is equal in their relationships. Nurses share some of the
responsibility for the manner in
which they present themselves
when interacting with physicians
because their approach may contribute to the perceived power
imbalance. Greenfield (1999) noted
that nurses used more “support/
agreement” messages when interacting with physicians, while physicians used more “give opinion”
messages when interacting with
nurses. These findings suggest that
assertiveness training may be beneficial for nurses; research indicates
that this training improves
assertiveness skills and self-esteem
(Lin et al., 2004).
Physicians’ higher mean scores
suggest that they value and use the
input from nurses, and are comfortable with the role of the physiciannurse team with respect to patient
care delivery. However, this perception was not shared by nurses in
this study. Of the items on the
physicians’ scale, item #3 (“I discuss with nurses the similarities
and differences in medical and
nursing approaches to care”) had
the lowest mean and SD (3.2 ± 1.36.)
These findings may reflect ineffective communication patterns
between the two professionals, as
demonstrated by the study’s theoretical framework.
Study Limitation
(on a scale of 1-6) on item #1 (“I ask
physicians about their expectations
regarding the degree of my involvement in health care decisions”) and
item #2 (“I negotiate with the physician to establish our responsibilities for discussion of different kinds
of information with patients”).
Until these issues are resolved,
nurses may not enjoy collegial, collaborative relationships with physicians in decision making. Moreover, nurses may be reluctant to
share their expertise and opinions
regarding patient care requirements because of perceived power
differences. Kramer and Schmalenberg (2003) noted that in collaborative relations, power is mutual
but not equal. In true collaborative
relations, each professional (nurse
Because the small sample size
represented one hospital in San
Diego, results cannot be generalized. However, the partial η2 (effect
size) suggested it was large enough
to detect differences in means
scores between the two groups.
Because this appears to be the first
study to describe nurses’ and physicians’ perceptions of collaborative behaviors in the medical-surgical environment, further studies
using a larger sample size are needed to determine if findings represent the true population means.
Conclusion
Findings indicated that collaborative practice between nurses
and physicians occurred at low-tomoderate levels on medical-surgical
units. Findings suggest that the rela-
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tionship between nurses and physicians has not changed over time.
Maximizing nurse-physician collaboration holds promise for improving
quality patient care and creating satisfying work environments for nurses and physicians (Rosenstein &
O’Daniel, 2005). Collaborative practice is a process that involves the
valued contributions of all team
members in reaching the best possible solutions. Additionally, collaboration between nurses and physicians requires intentional team
building at schools and work settings (Hojat et al., 2001). It is important for nurses and physicians to
develop a new culture of collaboration which merges the unique
strengths of each discipline with the
mutual goal of quality patient care. ■
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