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Collaboration between hospital physicians and nurses: An integrated literature review

C.J. Tang1 Candidate Bachelor of Science (Nursing) (Honour) program, S.W. Chan2 PhD in Nursing, W.T. Zhou3 Advanced Practice Nurse, Master in Nursing & S.Y. Liaw4 Registered Nurse, PhD in Medical Education 1 Student, 2 Professor, 3 Lecturer, 4 Assistant Professor, Alice Lee Centre for Nursing Studies, National University of Singapore, National University Health System, Singapore, Singapore

TANG C.J., CHAN S.W., ZHOU W.T. & LIAW S.Y. (2013) Collaboration between hospital physicians and nurses: An integrated literature review. International Nursing Review 60, 291–302

Background: Ineffective physician–nurse collaboration has been shown to cause work dissatisfaction among

physicians and nurses and compromised the quality of patient care.

Aim: The review sought to explore: (1) attitudes of physicians and nurses toward physician–nurse

collaboration; (2) factors affecting physician–nurse collaboration; and (3) strategies to improve

physician–nurse collaboration.

Methods: A literature search was conducted in the following databases: CINAHL, PubMed, Wiley Online

Library and Scopus from year 2002 to 2012, to include papers that reported studies on physician–nurse

collaboration in the hospital setting.

Findings: Seventeen papers were included in this review. Three of the reviewed articles were qualitative studies

and the other 14 were quantitative studies. Three key themes emerged from this review: (1) attitudes towards

physician–nurse collaboration, where physicians viewed physician–nurse collaboration as less important than

nurses but rated the quality of collaboration higher than nurses; (2) factors affecting physician–nurse

collaboration, including communication, respect and trust, unequal power, understanding professional roles,

and task prioritizing; and (3) improvement strategies for physician–nurse collaboration, involving

inter-professional education and interdisciplinary ward rounds.

Conclusion: This review has highlighted important aspects of physician–nurse collaboration that could be

addressed by future research studies. These include: developing a comprehensive instrument to assess

collaboration in greater depth; conducting rigorous intervention studies to evaluate the effectiveness of

improvement strategies for physician–nurse collaboration; and examining the role of senior physicians

and nurses in facilitating collaboration among junior physicians and nurses. Other implications include

inter-professional education to empower nurses in making clinical decisions and putting in place policies to

resolve workplace issues.

Correspondence address: Dr Sok Ying Liaw, Alice Lee Centre for Nursing Studies, National University of Singapore, National University Health System, Level 2, Clinical Research Centre, Block MD 11, 10 Medical Drive, Singapore 117597, Singapore; Tel: (65)-65167451; Fax: (65)-67767135; E-mail [email protected].

Conflict of interest: No conflict of interest has been declared by the authors.

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Literature Review

© 2013 International Council of Nurses 291

Keywords: Attitudes, Inter-Professional Collaboration, Inter-Professional Education, Nurse–Physician Relations,

Physician–Nurse Collaboration

Background Physician–nurse collaboration is defined by Petri (2010) as an interpersonal process where physicians and nurses present with shared objectives. Both parties should possess equal decision- making capacity, responsibility and power to manage patient care (Petri 2010). There should also be mutual trust and respect, and open and effective communication in this relationship. Each profession needs to be aware and accept the roles, skills and responsibilities of the other (Petri 2010). Historically, inter- actions between physicians and nurses were hierarchical (Thomas et al. 2003). Stein first wrote about the ‘Doctor-Nurse Game’ in 1967, a key study demonstrating that traditional rela- tionships between both physicians and nurses were largely char- acterized by medical dominance and nursing subservience (Vazirani et al. 2005). Such relationships set physicians firmly in charge and superior to nurses. Nurses were then expected to carry out orders and avoid open communication with physi- cians whenever possible (Vazirani et al. 2005). Many nurses have described such practice as a stifling experience, which devalued nurses’ professional worth and increased their job dis- satisfaction (Sirota 2007).

Hostile and adversarial relationships between both profes- sions still largely exist in many Western countries such as the USA, Italy, Germany, and Asian countries like China and Japan (Morinaga et al. 2008; Papathanassolgou et al. 2012; Rosenstein 2002). Studies found that physicians tend to have rude and intimidating personalities (Robinson et al. 2010; Rosenstein 2002; Rosenstein & O’Daniel 2005). They exhibited disruptive behaviours such as yelling and using abusive language towards nurses. Consequently, nurses experienced a lack of respect and autonomy (Robinson et al. 2010; Rosenstein 2002; Rosenstein & O’Daniel 2005). The ‘friendly stranger’ relationship was also evident in some studies where interactions between physicians and nurses were solely characterized by formal exchanges of information (Kramer & Schmalenberg 2003; Schmalenberg & Kramer 2009). Each party was fairly satisfied with only fulfilling their own tasks and responsibilities towards each other and patients (Kramer & Schmalenberg 2003; Schmalenberg & Kramer 2009). Nonetheless, there is evidence suggesting that physician–nurse relationships are in fact improving and moving slowly towards a collegial or collaborative nature (Kramer & Schmalenberg 2003; Schmalenberg & Kramer 2009). Collegial relationships are characterized by equal trust, respect and

autonomy over patient care. Both professions engage in open communication and value each other’s input about patient out- comes (Robinson et al. 2010; Schmalenberg & Kramer 2009). Collaborative relationships are based on mutual respect and trust, though at times nurses are expected to cooperate with physicians (Robinson et al. 2010; Schmalenberg & Kramer 2009). Effective physician–nurse collaboration has been found to greatly improve the quality of patient care and their health outcomes (Hughes & Fitzpatrick 2010; Messmer 2008; Rose 2011). As described, the patterns of physician–nurse collabora- tion are diverse and this could be attributed to the different atti- tudes, values and interpersonal skills held by each individual (Rosenstein 2002; Vazirani et al. 2005). Furthermore, behav- iours of physicians and nurses are largely influenced by their pre-licensure education and ward cultures, which differ across clinical settings and countries (Hughes & Fitzpatrick 2010; Robinson et al. 2010).

Ineffective physician–nurse relationships have led to work dissatisfaction, a lack of autonomy and poor health among nurses (Lim et al. 2010; Sirota 2007). Such working relation- ships have also caused many nurses to leave the profession, making retention and recruitment of nurses increasingly diffi- cult (Nelson et al. 2008; Rosenstein 2002; Thomson 2007). Phy- sicians were also reported to be easily frustrated when orders were not carried out timely and communication delivered was unclear. This contributed largely to work dissatisfaction among physicians (Rosenstein 2002; Rosenstein & O’Daniel 2005). Most importantly, ineffective collaboration had a significant impact on patient outcomes by compromising their quality of care and safety, which often led to increased mortality rates (Rosenstein 2002; Rosenstein & O’Daniel 2005). Moreover, poor physician–nurse collaboration was known to affect the satisfac- tion levels of both patients and family members during their hospital stay (McCaffrey et al. 2010; Robinson et al. 2010).

Aim Recognizing that collaboration is a two-way interpersonal process, it is important to understand the attitudes of both phy- sicians and nurses towards collaborative practice. This will aid in identifying the areas of improvement for physician–nurse collaboration (Petri 2010; Seitz et al. 2007). This integrated literature review therefore aimed to present the best available

292 C. J. Tang et al.

© 2013 International Council of Nurses

evidence on physician–nurse collaboration. The specific ques- tions to be addressed in this review include: 1 What are the attitudes of physicians and nurses towards physician–nurse collaboration? 2 What are the factors affecting physician–nurse collaboration? 3 What strategies could be recommended to improve physician–nurse collaboration?

Methods

Search method and process

The search sought to identify published papers in English which reported primary research studies on physician–nurse relationship or collaboration in hospitals. Relevant studies were searched via the following databases: CINAHL, PubMed, Wiley Online Library and Scopus. Key search terms included singly or in various combinations: ‘nurse-physician relations’, ‘attitudes’, ‘inter professional collaboration’, ‘collaboration’, ‘doctor’, ‘nurse’ and ‘hospital’. A manual search was carried out on Journal of Interprofessional Care and using the ancestry approach, reference lists of each retrieved article were reviewed for additional relevant journals. The search was limited to journals published in the last 10 years, from January 2002 to December 2012.

Initial review identified 23 potential articles. Each journal article was then read in full to assess its relevance. Exclusion cri- teria were also taken into consideration while extracting rel- evant journals. Studies conducted in outpatient clinics, nursing homes and operating theatres were excluded. Studies that largely discuss inter-professional education (IPE), work con- flicts and attitudes of healthcare students towards collaborative practice were also excluded. Studies that explored working rela- tionships between doctors or nurses and other allied health pro- fessionals were not considered.

Search outcomes

The search process, and total number of included and excluded articles are illustrated in Fig. 1. A total of six articles were excluded for the following reasons: (1) focus of the study was not largely based on physician–nurse collaboration; (2) explored relationships between physicians and advanced nurse practitioners; and (3) inappropriate target group where medical students, nurses and nurse managers were recruited as participants. Finally, 17 articles were reviewed.

Of the 17 reviewed studies, three were qualitative studies that used focus-group interviews or semi-structured interviews. The other 14 articles were quantitative studies. Ten of them adopted descriptive comparative designs, where questionnaires were used to evaluate the different attitudes physicians and nurses

have towards collaboration. Four used experimental designs to evaluate the effectiveness of interventions in improving physician–nurse collaboration. Table 1 summarizes the method- ologies and findings of the reviewed studies. These findings were pooled together and categorized into three key themes for discussion.

Results

Attitudes towards physician–nurse collaboration

The reviewed studies adopted different instruments to measure attitudes of physicians and nurses towards collaboration. The ‘Jefferson Scale of Attitudes toward Physician-Nurse Collabora- tion (JSAPNC)’ has been used in four of the reviewed studies (Garber et al. 2009; Hojat et al. 2003; Hughes & Fitzpatrick 2010; Thomson 2007). Other questionnaires used include ‘Baggs Collaboration and Satisfaction about Care Decisions (CSACD)’, ‘Collaboration & Satisfaction with Patient Care Deci- sions (CSPCD)’, ‘Collaborative Practice Scale (CPS)’, ‘Intensive Care Unit Management Attitudes Questionnaire (ICUMAQ)’, ‘Nurse-Physician Collaboration Scale’ and ‘Nurse-Physician Relationship Survey’ (Messmer 2008; Nair et al. 2012; Nathanson et al. 2011; Nelson et al. 2008; Rosenstein 2002; Rosenstein & O’Daniel 2005; Thomas et al. 2003). The validities and reliabilities of all these abovementioned instruments were well documented (Dougherty & Larson 2005; Thomas et al. 2003).

The attitudes towards physician–nurse collaboration are cat- egorized into two subthemes – importance of physician–nurse collaboration and the quality of physician–nurse collaboration.

Importance of physician–nurse collaboration

Several reviewed studies found that physicians and nurses valued collaboration (Hughes & Fitzpatrick 2010; Robinson et al. 2010; Rosenstein 2002). Both professions recognized that effective collaboration is essential in bringing about better quality patient care, which ultimately leads to improved health outcomes for patients (Hughes & Fitzpatrick 2010; Robinson et al. 2010; Rosenstein 2002). Two studies supported that physi- cians and nurses recognized the importance of collaboration in ensuring patient safety, satisfaction, faster recovery and lower mortality rates (Messmer 2008; Rosenstein & O’Daniel 2005).

However, more of the reviewed studies reported that physi- cians viewed collaboration as less important when compared with nurses (Garber et al. 2009; Hughes & Fitzpatrick 2010; Rosenstein 2002; Thomson 2007). On the contrary, nurses who were more likely to perceive collaboration as an important factor to providing better care demonstrate more interests and have greater desires than physicians to work collaboratively

Physician–nurse collaboration 293

© 2013 International Council of Nurses

(Garber et al. 2009; Hughes & Fitzpatrick 2010; Rosenstein 2002; Thomson 2007). The aforementioned studies that used descriptive comparative designs were conducted in various parts of USA and all revealed statistically significant differences between physicians and nurses in their attitudes towards col- laboration (Garber et al. 2009; Hughes & Fitzpatrick 2010; Rosenstein 2002; Thomson 2007). Hojat et al. (2003) conducted a cross-cultural study to compare attitudes towards collabora- tion between 2522 physicians and nurses from USA, Mexico, Israel and Italy. The study reported that despite differences in culture, nurses demonstrated a significantly more positive atti- tude than physicians towards the importance of collaboration (Hojat et al. 2003).

These different perceptions on the importance of physician– nurse collaboration could be explained by the fact that

physicians and nurses have different training and they adopt different care philosophies (Hughes & Fitzpatrick 2010; Sirota 2007). While physicians were traditionally trained to develop technical skills and focus on finding cure for diseases, nurses were trained in developing interpersonal skills with patients and colleagues, providing holistic care for patients and making deci- sions interdependently with physicians (Hughes & Fitzpatrick 2010; Sirota 2007). As a result of the training that focused on disease management, physicians were generally satisfied to prac- tice independently without much assistance from nurses (Hughes & Fitzpatrick 2010). In contrast, to achieve more holistic care for patients including social and psychological well- being, nurses felt that their valuable perspectives should be con- sidered during times of decision-making (Dougherty & Larson 2005). Nurses, therefore, see physician–nurse collaboration as

Key search terms: • Nurse–physician relations • Attitudes • Inter-professional collaboration • Collaboration • Doctor • Nurse • Hospital

Search strategies:

1. Searching for references through the use of the following databases: CINAHL, PubMed, Wiley Online Library and Scopus.

2. Manual search on Journal of Interprofessional Care.

3. Using the ancestry approach: the reference lists of each retrieved article were reviewed for additional relevant journals.

Inclusion criteria applied: • Primary research papers • Published in English • Published in the last 10 years, from January 2002

to December 2012 • Discuss about relationships or collaboration

between doctors and nurses in hospitals

23 potential journal articles were identified

and read in full to assess its relevance.

17 journal articles were included in the final

review

6 journal articles were

excluded

Reasons for exclusion: • Focus of study was not

largely based on physician– nurse collaboration (3)

• Explored relationships between physicians and advanced nurse practitioners (1)

• Inappropriate target group: medical students and nurses (1)

• Target group included nurse managers (1)

14 quantitative studies3 qualitative studies

Reasons for exclusion (67): • Commentaries, opinion papers

(12) • Literature reviews (10) • Conducted in outpatient

clinics, nursing homes and operating theatres (15)

• Largely discuss inter- professional education (10), work conflicts (7) and attitudes of healthcare students towards collaborative practice (8)

• Explored collaboration between doctors or nurses and other allied health professionals (5).

Fig. 1 Flow chart describing details of literature search.

294 C. J. Tang et al.

© 2013 International Council of Nurses

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-y ea

r

p er

io d

,i n

te rv

en ti

o n

an d

co n

tr o

l u

n it

s w

er e

cr ea

te d

in vo

lv in

g 1

1 1

h o

u se

o ffi

ce rs

,4 5

at te

n d

in g

p h

ys ic

ia n

s an

d 1

2 3

n u

rs es

• P

h ys

ic ia

n s

in th

e in

te rv

en ti

o n

gr o

u p

re p

o rt

ed si

gn ifi

ca n

tl y

gr ea

te r

co ll

ab o

ra ti

o n

an d

b et

te r

co m

m u

n ic

at io

n w

it h

n u

rs es

th an

d id

p h

ys ic

ia n

s in

th e

co n

tr o

l gr

o u

p .

• In

co n

tr as

t, n

u rs

es in

b o

th gr

o u

p s

re p

o rt

ed si

m il

ar le

ve ls

o f

co m

m u

n ic

at io

n an

d co

ll ab

o ra

ti o

n w

it h

p h

ys ic

ia n

s.

Physician–nurse collaboration 295

© 2013 International Council of Nurses

T ab

le 1

C o

n ti

n u

ed

A u

th or

s St

u d

y ai

m (s

) St

u d

y d

es ig

n S

am p

le ch

ar ac

te ri

st ic

s K

ey fi

n d

in gs

M es

sm er

(2 0

0 8

) T

o d

et er

m in

e th

e le

ve l

o f

n u

rs e–

p h

ys ic

ia n

co ll

ab o

ra ti

o n

d u

ri n

g si

m u

la ti

o n

tr ai

n in

g.

In te

rv en

ti o

n d

es cr

ip ti

ve st

u d

y

u si

n g

th e

K SN

P S,

C o

ll ab

o ra

ti o

n &

Sa ti

sf ac

ti o

n

w it

h P

at ie

n t

C ar

e D

ec is

io n

s,

an d

C li

n ic

al P

ra ct

ic e

G ro

u p

C o

h es

io n

to ev

al u

at e

th ei

r

te am

p er

fo rm

an ce

5 5

p ae

d ia

tr ic

m ed

ic al

re si

d en

ts

an d

5 0

n u

rs es

fr o

m a

ch il

d re

n ’s

h o

sp it

al in

So u

th ea

st er

n U

n it

ed St

at es

fo rm

ed 1

8 co

d e

te am

s an

d

u n

d er

w en

t th

re e

si m

u la

ti o

n

se ss

io n

s o

f li

fe -t

h re

at en

in g

sc en

ar io

s in

ch il

d re

n

• H

ig h

le ve

ls o

f gr

o u

p co

h es

io n

,c o

ll ab

o ra

ti o

n an

d sa

ti sf

ac ti

o n

w it

h

p at

ie n

t ca

re d

ec is

io n

s w

er e

id en

ti fi

ed am

o n

g b

o th

p h

ys ic

ia n

s an

d

n u

rs es

.

• T

h e

th re

e in

d ep

en d

en t

o b

se rv

er s

u si

n g

th e

K SN

P S

re p

o rt

ed th

at

w it

h m

o re

si m

u la

ti o

n se

ss io

n s,

co ll

ab o

ra ti

ve re

la ti

o n

sh ip

s

im p

ro ve

d w

it h

gr ea

te r

co m

m u

n ic

at io

n an

d co

ll eg

ia l

ex ch

an ge

s.

N at

h an

so n

et al

. (2

0 1

1 )

T o

m ea

su re

th e

d eg

re e

o f

si m

il ar

it y

o f

at ti

tu d

es o

n

co ll

ab o

ra ti

o n

b et

w ee

n n

u rs

es

an d

ju n

io r

d o

ct o

rs in

th e

IC U

.

D es

cr ip

ti ve

st u

d y

u si

n g

a

m o

d ifi

ed ve

rs io

n o

f th

e B

ag gs

C o

ll ab

o ra

ti o

n an

d Sa

ti sf

ac ti

o n

ab o

u t

C ar

e D

ec is

io n

s

in st

ru m

en t

3 1

n u

rs es

an d

4 6

ju n

io r

d o

ct o

rs

fr o

m a

m ed

ic al

/s u

rg ic

al IC

U in

th e

N o

rt h

ea st

er n

U n

it ed

St at

es

• M

o d

es t

ag re

em en

t am

o n

g th

e p

ar ti

ci p

an ts

th at

d ec

is io

n -m

ak in

g

re sp

o n

si b

il it

ie s

ar e

n o

t sh

ar ed

.N u

rs es

p er

ce iv

e th

is as

in ad

eq u

at e

co ll

ab o

ra ti

o n

.

• Ju

n io

r d

o ct

o rs

w er

e sa

ti sfi

ed w

it h

co ll

ab o

ra ti

o n

.

• Si

gn ifi

ca n

t d

if fe

re n

ce b

et w

ee n

ju n

io r

d o

ct o

rs an

d n

u rs

es ’

o ve

ra ll

sa ti

sf ac

ti o

n w

it h

te am

d ec

is io

n s.

W el

le r

et al

. (2

0 1

1 )

T o

u n

d er

st an

d th

e n

at u

re o

f

in te

ra ct

io n

s, ac

ti vi

ti es

an d

is su

es af

fe ct

in g

m ed

ic al

an d

n u

rs in

g gr

ad u

at es

in o

rd er

to

in fo

rm in

te rv

en ti

o n

s to

im p

ro ve

in te

r- p

ro fe

ss io

n al

co ll

ab o

ra ti

o n

in th

is co

n te

xt .

Q u

al it

at iv

e st

u d

y u

si n

g

se m

i- st

ru ct

u re

d in

te rv

ie w

s

1 3

ju n

io r

d o

ct o

rs an

d 1

2 ju

n io

r

n u

rs es

fr o

m h

o sp

it al

s ac

ro ss

N ew

Z ea

la n

d

• A

co d

in g

th eo

re ti

ca l

fr am

ew o

rk w

as id

en ti

fi ed

,s h

o w

in g

th e

fa ct

o rs

n ec

es sa

ry fo

r co

ll ab

o ra

ti o

n .

• Q

u al

it y

o f

co ll

ab o

ra ti

o n

: m

u tu

al re

sp ec

t, tr

u st

,o rg

an iz

at io

n al

st ru

ct u

re o

r cu

lt u

re .

• Sh

ar ed

m en

ta l

m o

d el

s: h

o w

in fo

rm at

io n

is sh

ar ed

,s h

ar ed

p ri

o ri

ti es

.

• T

ea m

co o

rd in

at io

n :

d efi

n in

g ro

le s

w it

h in

th e

te am

,c o

o rd

in at

in g

d ec

is io

n -m

ak in

g ac

ro ss

th e

te am

,t ea

m le

ad er

sh ip

,o ri

en ti

n g

n ew

te am

m em

b er

s

• C

o m

m u

n ic

at io

n en

vi ro

n m

en t:

o p

en n

es s

o f

co m

m u

n ic

at io

n ,

sp ea

k in

g u

p .

H u

gh es

& F

it zp

at ri

ck (2

0 1

0 )

T o

ev al

u at

e at

ti tu

d es

to w

ar d

s

co ll

ab o

ra ti

o n

am o

n g

n u

rs es

an d

p h

ys ic

ia n

s.

C o

m p

ar at

iv e

d es

cr ip

ti ve

st u

d y

u si

n g

T h

e Je

ff er

so n

Sc al

e o

f

A tt

it u

d es

to w

ar d

P h

ys ic

ia n

-N u

rs e

C o

ll ab

o ra

ti o

n

1 1

8 n

u rs

es an

d 5

3 p

h ys

ic ia

n s

fr o

m a

co m

m u

n it

y h

o sp

it al

in

th e

N o

rt h

ea st

er n

U n

it ed

St at

es

• N

u rs

es h

av e

a si

gn ifi

ca n

tl y

m o

re p

o si

ti ve

at ti

tu d

e th

an p

h ys

ic ia

n s

to w

ar d

s co

ll ab

o ra

ti o

n .

• N

u rs

es p

er ce

iv e

th e

im p

o rt

an ce

o f

sh ar

ed ed

u ca

ti o

n m

o re

th an

p h

ys ic

ia n

s. N

u rs

es sc

o re

d h

ig h

er th

an p

h ys

ic ia

n s

o n

‘p h

ys ic

ia n

’s

au th

o ri

ty ’.

N el

so n

et al

. (2

0 0

8 )

T o

d es

cr ib

e n

u rs

e– p

h ys

ic ia

n

p er

ce p

ti o

n s

o f

co ll

ab o

ra ti

o n

re la

ti o

n sh

ip o

n ge

n er

al

m ed

ic al

su rg

ic al

u n

it s.

D es

cr ip

ti ve

st u

d y

u si

n g

th e

C P

S 9

5 n

u rs

es an

d 4

9 p

h ys

ic ia

n s

fr o

m

a h

o sp

it al

in Sa

n D

ie go

,

C al

if o

rn ia

• St

at is

ti ca

l si

gn ifi

ca n

t d

if fe

re n

ce in

p er

ce p

ti o

n s

o f

co ll

ab o

ra ti

ve

b eh

av io

u rs

b et

w ee

n th

e n

u rs

es an

d p

h ys

ic ia

n s.

• N

u rs

es la

ck as

se rt

iv en

es s

in co

m m

u n

ic at

in g

w it

h d

o ct

o rs

th ei

r

co n

tr ib

u ti

o n

s to

p at

ie n

t ca

re .

• P

h ys

ic ia

n s

va lu

e an

d u

se in

p u

t fr

o m

n u

rs es

an d

ar e

co m

fo rt

ab le

w it

h th

e ro

le o

f p

h ys

ic ia

n –

n u

rs e

co ll

ab o

ra ti

o n

im p

ro vi

n g

p at

ie n

t

ca re

.

T h

o m

so n

(2 0

0 7

) T

o d

et er

m in

e at

ti tu

d es

o f

n u

rs es

an d

p h

ys ic

ia n

s re

ga rd

in g

th ei

r

co ll

ab o

ra ti

o n

.

D es

cr ip

ti ve

p ro

sp ec

ti ve

st u

d y

u si

n g

T h

e Je

ff er

so n

Sc al

e o

f

A tt

it u

d es

to w

ar d

P h

ys ic

ia n

-N u

rs e

C o

ll ab

o ra

ti o

n

6 5

n u

rs es

an d

3 7

p h

ys ic

ia n

s fr

o m

a m

ed ic

al ce

n tr

e in

So u

th er

n

U n

it ed

St at

es

• N

u rs

es h

ad m

o re

p o

si ti

ve at

ti tu

d es

th an

p h

ys ic

ia n

s to

w ar

d s

co ll

ab o

ra ti

o n

.

• B

o th

sh ar

ed p

o si

ti ve

at ti

tu d

es re

ga rd

in g

co ll

ab o

ra ti

o n

in ar

ea s

o f

sh ar

ed ed

u ca

ti o

n an

d te

am w

o rk

,c ar

in g

vs .c

u ri

n g,

an d

n u

rs es

au to

n o

m y.

296 C. J. Tang et al.

© 2013 International Council of Nurses

B u

rn s

(2 0

1 1

) T

o d

et er

m in

e if

w ar

d ro

u n

d s

im p

ro ve

p h

ys ic

ia n

– n

u rs

e

co ll

ab o

ra ti

o n

.

In te

rv en

ti o

n st

u d

y w

h er

e

p h

ys ic

ia n

– n

u rs

e ro

u n

d s

w er

e

im p

le m

en te

d o

ve r

4 w

ee k

s,

fo ll

o w

ed b

y fi

ve -q

u es

ti o

n

L ik

er t

sc al

e su

rv ey

N u

rs es

an d

p h

ys ic

ia n

s fr

o m

a

4 5

-b ed

m ed

ic al

u n

it in

a

tr au

m a

h o

sp it

al w

it h

in a

la rg

e

M id

w es

te rn

ci ty

• N

u rs

e– p

h ys

ic ia

n ro

u n

d s

in cr

ea se

d ca

re ef

fi ci

en cy

.A ve

ra ge

n u

m b

er o

f ca

ll s

m ad

e to

p h

ys ic

ia n

s d

ec re

as ed

af te

r

im p

le m

en ta

ti o

n o

f ro

u n

d s.

• N

u rs

e– p

h ys

ic ia

n ro

u n

d s

im p

ro ve

d q

u al

it y

o f

p at

ie n

t ca

re an

d

in te

r- p

ro fe

ss io

n al

co m

m u

n ic

at io

n .

R o

se n

st ei

n (2

0 0

2 )

T o

as se

ss th

e at

m o

sp h

er e

an d

si gn

ifi ca

n ce

o f

n u

rs e–

p h

ys ic

ia n

re la

ti o

n s

an d

d et

er m

in e

th e

in fl

u en

ce o

f d

is ru

p ti

ve

p h

ys ic

ia n

b eh

av io

u r

o n

n u

rs e

sa ti

sf ac

ti o

n an

d re

te n

ti o

n .

D es

cr ip

ti ve

st u

d y

u si

n g

N u

rs e-

P h

ys ic

ia n

R el

at io

n sh

ip

Su rv

ey

7 2

0 n

u rs

es an

d 1

7 3

p h

ys ic

ia n

s

fr o

m 8

4 h

o sp

it al

s ac

ro ss

W es

t

C o

as t

• P

h ys

ic ia

n s

ra te

d at

m o

sp h

er e

o f

w o

rk re

la ti

o n

sh ip

s m

o re

p o

si ti

ve ly

th an

n u

rs es

,v ie

w ed

w o

rk re

la ti

o n

sh ip

s le

ss si

gn ifi

ca n

t

th an

n u

rs es

,a n

d p

er ce

iv ed

th at

th ey

va lu

e n

u rs

es ’

in p

u ts

an d

co ll

ab o

ra ti

o n

.

• N

u rs

es ra

te d

‘p h

ys ic

ia n

aw ar

en es

s o

f im

p o

rt an

ce o

f th

e

n u

rs e-

p h

ys ic

ia n

re la

ti o

n sh

ip to

n u

rs e

sa ti

sf ac

ti o

n ’l

o w

er th

an

p h

ys ic

ia n

s d

id .

• D

is ru

p ti

ve p

h ys

ic ia

n b

eh av

io u

r af

fe ct

ed n

u rs

e re

te n

ti o

n ra

te s,

sa ti

sf ac

ti o

n le

ve ls

an d

m o

ra le

.

M il

le r

et al

. (2

0 0

8 )

T o

ex am

in e

n u

rs in

g em

o ti

o n

w o

rk an

d in

te r-

p ro

fe ss

io n

al

co ll

ab o

ra ti

o n

in o

rd er

to

u n

d er

st an

d an

d im

p ro

ve

co ll

ab o

ra ti

ve n

u rs

in g

p ra

ct ic

e.

Q u

al it

at iv

e st

u d

y u

si n

g

n o

n -p

ar ti

ci p

an t

o b

se rv

at io

n ,

sh ad

o w

in g

an d

se m

i- st

ru ct

u re

d in

te rv

ie w

s

C o

n d

u ct

ed in

th re

e p

u b

li c

h o

sp it

al s

in C

an ad

a w

it h

2 0

n u

rs es

,7 d

o ct

o rs

,1 8

al li

ed

h ea

lt h

p ro

fe ss

io n

al s

an d

5

ad m

in is

tr at

iv e/

m an

ag em

en t

st af

f

• N

u rs

es ’

co ll

ab o

ra ti

o n

w it

h o

th er

h ea

lt h

p ro

fe ss

io n

al s

is sh

o w

n to

b e

in fl

u en

ce d

b y

em o

ti o

n w

o rk

co n

si d

er at

io n

s.

R o

b in

so n

et al

. (2

0 1

0 )

T o

ex p

lo re

n u

rs e

an d

p h

ys ic

ia n

p er

ce p

ti o

n s

o f

ef fe

ct iv

e an

d

in ef

fe ct

iv e

co m

m u

n ic

at io

n

b et

w ee

n th

e tw

o p

ro fe

ss io

n s.

Q u

al it

at iv

e st

u d

y u

si n

g fo

cu s

gr o

u p

in te

rv ie

w s

C o

n d

u ct

ed at

a h

ea lt

h sc

ie n

ce

ce n

tr e

in th

e U

SA ,w

it h

1 8

re gi

st er

ed n

u rs

es an

d

p h

ys ic

ia n

s o

f at

le as

t 5

ye ar

s o

f

w o

rk in

g ex

p er

ie n

ce s

• T

h em

es ch

ar ac

te ri

zi n

g ef

fe ct

iv e

co m

m u

n ic

at io

n an

d in

ef fe

ct iv

e

co m

m u

n ic

at io

n w

er e

id en

ti fi

ed .

• F

o r

ef fe

ct iv

e co

m m

u n

ic at

io n

: cl

ar it

y an

d p

re ci

si o

n o

f m

es sa

ge

th at

re li

es o

n ve

ri fi

ca ti

o n

,c o

ll ab

o ra

ti ve

p ro

b le

m so

lv in

g, ca

lm an

d

su p

p o

rt iv

e d

em ea

n o

u r

u n

d er

st re

ss ,m

ai n

te n

an ce

o f

m u

tu al

re sp

ec t,

an d

au th

en ti

c u

n d

er st

an d

in g

o f

th e

u n

iq u

e ro

le .

• F

o r

in ef

fe ct

iv e

co m

m u

n ic

at io

n :

m ak

in g

so m

eo n

e le

ss th

an ,

d ep

en d

en ce

o n

el ec

tr o

n ic

sy st

em s,

an d

li n

gu is

ti c

an d

cu lt

u ra

l

b ar

ri er

s.

N ai

r et

al .

(2 0

1 2

) T

o d

el in

ea te

fr eq

u en

tl y

u se

d fr

o m

in fr

eq u

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more important to achieve better patient outcomes (Dougherty & Larson 2005; Hughes & Fitzpatrick 2010; Sirota 2007).

Quality of physician–nurse collaboration

Three quantitative studies (Rosenstein 2002; Thomas et al. 2003; Vazirani et al. 2005) revealed that physicians rated the quality of collaboration – effectiveness and satisfaction level – higher than that of nurses. For example, Thomas et al. (2003) conducted a study in eight intensive care units (ICUs) within Houston where 90 physicians and 230 nurses were surveyed using the ICUMAQ. Seventy-three per cent (n = 90) of physi- cians rated the quality of collaboration and communication with nurses as high or very high. However, only 33% (n = 230) of nurses rated the quality of collaboration with physicians as high or very high (Thomas et al. 2003). The results could be related to how the two professions defined physician–nurse col- laboration. Physicians equated collaboration with giving orders and expecting cooperation from nurses to follow through with their decisions (Sirota 2007). Although nurses were able to perform tasks and carry out physicians’ orders correctly, many of them looked forward to having greater autonomy and shared decision-making capacities with physicians to influence patient care (Sirota 2007; Vazirani et al. 2005).

Physicians and nurses’ satisfaction with their collaboration may also be influenced by traditionally rooted stereotypical ideals that society imposes on their roles as healthcare profes- sionals (Hojat et al. 2003; Thomas et al. 2003). Nurses were often viewed as ‘handmaidens’ of physicians, while physicians were perceived as leaders of the healthcare team. The different statuses and autonomy attached with these stereotypical ideals have made collaboration a stifling experience for many nurses (Thomas et al. 2003; Vazirani et al. 2005). Conversely, physi- cians possess greater power in decision-making which could have caused them to have a lesser interest and thereby lower expectations for effective collaboration (Hansson et al. 2009; Hojat et al. 2003).

Factors affecting physician–nurse collaboration

Many of the reviewed studies have identified major factors that affected collaboration such as communication, respect and trust, and unequal power between physicians and nurses (McCaffrey et al. 2010; Robinson et al. 2010; Rosenstein 2002; Rosenstein & O’Daniel 2005; Thomas et al. 2003; Weller et al. 2011). The lack of understanding about each others’ profes- sional roles and task prioritizing were also found to be influenc- ing factors (Nathanson et al. 2011; Robinson et al. 2010; Rosenstein 2002; Weller et al. 2011).

Communication

Effective communication is essential to building good working relationships between physicians and nurses (Petri 2010) and ensuring patient care is delivered correctly and timely (Sirota 2007). However, four reviewed studies found that communica- tion between both professions tends to be unclear and imprecise (McCaffrey et al. 2010; Robinson et al. 2010; Rosenstein 2002; Weller et al. 2011). This resulted in delayed delivery of patient care and more frequent medical errors that ultimately jeopard- ized patients’ safety (McCaffrey et al. 2010; Rosenstein 2002). Such problematic communication issues between physicians and nurses were reported to occur more commonly in medical– surgical wards than in ICUs (McCaffrey et al. 2010; Robinson et al. 2010; Rosenstein 2002; Weller et al. 2011). Unlike in medical–surgical wards, a continuous and regular presence of doctors in ICUs enabled nurses to clarify any doubts face-to- face and thereby improve the communication process (Schmalenberg & Kramer 2009). Furthermore, a higher acuity of patients in ICUs may have encouraged greater vigilance among physicians and nurses in ensuring their clarity of com- munication (Robinson et al. 2010; Sirota 2007).

Ambiguous communication between physicians and nurses has led to unpleasant behaviours, especially among the physi- cians. A study by Rosenstein (2002) on the perceptions of 720 nurses and 173 physicians from 84 hospitals in Northern Cali- fornia towards collaboration highlighted that nurses often failed to gather all relevant patient information before calling the phy- sicians. This unclear communication caused physicians to raise their voices rudely, which significantly affected the nurses’ atti- tudes towards patient care and hindered teamwork (Rosenstein 2002). Moreover, Weller et al. (2011) observed that physicians and nurses nowadays communicated more frequently through written patient care records, where information was not always conveyed accurately or read timely. The dependence on elec- tronic messaging systems has also caused more problems in communication between physicians and nurses (Robinson et al. 2010).

Respect and trust

Nurses in several reviewed studies perceived that their effort, professional assessments or inputs regarding patient care were not valued by the physicians (Robinson et al. 2010; Rosenstein 2002; Rosenstein & O’Daniel 2005; Thomas et al. 2003; Weller et al. 2011). This finding was evident across both medical– surgical wards and ICUs (Thomas et al. 2003; Weller et al. 2011). Such dismissive attitudes caused nurses to experience a lack of respect and trust, which significantly hampered the development of a more collaborative physician–nurse relation- ship (Thomas et al. 2003; Weller et al. 2011). The perceived

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arrogance of some physicians further contributed to the hostile working environment, making it difficult to establish respectful relationships (Sirota 2007; Weller et al. 2011). In contrast, a quantitative study conducted by Nelson et al. (2008) using ‘Col- laborative Practice Scale (CPS)’ revealed that physicians actually highly valued and utilized the inputs contributed by nurses. Although this finding was incongruent to the other reviewed studies, the possibility of research biases from single site study and convenience sampling has been acknowledged by the authors (Nelson et al. 2008).

Many reviewed studies found that physicians tended to display disruptive behaviours towards nurses, though some- times the reverse is observed as well (Robinson et al. 2010; Rosenstein 2002; Rosenstein & O’Daniel 2005). In a qualitative study using focus group interviews, nurses expressed that physi- cians often used words that were rude and humiliating. This made them feel incompetent and intimidated, which had resulted in a lack of and fear of communication with physicians (Robinson et al. 2010). Other disruptive behaviours reported included yelling, using condescending tones towards another, and berating patients and colleagues. These behaviours had sig- nificantly affected the nurses’ work satisfaction, their attitudes towards patients, and perceptions towards collaboration (Rosenstein 2002; Vazirani et al. 2005). It had also compromised the quality and safety of patient care delivered (Rosenstein 2002; Rosenstein & O’Daniel 2005).

Understanding professional roles

Robinson et al. (2010) pointed out that there is a lack of under- standing about the unique professional role of nurses, leading to ineffective collaboration between physicians and nurses. Nurses were often perceived by physicians to be only responsible for carrying out their treatment orders (Robinson et al. 2010). Sirota (2007) highlighted that nurses, who have frequent contact with patients and family members, could actually con- tribute more to patient care by offering their perspectives and participate in decision-making. However, physicians tend to have minimal insights into these roles of nurses and this could be observed through certain dismissive words or behaviours they exhibit (Sirota 2007). Hence, the important role of nurses in making such contributions towards patient care is disre- garded (Nathanson et al. 2011; Robinson et al. 2010). This inevitably caused nurses to experience a lack of autonomy and lower professional worth with respect to decision-making, which in turn limits the effectiveness of physician–nurse col- laboration (Nathanson et al. 2011).

Task prioritizing

Two of the reviewed studies, despite varying in methodological approaches, reported consistently that collaboration was

affected by the different priorities physicians and nurses had with regard to patient care (Rosenstein 2002; Weller et al. 2011). The junior physicians in Weller et al.’s study (2011) reported that nurses did not always understand the rationale behind certain treatments. As a result, given limited work time, nurses chose to complete other tasks that they perceived as more important or urgent (Weller et al. 2011). These differences in task prioritizing not only caused physicians and nurses to develop feelings of frustration towards each other, but in some cases led to delays in the delivery of effective patient care (Rosenstein 2002; Weller et al. 2011).

Similarly, junior nurses reported feeling annoyed when physi- cians chose to disregard certain important concerns they had about patients’ condition and progress (Weller et al. 2011). Stein-Parbury & Liaschenko (2007) explained that this phe- nomenon could be due to physicians and nurses possessing dif- ferent knowledge about their patients. Physicians tend to assess patients’ conditions based on objective values such as vital signs and laboratory investigations whereas nurses tend to use more of their intuitions, observations and understanding of human experiences of diseases (Stein-Parbury & Liaschenko 2007). Therefore, it was observed that physicians chose to review patients more promptly when nurses reported factual evidence of deterioration such as vital signs, rather than their general observations of patients (Stein-Parbury & Liaschenko 2007; Weller et al. 2011).

Unequal power

Petri (2010) advocated that physicians and nurses should possess equal decision-making capacity, responsibility and power. However, a descriptive comparative study by Nelson et al. (2008) reported that nurses did not feel confident or asser- tive enough to communicate and discuss patient care on equal platforms with physicians. Nurses perceived a power imbalance between both professions (Nelson et al. 2008). Hansson et al. (2009) explained that this unequal power could be attributed to the different levels of education, status and prestige that are unique to each profession. Although both aforementioned studies were conducted in medical–surgical wards, similar find- ings were observed in studies carried out within ICUs (Papathanassolgou et al. 2012; Rose 2011). In several reviewed studies, it was also suggested that interactions between physi- cians and nurses were strongly influenced by their traditional cultural roots, where typically there was medical dominance and nursing subservience (Hansson et al. 2009; Hojat et al. 2003; Thomas et al. 2003; Vazirani et al. 2005). By possessing more powerful positions, physicians often do not see collabora- tion with nurses or shared decision-making as being necessary

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for effective patient care. Furthermore, nurses at the same time hesitate to communicate on ground levels with physicians (Hansson et al. 2009).

Another descriptive comparative study by Nair et al. (2012) found that ‘decision-making on care or cure’ was the least fre- quent physician–nurse collaborative behaviour used by both professions. Physicians tended to dominate the decision-making process whereas nurses were usually seen to simply follow suit (Hansson et al. 2009; Hojat et al. 2003; Nair et al. 2012). As nurses were traditionally more likely to use obliging and com- promising conflict management styles and avoid assertive behaviours, it allowed physicians to possess greater authority in clinical decision-making (Nair et al. 2012). This has further contributed to the power imbalance between both healthcare professions (Nair et al. 2012).

Improvement strategies for physician–nurse collaboration

Majority of the reviewed studies strongly proposed the imple- mentation of strategies to enhance physician–nurse collabora- tion. The strategies implemented by four interventional studies include IPE (McCaffrey et al. 2010; Messmer 2008) and inter- disciplinary ward rounds (Burns 2011; Vazirani et al. 2005).

IPE

McCaffrey et al. (2010) implemented an inter-professional edu- cational program in a hospital setting over a 6-month period, involving 50 medical residents and 65 nurses who worked in medical wards. The program covered topics such as effective communication skills, body language, and essential determi- nants of good collaborative practice (McCaffrey et al. 2010). The effectiveness of the program was evaluated using focus group interviews. Both physicians and nurses shared that the program has helped them foster comfortable friendships, develop positive communication skills, learn to accept each others’ perspectives regarding patients’ condition, and prioritize patient care together (McCaffrey et al. 2010).

Using a quantitative study approach, Messmer (2008) con- ducted an inter-professional simulation program in a children’s hospital, where physicians and nurses were exposed to three dif- ferent life-threatening simulated situations. Their performances and interactions were observed and scored by three independ- ent observers using the Kramer and Schmalenberg Nurse- Physician Scale. The study outcome revealed that with more simulation exposures, physician–nurse collaboration improved significantly where both professions treated each other with greater respect and trust, and gained deeper insights into each others’ roles and responsibilities (Messmer 2008).

Interdisciplinary ward rounds

Two intervention studies explored the effectiveness of interdis- ciplinary ward rounds in medical units in different parts of the USA (Burns 2011; Vazirani et al. 2005). Both studies provided evidence on the effectiveness of daily medical ward rounds in improving the quality of patient care and physician–nurse com- munication. With effective ward rounds, communication of important information could be done face-to-face and thereby reducing the need for subsequent phone calls to clarify doubts (Burns 2011; Vazirani et al. 2005). A similar outcome was also reported in Schmalenberg & Kramer’s (2009) study, which evaluated interdisciplinary ward rounds in ICUs and specialized units from across 26 hospitals in 2003 and 34 hospitals in 2007 within the USA. The study reported that regular interdiscipli- nary rounds with active participation from nurses could boost their self-confidence in communicating with physicians. Such intervention also significantly improved physician–nurse col- laboration (Schmalenberg & Kramer 2009).

Despite the effectiveness of ward rounds in improving col- laboration, the heavy patient workload and insufficient time to complete individual tasks had affected the doctors and nurses’ willingness and sense of urgency to round as a team (Burns 2011; Miller et al. 2008; Rosenstein 2002; Weller et al. 2011). In Burn’s study (2011), it was observed that participation rates in ward rounds declined after the fourth week of implementa- tion. Vazirani et al. (2005) recommended that the implementa- tion and evaluation of interdisciplinary ward rounds be conducted over a longer period, for example, 2 years, in order to observe any significant improvements in physician–nurse collaboration.

Discussion Physician–nurse collaboration is a complex interpersonal process between physicians and nurses. In reviewing the litera- ture on the attitudes of hospitals’ physicians and nurses towards collaboration, it was found that such attitudes have been explored mainly in the hospitals in Western countries, especially those within the USA. Little is known about the atti- tudes of physicians and nurses towards collaboration in hospi- tals beyond this region. As a result of possible cultural and social differences, findings of studies conducted in one country or region may not be fully applicable to other countries. A mutual understanding of attitudes towards collaboration can serve as a first step for physicians and nurses to recognize spe- cific challenges both face in working together, and identify solutions to enhance partnership (James et al. 2010). More future studies are therefore needed to continue exploring the attitudes of physicians and nurses towards collaboration in various settings. Besides exploratory studies, the review

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identified the need for more intervention research studies that use more rigorous methodology such as randomized controlled trials to evaluate their effectiveness on improving physician– nurse collaboration.

Different types of questionnaires were adopted by the reviewed studies to measure attitudes of physicians and nurses towards collaboration. Although the validities and reliabilities of these questionnaires were well documented, each questionnaire was developed to only intentionally measure attitudes towards certain aspects of collaboration in specific settings (Dougherty & Larson 2005). A broad rather than narrow focus is important in enhancing the understanding of physician–nurse collabora- tion. Moreover, the findings of this review have identified several factors affecting physician–nurse collaboration in a hos- pital environment. Future research could aim to develop a com- prehensive instrument that explores attitudes in a greater depth and broader scope.

The review identified a considerable amount of literature addressing perceptions towards improving collaboration from physicians and nurses working on the ground level. There has been little research that examined the role of senior physicians and nursing administrators in facilitating collaboration. James et al. (2010) highlighted a need for the executive hospital com- mittee from both medicine and nursing to clarify perceptions and define expectations for the two professions before taking the lead to develop a partnered plan for enhanced working relationships.

In view of unequal power existing between physicians and nurses, policy makers could look more into regulation of the nursing profession whereby nurses are granted more autonomy in making clinical decisions on patient care. To further empower nurses with clinical knowledge and decision-making skills, there could be hospital-based IPE programs for both phy- sicians and nurses to learn from one another. With greater knowledge and capacity to make clinical decisions, it is believed that nurses may become more confident in communication and satisfied with the collaborative practice experience. Further- more, leaders of the hospital management boards could take more concrete steps to deal with workplace issues such as con- flicts and disagreements between both professions, for instance, by creating an open forum and conducting regular discussion sessions for physicians and nurses to resolve differences or share any unpleasant experiences related to collaboration (Rosenstein 2002). Conflict management guidelines could also be drawn up and disseminated to both professions, so that any discontent- ment can be addressed promptly and effectively.

This literature review has several limitations. Although undertaken carefully and systematically, the listed search strat- egy might not have identified all the relevant literature. The

relatively small number of articles that met the inclusion criteria in this review and their methodological approaches could have introduced bias.

Conclusion This integrated literature review has sought to present the best available evidence on physician–nurse collaboration. The review found that both physicians and nurses working in the hospital setting possessed differing attitudes towards the importance and quality of physician–nurse collaboration. Their attitudes were found to be influenced by factors including communication, respect and trust, unequal power, understanding other profes- sional roles, and task prioritizing. The review also identified strategies such as IPE and interdisciplinary ward rounds that could improve physician–nurse collaboration. More research efforts, along with policy and practice implications, would be key to improving collaborative practice between hospital physi- cians and nurses.

Author contributions All the above authors have approved the final version of the article. I acknowledge that all those entitled to authorship are listed as authors. Charmaine Tang has contributed to the con- ception design of the study, acquisition of data, analysis and interpretation of the data, drafting the article, and critical revi- sion of the article. Sally Wai-chi Chan has contributed to the conception design of the study and critical revision of the article. Wentao Zhou has contributed to the critical revision of the article. Sok Ying Liaw has contributed to the conception design of the study, analysis and interpretation of the data, criti- cal revision of the article, and supervision.

References Burns, K. (2011) Nurse-physician rounds: a collaborative approach to

improving communication, efficiencies, and perception of care. Medsurg

Nursing, 20 (4), 194–199.

Dougherty, M.B. & Larson, E. (2005) A review of instruments measuring

nurse-physician collaboration. The Journal of Nursing Administration,

35 (5), 244–253.

Garber, J., Madigan, E., Click, E. & Fitzpatrick, J. (2009) Attitudes towards

collaboration and servant leadership among nurses, physicians and resi-

dents. Journal of Interprofessional Care, 23 (4), 331–340.

Hansson, A., et al. (2009) Working together- primary care doctors’ and

nurses’ attitudes to collaboration. Scandinavian Journal of Public Health,

38, 78–85.

Hojat, M., et al. (2003) Comparisons of American, Israeli, Italian and

Mexican physicians and nurses on the total and factor scores of the

Jefferson scale of attitudes toward physician-nurse collaborative relation-

ships. International Journal of Nursing Studies, 40, 427–435.

Physician–nurse collaboration 301

© 2013 International Council of Nurses

Hughes, B. & Fitzpatrick, J. (2010) Nurse-physician collaboration in an

acute care community hospital. Journal of Interprofessional Care, 24 (6),

625–632.

James, J., Butler-Williams, C., Hunt, J. & Cox, H. (2010) Vital signs for

vital people: an exploratory study into the role of the healthcare

assistant in recognising, recording and responding to the acutely ill

patient in the general ward setting. Journal of Nursing Management, 18,

548–555.

Kramer, M. & Schmalenberg, C. (2003) Securing ‘good’ nurse physician

relationships. Nursing Management, 34 (7), 34–38.

Lim, J., Bogossian, F. & Ahern, K. (2010) Stress and coping in Singaporean

nurses: a literature review. Nursing and Health Sciences, 12,

251–258.

McCaffrey, R., et al. (2010) A program to improve communication and

collaboration between nurses and medical residents. Journal of Continu-

ing Education in Nursing, 41 (4), 172–178.

Messmer, P. (2008) Enhancing nurse-physician collaboration using pediat-

ric simulation. Journal of Continuing Education in Nursing, 39 (7), 319–

327.

Miller, K.L., et al. (2008) Nursing emotion work and interprofessional col-

laboration in general internal medicine wards: a qualitative study.

Journal of Advanced Nursing, 64 (4), 332–343.

Morinaga, K., Ohtsubo, Y., Yamauchi, K. & Shimada, Y. (2008) Doctors’

traits perceived by Japanese nurses as communication barriers: a

questionnaire survey. International Journal of Nursing Studies, 45, 740–

749.

Nair, D.M., et al. (2012) Frequency of nurse-physician collaborative behav-

iors in an acute care hospital. Journal of Interprofessional Care, 26 (2),

115–120.

Nathanson, B.H., et al. (2011) How much teamwork exists between nurses

and junior doctors in the intensive care unit? Journal of Advanced

Nursing, 67 (8), 1817–1823.

Nelson, G., King, M. & Brodine, S. (2008) Nurse-physician collaboration

on medical-surgical units. Medsurg Nursing, 17 (1), 35–40.

Papathanassolgou, E.D.E., et al. (2012) Professional autonomy, collabora-

tion with physicians, and moral distress among European intensive care

nurses. American Journal of Critical Care, 21, e41–e52.

Petri, L. (2010) Concept analysis of interdisciplinary collaboration. Nursing

Forum, 45 (2), 73–82.

Robinson, F., Gorman, G., Slimmer, L. & Yudkowsky, R. (2010) Perceptions

of effective and ineffective nurse-physician communication in hospitals.

Nursing Forum, 45 (3), 206–216.

Rose, L. (2011) Interprofessional collaboration in the ICU: how to define?

Nursing in Critical Care, 16 (1), 5–10.

Rosenstein, A.H. (2002) Nurse-physician relationships: impact on nurse

satisfaction and retention. The American Journal of Nursing, 102 (6),

26–34.

Rosenstein, A.H. & O’Daniel, M. (2005) Disruptive behavior & clinical out-

comes: perceptions of nurses & physicians. Nursing Management, 36 (1),

18–29.

Schmalenberg, C. & Kramer, M. (2009) Nurse-physician relationships in

hospitals: 20 000 nurses tell their story. Critical Care Nurse, 29 (1),

74–83.

Seitz, S.J., Lord, C.G. & Taylor, C.A. (2007) Beyond pleasure: emotion

activity affects the relationship between attitudes and behavior. Personal-

ity and Social Psychology Bulletin, 33 (7), 933–947.

Sirota, T. (2007) Nurse/physician relationships: improving or not? .

Nursing, 37 (1), 52–56.

Stein-Parbury, J. & Liaschenko, J. (2007) Understanding collaboration

between nurses and physicians as knowledge at work. American Journal

of Critical Care, 16 (5), 470–478.

Thomas, E.J., Sexton, J.B. & Helmreich, R.L. (2003) Discrepant attitudes

about teamwork among critical care nurses and physicians. Critical Care

Medicine, 31 (3), 956–959.

Thomson, S. (2007) Nurse-physician collaboration: a comparison of the

attitudes of nurses and physicians in the medical-surgical patient care

setting. Medsurg Nursing, 16 (2), 87–91.

Vazirani, S., Hays, R.D., Shapiro, M.F. & Cowan, M. (2005) Effect of a

multidisciplinary intervention on communication and collaboration

among physicians and nurses. American Journal of Critical Care, 14 (1),

71–77.

Weller, J., Barrow, M. & Gasquoine, S. (2011) Interprofessional collabora-

tion among junior doctors and nurses in the hospital setting. Medical

Education, 45 (5), 478–487.

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© 2013 International Council of Nurses

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