By Maureen Habel, RN, MA
Older nurses can remember a time that when a physician came to a patient unit, nurses who were charting or on the phone relinquished their chairs and gathered charts to help the physician during patient rounds. In previous eras, nurses were expected to function in a subordinate role to physicians. In fact, critical thinking and problem-solving on their own were discouraged. Nursing developed in a time when men were viewed as superior to women.1 The traditional cultural assignment of power roles to males contributed to the caste-like relationship between primarily male physicians and predominately female nurses. This problem has been compounded by media portrayals of nurses, in which nurses are often cast roles in which they appear less scholarly and less able to make effective clinical judgments than physicians.2
Good Communication = Safety + Quality
Healthcare has changed dramatically. Medical and nursing knowledge has increased exponentially, and a wealth of research now drives evidence-based practice. The patient care environment is also more complex than ever. Both nurses and physicians must provide patient care at a rapid and efficient rate while at the same time reducing costs and improving outcomes. Providing safe and effective care increasingly depends on nurses and physicians working closely together to achieve optimum patient outcomes. Agencies such as the Centers for Medicare & Medicaid Services, The Joint Commission and the Institute for Healthcare Improvement emphasize the critical need for healthcare professionals to communicate in a way that prevents errors and improves quality.3 The Institute of Medicine’s 1999 “To Err Is Human” report was a wake-up call, documenting about 98,000 patient deaths each year in the U.S., with communication breakdowns being the cause of a substantial number of preventable errors. The report served as an impetus for studies about nurse-physician collaboration and their impact on patient safety.
Increasingly, the patient safety literature emphasizes the importance of creating a culture of safety, one that expects all staff to speak up when a patient may be harmed. A classic study done in intensive care settings found that communication between physicians and nurses was the most significant factor associated with patient mortality.4 More recent studies have confirmed these findings.5,6 Healthcare organizations that participate in the American Nurses Credentialing Center’s Magnet Recognition Program are recognized by providing nursing excellence. Some authors propose that outstanding nurse-physician collaboration may account for the lower patient mortality seen in Magnet hospitals.5,6 One study documented that specific characteristics of Magnet hospitals (e.g., nursing involvement in hospital affairs, a professional nursing practice model and adequate staffing) were all important factors that enhanced nurse-physician communication.6
Faced with the need to attract and retain nurses, a large healthcare network conducted a nurse-physician relationship survey in 2002 that solicited the opinions of 1,200 participants, including nurses, physicians and administrators. This study verified that nurse-physician relationships strongly affect nurses’ morale and job satisfaction.7 The findings also documented that physicians viewed nurse-physician relationships as less important than did nurses and administrators.7
The journal Nursing conducted a major survey of nurse-physician relationships in 1991 that was repeated in 2007. In the more recent survey, a majority of nurses reported that they were basically satisfied with their relationships with physicians, indicating improvement from 1991, when only 43% of nurses reported satisfactory relationships.8 However, the 2007 survey found that 43% of nurses continue to have unsatisfactory relationships with physicians.8 Nurses mentioned several factors that influenced optimal nurse-physician relationships, including male physicians’ perceptions of traditional gender roles, physicians’ feelings of superiority combined with nurses’ feelings of inferiority and a hospital culture in which nurses were seen as subordinate to physicians.8 The majority of the nurses responding to the 2007 survey reported they had been treated disrespectfully, experienced a sense of being inferior to physicians and believed their opinions were sometimes misunderstood or ignored.8 They also believed that healthcare organizations did not enforce sanctions for physicians who demonstrated disruptive behavior.8 Some of those surveyed also reported that older physicians and those from cultures characterized by male/female inequality were more likely to view nurses as subordinates.8 A literature review of physician-nurse collaboration proposed assessing collaboration in more depth, conducting studies to evaluate the effectiveness of communication improvement strategies and examining how senior physicians and nurses can affect interprofessional collaboration.9
The impact of gender and cultural differences in Mexico and the U.S. on nurse-physician relationships was the subject of a recent study. Results indicated that U.S. physicians and nurses expressed more positive attitudes about the value of collaboration than did their Mexican counterparts.10 In both countries, nurses had more positive attitudes toward collaboration than did physicians. There was no difference among female physicians in either country regarding nurse-physician collaboration.10
In a survey of 14 Magnet hospitals, power was the most important factor driving nurse-physician relationships.5 In this survey, five types of relationships were described, ranging from collegial to negative:5
• Collegial — “different but equal” — a true partnership
• Collaborative: Mutual trust and respect produce willing cooperation
• Student-teacher: Physicians and nurses teach and explain. Power is unequal but patient outcomes benefit.
• Neutral: A near absence of relationship
• Negative: Avoidance of communication. Patient outcomes are compromised.
The “different but equal” style characterizing collegial relationships benefits everyone: physicians, nurses and, most important, patients. Working as colleagues, nurses and physicians plan the most appropriate care for individual patients. Collegial relationships represent a true partnership in which nurses feel equal to physicians in caring for patients and both disciplines value the positive effect that medical expertise and nursing expertise combined have on patient care.5 In a collaborative relationship, willing cooperation results from mutual trust and respect. Nurses are afforded some power because of their close contact with patients and their experience in recognizing and solving patient care problems. However, power is not distributed equally.5 Nurses who describe their relationships with physicians as collegial or collaborative rank patient care quality significantly higher than do nurses in situations where power is less equally shared.5 In a student-teacher relationship, both physicians and nurses share information and are willing to explain and teach one another, although the physician member retains power. A neutral relationship is characterized by information exchange only; as a result, there is essentially no relationship.5 In a negative relationship, characterized as one of frustration and hostility, nurses communicate only what is essential. As a result, valuable nursing input necessary for positive patient outcomes is lost.5 In all 14 hospitals surveyed, a positive relationship was found between the quality of nurse-physician relationships and the perceived quality of patient care.5 All of these hospitals surveyed also had developed formal collaborative practice structures that provided a foundation for excellent collaborative practice.5
A Scale of Attitudes
Responding to the need for increased emphasis on interprofessional teamwork, the Thomas Jefferson Medical College Center for Research in Medical Education and Health Care developed the Jefferson Scale of Attitudes Toward Nurse-Physician Collaboration.11 The following are some of the statements posed in this 15-item Likert-type rating questionnaire:11
• Physicians should be the authority in all healthcare matters.
• A nurse should be viewed as a collaborator and colleague with a physician rather than an assistant.
• Interpersonal relationships between physicians and nurses should be included in their educational programs.
• Nurses are qualified to assess and respond to psychological aspects of patients’ needs.
Negative nurse-physician relations jeopardize the ability of nurses to provide optimum patient care. One study reported that daily interactions between nurses and physicians strongly influenced nursing morale.7 Although this survey indicated that only between 2% and 3% of medical staff exhibit disruptive behavior, both nurses and physicians agreed that such behavior negatively affects nurses’ attitudes and is a barrier to the effective teamwork that is essential for safe and effective care. More than 92% of respondents in this study reported witnessing disruptive physician behavior, including yelling, acting in a condescending way, insulting or demeaning staff and using abusive language.7
Nurses reported that disruptive physician behavior was most likely to be associated with calls to physicians, questioning or trying to clarify orders and physician perceptions that orders were delayed. Physicians reported that not having orders carried out promptly and being called inappropriately were their major causes of concern. They also said that being contacted by nurses who lacked relevant patient information was a source of frustration.7 Nurses in this survey also documented barriers that prevented them from reporting abusive physician behavior, including fear of retribution, a perception that “nothing ever changes,” a lack of administrative support and an unwillingness to change on the part of some physicians. Fear of retribution or retaliation was cited as the most important reporting barrier.7 Physicians who avoid communicating with nurses can create an additional source of disruption, forcing nurses to provide care without the benefit of medical collaboration.12 Sixty-seven percent of nurses participating in both the Nursing 1991 and Nursing 2007 surveys reported they had witnessed disruptive physician behavior, confirming that this remains a major workplace problem.
Physicians have learned certain behaviors that reinforce their dominant role in healthcare, such as expecting orders to be carried out immediately. Nurses have also learned a set of behaviors that are often reinforced in work settings, such as unassertive communication and conflict avoidance. In addition to apologizing for interrupting a physician’s work, many nurses would rather avoid conflict than confront a problem head on. Many nurses also find it difficult to directly approach other nurses whose behavior is inappropriate.1 In addition, nurses often avoid communicating with physicians who demonstrate unpleasant behaviors.1 The good news is that learned behaviors can be replaced by new behaviors that can build professionally satisfying work relationships.
Waiting for Empowerment
Every nurse has the ability for self-empowerment. Rather than waiting for empowerment to be bestowed externally, individual nurses can take a leadership role in achieving collaborative practice relationships. The basis of professional partnerships is clinical competence. Nurse leaders can emphasize the importance of a “different but equal” relationship model by communicating that nursing knowledge is different from physician knowledge but as important to patient care.5 Nurse managers can promote a collegial working environment by supporting educational opportunities that continually enhance clinical competence.5
The literature on Magnet organizations describes the positive effect between nursing staff with higher education and improved patient outcomes.12 Encouraging nurses to obtain more nursing education and specialty certification is an important way to support nurses in becoming intellectual peers with physicians.12 Nurse leaders have a key role in this effort by implementing clinical ladders that emphasize professional development, designing flexible work schedules and providing tuition and certification reimbursement.12 Nurses can continue to expand their clinical expertise through participation in continuing education programs and by being knowledgeable about research and evidence-based practice guidelines. Participation in nursing professional organizations is another way to be on the cutting edge of new developments. Participating on interprofessional committees provides nurses with the opportunity to have not only an important voice in organizational policies but also the opportunity for others to view nurses as professionals with excellent problem-solving abilities.3 Nurses who have served in leadership roles on hospital committees can role model to other nurses how to represent nursing in a positive way.
Encouraging physician participation in nursing continuing education is a good opportunity for physicians to be exposed to the breadth of nursing knowledge. For example, a physician who is concerned about the quality of postoperative care for his or her patients could be invited to provide a program about specific surgical procedures and the critical importance of postoperative care. By encouraging physician involvement in educational activities, a nurse manager helps improve clinical knowledge and at the same time establishes a climate in which physicians and nurses can interact without the stress of solving immediate clinical problems.12
Administrators should take the lead in establishing zero-tolerance policies for disruptive behavior from any staff member, including having physicians sign a code of conduct describing expectations for interprofessional collaboration when they join the staff or are recredentialed.7 Physicians can also be encouraged to participate in nursing recruitment activities to let them gain an understanding of factors that matter to nurses seeking employment.7 Nurses can also learn more effective ways to communicate with physicians.
Nurses and physicians use different communication styles. In general, nurses are narrative and descriptive as compared with physicians, who are listening for the bottom line.13 Thousands of times a day, a nurse calls a patient’s physician, often describing a broad narrative picture while the physician is waiting to hear what the problem is so it can be fixed.13 In addition, physicians consistently report frustration with nurses when they perceive a nurse has not gathered enough information or cannot appropriately express why a changing patient situation demands the physician’s attention. Obviously, nurses should be able to clearly articulate the reason for a call and should provide the data the physician needs to make a decision about diagnostic or treatment interventions. Nurses should also refrain from apologizing for making a call and should avoid making statements such as “I do not know this patient very well” or “This is not really my patient.”
Kaiser Permanente has developed a communication tool known as SBAR (Situation, Background, Assessment and Recommendation) that provides a practical framework for organizing and communicating patient information.14 In the Situation section, the nurse states that he or she is calling about a specific patient and defines the problem (e.g., “the patient has developed a sudden change in mental status; he is disoriented and anxious”). The Background section prompts the nurse to provide information about relevant assessment data (e.g., the patient’s prior mental status, vital signs and neurological status). In the Assessment section, the nurse clearly states what he or she thinks is the problem. In the final section, Recommendation, the nurse requests what he or she wants done, such as transferring the patient to intensive care, having the physician come in to see the patient or asking an on-call resident to see the patient promptly. The nurse also asks about whether the physician wants any additional diagnostic tests; if a change in treatment is ordered, the nurse also finds out what treatment outcomes are expected and the parameters for calling the physician again.14 SBAR can be an effective tool for nurse-physician communication, especially when a change in a patient’s conditions warrants close collaboration.13 A recent study of after-hours communication using SBAR reported that simply using an SBAR format didn’t ensure complete communication of vital information. In this study, nurses often did not communicate significant background information and physicians didn’t follow up by asking for necessary information.15 ( Level A)
When a nurse advocates for a plan of action for a patient and the patient’s physician disagrees or ignores a recommendation, the nurse is put in a position of participating in an action that she or he believes is wrong.1 This is why it is vital for nurses to have managerial and administrative support for advocating for a patient’s best interests. Nurse managers can reward critical thinking about patient care issues and coach nurses about the most effective ways to advocate and communicate.12
Nurses consistently report that their work environment is the most significant problem underlying the nursing shortage; at the core of a rewarding and meaningful work environment is the quality of interpersonal relationships. The hectic pace of many patient care settings can reduce the quality of working relationships and in turn can negatively affect the work environment.1 In response to the need to do more and do it faster, the time healthcare professionals spend getting to know one another as individuals with a shared humanitarian purpose has eroded. By learning more about one another as people with families, pets, hobbies, aspirations and challenges, nurses and physicians can help create a working environment in which people are respected and valued.1 When was the last time you had the chance to talk with a physician about anything besides patient care — or he or she with you? If there is not time to build basic social relationships on a patient care unit, innovative ways to do so should be explored. Strategies such as teaching educational programs collaboratively or inviting physicians to unit social events can build the kind of down-to-earth relationships that are the basis for communicating about ways to care for patients.
Nurses can take responsibility for improving nurse-physician collaboration and initiate strategies that free the profession from the subservient role that persists in some organizations.2 Valuable strategies include being assertive, approaching conflict directly rather than avoiding it and using a clear and persistent approach when communicating with physicians and other members of the healthcare team. Nurses can also benefit by role modeling their expertise in caring for patients holistically rather than focusing on tasks.2 Nurses who have excellent relations with their physician colleagues can be enlisted to coach and mentor younger nurses or those who wish to improve their collaboration skills. Nurses might also consider the stresses on their physician colleagues, especially in today’s healthcare environment. Besides being expected to have expert and comprehensive knowledge and working harder and longer, physicians are faced with both reduced reimbursement for their services and skyrocketing malpractice rates.
Creating open communication structures is a responsibility that nurses, physicians and administrators share. Outstanding nurse-physician relationships offer hospitals a competitive advantage. A healthy work climate saves money by lowering recruitment and turnover costs, and an organization gains market share when consumers and insurance providers see it as a safe environment with high-quality outcomes.12
Maureen Habel, RN, MA, is an award-winning nurse author living in Seal Beach, Calif.
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