23634605 nurse physician relationships solutions and recommendations for change

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Nurse-Physician RelationshipsSolutions & Recommendations for Change

MOHLTC Grant # 06221

Comprehensive Report for the Nursing Secretariat and Ministryof Health and Long-Term Care Research Unit

July 1, 2004 - March 31, 2005

REVISED December, 2005

Prepared by

Linda O’Brien-Pallas, RN, PhD

Julie Hiroz, Bsc (Hons)

Amanda Cook, MES

Barbara Mildon, RN, MN, CHE

www.nhsru.com



Nurse-Physician Relationships – Solutions & Recommendations for Change

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TABLE OF CONTENTS

TABLE OF CONTENTS...................................................................................................................2

EXECUTIVE SUMMARY.................................................................................................................4

DETAILED SUMMARY...................................................................................................................5

INTRODUCTION ..........................................................................................................................8

CONTEXT FOR THIS DISCUSSION................................................................................................8

NURSE STAFFING IN HEALTH HUMAN RESOURCE PLANNING......................................................9

IMPORTANCE OF NURSE-PHYSICIAN COMMUNICATION AND COLLABORATION........................10

OUTCOMES OF COLLABORATIVE NURSE-PHYSICIAN RELATIONSHIPS......................................11

IMPETUS FOR INTERDISCIPLINARY COMMUNICATION/ COLLABORATION...............................12

SCOPE OF THE PROBLEM...........................................................................................................13

BARRIERS TO NURSE-PHYSICIAN COLLABORATION .................................................................13

FACTORS AFFECTING NURSE-PHYSICIAN COMMUNICATION ....................................................14

EVOLVING NURSE-PHYSICIAN RELATIONSHIPS .......................................................................14

NURSES & PHYSICIANS’ PERCEPTIONS OF NURSE-PHYSICIAN RELATIONSHIPS......................15

COLLABORATIVE VS COLLEGIAL ...............................................................................................16

COLLABORATIVE VS CONSULTATIVE.........................................................................................17

MAGNET HOSPITAL LITERATURE and NURSE-PHYSICIAN RELATIONSHIPS ..............................18 Definition of a magnet hospital ...................................................................................................... 18 Nurse-Physician Relationships........................................................................................................ 19 Interrelationship of Magnet Hospital Characteristics.......................................................................... 20 Figure 1: A conceptual model of the “Essentials of Magnetism”.......................................................... 21 Figure 2: Factors that Enable Adequate Staffing............................................................................... 22 Moving Forward To Create a Magnet Hospital Environment................................................................ 22 Figure 3: Quality Health Outcomes Model........................................................................................ 23 Strategies to Foster Positive Nurse-Physician Relationships and Magnet Hospital Attributes ................... 24

COLLABORATIVE INTERVENTIONS TO FOSTER NURSE-PHYSICIAN RELATIONSHIPS................26 Summary of Interventions ............................................................................................................27

CONCLUSION AND RECOMMENDATIONS ................................................................................... 28




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APPENDICES

APPENDIX 1..............................................................................................................................37 Client Care Delivery Model (O’Brien-Pallas et al., 2001) ....................................................................37

APPENDIX 2..............................................................................................................................38 Inclusion Criteria for Review of Interventions for Nurse-Physician Relationships and For Magnet Hospital

Literature Review......................................................................................................................... 38

APPENDIX 3..............................................................................................................................40 Selected List of Interventions ........................................................................................................ 40

APPENDIX 4..............................................................................................................................42 Summary of Instruments & Tools Reported in the Literature.............................................................. 42

APPENDIX 5..............................................................................................................................44 Summary of Literature Findings Related to Nurse-Physician Relationships ........................................... 44 EDUCATION ................................................................................................................................ 44 RESEARCH .................................................................................................................................. 46 OTHER........................................................................................................................................ 47

APPENDIX 6..............................................................................................................................49 A Conceptual Model Representing Strategies Identified by Kramer & Schmalenberg (2002) and Hinshaw(2002) as Fostering Magnet Hospital Characteristics......................................................................... 49

APPENDIX 7..............................................................................................................................50 Nurse-Physician Focused Survey Questions From Health Human Resources Modelling: Challenging thePast, Creating the Future Study (Project 3) ..................................................................................... 50




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EXECUTIVE SUMMARY

This report presents the findings of the Ministry of Health and Long Term Care(MOHLTC) directed research on the topic of nurse-physician relationships, and

includes recommendations arising from the in depth literature review conducted andwhich are directed toward the Research Unit and Nursing Secretariat, at the

MOHLTC. They have been developed with the goal of raising awareness of theimportance of positive nurse-physician relationships throughout the healthcare

system, and informing policy and decision-makers regarding initiatives and

interventions that strengthen and optimize nurse-physician relationships. Therecommendations are as follows:

1. As part of the NHSRU University of Toronto site’s ministry-directed research for

2005-2006:

• Write a feasibility study proposal (i.e., intervention group, demonstration study).

• Develop fact sheets on nurse-physician relationships, and magnet healthcareorganization attributes to be used for clinical and policy direction.

• Develop a distribution/dissemination plan for the fact sheets.

• Summarize findings from the nurse-physician relationship focused questionscontained in the Health Human Resource Modelling: Challenging the Past,

Creating the Future study (project 3), scheduled for distribution in September2005 (see Appendix 7).

• Conduct an environmental scan on nurse-physician relationships (e.g., nurse-physician relationship awareness and/or activities of organizations such as the

Canadian Council on Health Services Accreditation, Canadian Health CareAssociation, Canadian Association for Schools of Nursing, Canadian Nurses

Association, Ontario Nurses Association, Registered Nurses Association of

Ontario, Registered Practical Nurses Association, College of Physicians andSurgeons of Ontario etc).

2. Develop strong indicators that are valid and reliable and then measure nurse-physician relationship indicators as part of the hospital report card system and

RFP Template for Community Care Access Centres (or contract monitoringprotocols).

3. Explore the feasibility of including initiatives related to nurse-physicianrelationships and magnet hospital attributes in the strategic plan of the Joint

Provincial Nursing Committee:

• Commission (RFP process or alternate) a research project to test anintervention(s) designed to positively influence nurse-physician relationships.

4. Following additional research and the implementation of an intervention study, anurse-physician collaboration component could be added to the funded Ontario

Nursing Strategy Initiatives. A Request for Proposal could be developed forhealthcare organizations to submit their project ideas to optimize nurse-physician

collaboration that could then be considered for funding to a level established bythe MOHLTC.

5. Encourage the Canadian Association for Schools of Nursing and the Council of

Ontario Universities to develop curricula for their health discipline programs tobuild communication skills and foster optimal collaboration between nursing and

medical faculties, students, and graduates.6. Commission a best practice guideline on nurse-physician collaboration as part of

the Registered Nurses Association of Ontario’s “Best Practice Guidelines” programfunded by the MOHLTC.




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DETAILED SUMMARY

At the request of the MOHLTC, a research project was undertaken on the topic of nurse-physician relationships. This report presents the findings of that research,

including potential solutions and recommendations arising from the literature review.As optimal nurse-physician relationships are a primary characteristic of “magnet

hospitals”, a comprehensive overview of magnet hospital concepts and literature isalso included.

The current nursing shortage has focused public attention on the importance of nursing care (Williamson, 2003), and the unfavourable conditions under which most

nurses work: poor financial rewards, low professional autonomy, and limitedparticipation in decision making processes (Stein et al., 1990). Jansky (2004), states

that the current nursing shortage is directly affected by nurse-physicianrelationships. When those relationships are positive, nurses are more likely to feel

satisfied within their workplace and to remain in their current positions. This jobsatisfaction maintains nurses’ equilibrium, and prevents burnout. Furthermore, The

Evidence Based Staffing Study (O’Brien-Pallas et al., 2004) contends that “as

relationships between nurses and physicians improve, nurses are more likely to bephysically healthy” (p. 15). This conclusion is further supported by studies that

examined nurse-physician collaboration within magnet hospitals (Smith, 2004; Scottet al., 1999). Additionally, increased collaboration has also been associated with

higher job satisfaction, and productivity levels in physicians (Miccolo & Spanier,1993; Genet et al., 1995, as cited in Corser, 1998).

Nurse-physician relationships have long been the focus of ongoing debate. In 1967

Stein compared the nurse-physician relationship to a game model, with nurses

making recommendations for patient care in such a way that it appeared as if thephysicians initiated them. Stein also commented that “the game is basically a

transactional neurosis” (Stein, 1967, p. 703). If the game were played correctly,both sides would benefit, however any divergence from this openly accepted method

of interaction could result in severe penalties. The training of medical and nursingstudents was believed to be the root of the problem, as this was acknowledged as

shaping the future attitudes of nurses and doctors (Stein, 1967).

The nurse-physician relationship is constantly evolving. Recent changes include the

fact that nurses are no longer exclusively female and physicians are more likely to befemale. In addition, public esteem for physicians has deteriorated, there is increased

public awareness of disease treatments and outcomes, and the commercialization of medical care has undermined public confidence in the physicians’ commitment to

altruistic concerns (Stein et al., 1990; Williamson, 2003).

Rosenstein (2002) conducted a survey targeting nurses, physicians, and healthcareexecutives in a large network of hospitals. The majority of respondents reported

some degree of disruptive physician behaviour in their institutions, and both

physicians and nurses agreed that it influences nurses’ as well as other staff members’ attitudes towards patient care, inhibits teamwork, and affects the

outcomes of patient care. This is backed up further by studies which havedemonstrated that communication and collaboration between nurses and physicians

can have a profound effect on workplace environment and patient care (Baggs et al.,1997; Pike, 1991; Knaus et al., 1986; Lo, 1995).




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Interestingly, good nurse-physician relationships have been repeatedly identified as

a fundamental characteristic of magnet hospitals (McClure, Poulin, Sovie, & Wandelt,

1983; Kramer & Schmalenberg, 2002; Hinshaw, 2002) and the link between magnethospitals and positive nurse-physician collaboration has been strongly established. A

study was carried out in 14 magnet hospitals where nurses and nurse managerswere interviewed. Regardless of the definition of collaboration used, a positive

correlation was found between the quality of nurse-physician relationships and thereported quality of care for patients (Kramer & Schmalenberg, 2003). Furthermore,

magnet hospitals have been shown to have better patient outcomes, including lower

mortality rates (Aiken et al., 1994; Laschinger et al., 2003).

Magnet hospitals are organizational settings characterized by an emphasis onprofessional autonomy, decentralized organizational structures, participatory

management, and self-governance (Upenieks, 2003). Magnet hospitals consistentlydemonstrate three key characteristics: nurses have the status needed to influence

people and to get the resources for good patient care; good collaboration exists

between nurses, physicians, and administrators; and established systems ensurenurses’ participation in policy decisions (autonomy within clinical practice) (Jones-

Schenk, 2001; Scott et al., 1999; Havens & Aiken, 1999).

The magnet hospital literature has been less clear about how magnet facilities cometo achieve good nurse-physician relationships. Various statements are made that

infer a synergistic or cumulative association between the various magnet hospital

characteristics, making a clear cause and effect process with regard to nurse-physician relationships difficult, if not impossible, to identify/isolate. Moreover,

Hinshaw (2002) observes, through her thorough appraisal of the magnet literaturethat the research is not as explicit in suggesting strategies for promoting positive

nurse-physician relationships as for other magnet characteristics. Whether or not thistruly reflects an inability to isolate a precise cause and effect relationship, or that

nurse-physician relationships are simply more multidimensional than other

characteristics of magnet hospitals, is unclear. It could also be due to a lack of

sufficient measurement tools with regard to nurse-physician relationships, hinderingresearchers’ ability to reliably study the characteristic at this point in time.

While hospitals may have little control over patient characteristics such as theseverity or complexity of the patients’ conditions, they can have a significant impact

on other aspects of the overall system (O’Brien-Pallas et al., 2004). These aspects

include nurse characteristics, system characteristics and behaviours, andenvironmental complexity factors, which are amenable to policy and management

interventions (O’Brien-Pallas, Giovannetti, Peereboom, & Marton, 1995). Accordingly,interventions targeted at certain areas of patient-care delivery (e.g., nurse-physician

relationships), may be extremely useful in improving nurses’ workplace environment,satisfaction, and concomitantly the recruitment and retention of nurses (Rosenstein,

2002).

Collaborative nurse-physician relationships are associated with improved patient,

nurse and physician outcomes (Corser, 1998). For example, significant patientoutcomes which have been noted include: improved patient satisfaction (Baggs &

Ryan, 1990; Devereaux, 1981; King, 1990; McEwan, 1994; Liedtka & Whitten,1998); improved patient care or outcomes (Horak et al., 2004; Aiken, 2001; Gitell et

al., 2000; and others); and reduced medication errors (Sim & Joyner, 2002; Lassenet al., 1997). Nurse outcomes include decreased job associated stress (Baggs &

Ryan, 1990) and improved efficiency (Aiken, 2001). Physician outcomes include




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improved job satisfaction and decreased job associated stress (Miccolo & Spanier,

1993). Organizational outcomes associated include: decreased costs (Liedtka &

Whitten, 1998; Lassen et al., 1997); and improved efficiency of healthcare workers(Aiken, 2001).

Although collaboration has been identified as “an essential element of quality

healthcare” (Coeling & Cukr, 2000, p. 63), with several positive outcomes as shownabove, the belief is that it is still not commonplace within the majority of healthcare

organizations (Coeling & Cukr, 2000; Barrere & Ellis, 2002). This could be due in part

to barriers which still exist in a variety of different healthcare settings (Ryan, 1999;Resnick & Bonner, 2003; Neale, 1999; Taylor-Seehafer, 1998; Rosenstein, 2002;

Castledine, 2004). Barriers to nurse-physician collaboration are reported to occurdue to: role misunderstanding; real and perceived differentials in power (Corser,

2000), position and respect; and varying perceptions of decision-making input andautonomy (Baggs et al., 1997; Baldwin et al., 1987; Pike, 1991; Knaus et al., 1986;

Lo, 1995; as cited in Larson et al., 1998). In addition to barriers, Coeling and Cukr

(2000) state that it is not enough to insist that healthcare professionals collaboratemore, as lack of collaboration in most cases is due to a lack of relevant skills.

Successful collaboration fosters quality, satisfaction, and enhanced productivity forthose who provide and those who receive healthcare (Korabek et al., 2004; Warrenet al., 1998). As a result, collaboration has the potential to significantly impact on

healthcare organizations (Warren et al., 1998); and “It is becoming increasingly clear

that now and in the future a health care model consisting of partnerships that buildcollaborative interventions is the approach that will lead to improved health

outcomes for the public at large and in particular to vulnerable and at-riskpopulations” (Bolton et al., 1998, p. 6).

This report documents the strong evidence that exists in support of the importance

of positive nurse-physician relationships. It is clear that these relationships are an

essential attribute of “magnet” healthcare organizations and promote optimal

outcomes for nurses, physicians, patients and healthcare organizations. The in depthliterature review uncovers a series of recommendations to foster positive nurse-physician relationships and magnet hospital attributes. These include: training

workshops in collaboration and communication skills, joint interdisciplinary staff meetings, case scenarios, co-ordination of care, and patient centered care efforts.

These interventions are offered as ways in which nurse-physician relationships may

be improved and consequently improve nurses’ job satisfaction, promote retention of the current nursing workforce, recruitment of new graduates, and decrease

healthcare costs.

Selected policy implications arising from this report include: (1) The need to raiseawareness of the importance of positive nurse-physician relationships with such

individuals or associations as the Ontario Ministry of Health and Long-Term Care,

Ontario Ministry of Training, Colleges and Universities, Ontario Hospital Association,Ontario College of Physicians and Surgeons, Council of Universities, Joint Provincial

Nursing Committee, Joint Provincial Planning Committee, etc.; (2) the need tomeasure nurse-physician relationship indicators as part of the hospital report card

system and RFP Template for Community Care Access Centres (or contractmonitoring protocols); and (3) the need to incorporate collaborative education

models and curricula for nurses and physicians.




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INTRODUCTION

Research into nurse-physician relationships is timely as efforts to implement healthy

workplaces and promote long-term recruitment and retention for nurses are beingemphasized in the context of today’s healthcare system. Communication and

collaboration between nursing and medicine can have a profound effect on workplace

environment and patient care (Baggs, Schmitt, Mushlin, Eldredge, Oakes, & Hutson,1997; Pike, 1991; Knaus, Draper, Wagner, & Zimmerman, 1986; Lo, 1995). Jansky

(2004), states that the current nursing shortage is directly affected by nurse-physician relationships. When those relationships are positive, nurses are more likely

to feel satisfied with their work place and remain in their current positions. Thissatisfaction in turn maintains the nurses’ equilibrium, and prevents burnout. Further

evidence of this conclusion is provided by studies which examined nurse-physician

collaboration, usually within magnet hospitals (Smith, 2004; Scott, Sochalski, & Aiken, 1999). In the 1980s, research identified that Magnet, or “gold standard”

hospitals are able to recruit and retain nurses during a nursing shortage (Dechairo-Marino, Jordan-Marsh, Traiger, & Saulo, 2001). Further research (Scott et al., 1999)

identified collaboration amongst healthcare professionals as one of the variables

which affects an organization’s ability to recruit and retain nursing staff.

CONTEXT FOR THIS DISCUSSION

Current global nursing shortages have highlighted the need for effective recruitment

and retention strategies for nurses. Major restructuring within healthcare hasbrought about a new organizational framework, which has prompted the need to

focus on important factors within healthcare organizations. O’Brien-Pallas, Thomson,

Alksnis, and Bruce (2001, p. 44) stated that “during periods of undersupply nurseswill leave an organization if they are dissatisfied with the working conditions”, and

this turnover of nurses will decrease the productivity of nursing units (O’Brien-Pallas,Thomson, McGillis Hall, Pink, Kerr, Wang et al., 2004; O’Brien-Pallas, Thomson, et

al., 2001). Nurse-physician relations have been cited as a key factor in nurseretention and healthy workplaces.

Changes which have been observed in healthcare within the past decade include:

increased responsibilities for healthcare professionals; elimination of healthcare

positions; higher acuity and complexity of hospital patients; a significant decrease inthe number of hospital beds (O’Brien-Pallas, Baumann, & Lochhass-Gerlach, 1998) a

reduction in the average hospital length of stay (O’Brien-Pallas et al., 1998); morestressful work environments; inappropriate staffing levels which have led to

increased workloads, reduced job satisfaction, and low morale; reduced job security;substitution of RNs and RPNs with unregulated care providers; a reduction in the

ratio of full time to part time nursing staff; and increased utilization of agency nurses

(O’Brien-Pallas, Thomson, et al., 2001; O’Brien-Pallas et al., 2004; Bruce, Sale,

Shamian, O’Brien-Pallas, & Thomson, 2002). In combination, these factors lead tolower professional and organizational commitment (Baumann, Giovannetti, O’Brien-Pallas, Mallette, Deber, Blythe et al., 2001).

“Healthcare restructuring in Canada is currently being addressed at national,

provincial and regional levels” (Korabek, Rosenau, Slauenwhite, & Ross, 2004, p.

261). This trend has put particular emphasis on healthcare research with a move toincorporate evidence based practice, integrate healthcare services provided by

different disciplines across the care continuum, and design and implement primary




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care models incorporating collaborative practices and partnerships between

healthcare professionals (Korabek et al., 2004).

NURSE STAFFING IN HEALTH HUMAN RESOURCE PLANNING

According to the World Health Organization (2000) health human resource planning

(HHRP) is a means of determining the appropriate quantity, mix, and distribution of healthcare personnel. “The different kinds of clinical and non-clinical staff who make

each individual and public health intervention happen are the most important inputs

of the health system” (WHO, 2000; as cited in O’Brien-Pallas, 2002, p. 3). “Globallynot many countries have made the link between population health outcomes,

planning, quality of work environments and recruitment and retention of nursingpersonnel”. (O’Brien-Pallas, 2002, p. 3)

Nurse staffing is closely linked to patient outcomes and system effectiveness, which

has prompted policy makers and hospital administrators to seek evidence on whichto base their future decisions regarding health human resources. These decisions

include the number of healthcare providers required, and the appropriate mix of

skilled professionals that will allow the healthcare organization to provide theappropriate level of care (O’Brien-Pallas et al., 2004).

Nurse staffing levels are particularly significant in light of current research, which

shows that patients’ health improves when nurses have a satisfying workenvironment (O’Brien-Pallas et al., 2004; Estabrooks, Midodzi, Cummings, Ricker, &

Giovannetti, 2005). The Client Care Delivery Model (O’Brien-Pallas, Doran, Murray,Cockerill, Sidani, Laurie-Shaw et al., 2001, see Appendix 1) depicts the relationship

between inputs, outputs, and throughputs within the healthcare community and how

these affect patient care.

The client care delivery model “highlights that client, provider, and agency inputscross the boundaries of the client care delivery system. A transformation occurs as a

consequence of interactions and processes among system substructures which resultin outputs and feedback for the entire system” (O’Brien-Pallas, Doran, et al., 2001,

p. 269). Inputs include client characteristics and patient care needs. Providercharacteristics take into consideration the professional status of the nurse,

educational status (i.e., diploma or degree prepared), experience as a nurse, and

other demographics. Agency or hospital unit characteristics include the geographiclocation or patient population, and the human resources decisions made by the

organization (e.g., caseload, skill mix, and continuity of care provided). Throughputsare the interventions provided to patients and are influenced by environmental

complexity factors. These factors reflect the unpredictable and complex nature of thework environment (e.g., unanticipated case complexity, re-sequencing of work,

changes in patient acuity and characteristics, and the composition of the caregivingteam). Outputs in this model are the outcomes of care for the client (e.g., knowledge

and behaviour), for the provider (e.g., nurses’ perception of the quality of care and

time available in each visit), and the organization (e.g., length of stay, cost, quality,etc.). Testing of this model in home care and acute hospital cardiovascular settings

(O’Brien-Pallas et al., 2004), provided evidence to inform nurse staffing levels andutilization.

O’Brien-Pallas et al. (2004) state that although hospitals have little control over

patient characteristics such as the severity or complexity of the patients’ conditions,they may have a significant influence on other aspects of the overall system. These




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aspects include nurse characteristics, system characteristics and behaviours, and

environmental complexity factors, which are amenable to policy and management

interventions, as illustrated in the Patient Care Delivery Model (O’Brien-Pallas et al.,2004). This is timely as studies have shown that improving nurses’ trust in

management and reducing burnout, can impact on quality of nursing worklife andultimately the quality of patient care (Laschinger, Shamian, & Thomson, 2001).

Combined with autonomy, control over practice, and collaborative relationships withphysicians, these are some of the factors which “are essential to retaining highly

qualified, motivated nursing staff” (Laschinger et al., 2001, p. 10).

One possible area of patient care delivery which may be targeted is inter-disciplinary

communication and collaboration between nurses and physicians. This area isparticularly relevant as higher levels of collaboration have been associated with lower

predicted death rates, lower risk adjusted length of stay, lower nurse turnover, lessfragmentation of care, patient satisfaction, and better patient outcomes (Laschinger

et al., 2001; Laschinger, Almost, & Tuer-Hodes, 2003).

The Evidence Based Staffing Study (O’Brien-Pallas et al., 2004) set out to measure

the effect of certain variables which were believed to impact on patient, nurse, and

system outcomes; t h e r e s u l t s i d e n t i f i e d t h a t “ a s r e l a t i o n s h i p s b e t w e e n n u r s e s

a n d p h y s i c i a n s im p r o v e , n u r s e s a r e m o r e l i k e ly t o b e p h y s i ca l ly h e a l t h y ”

(O’Brien-Pallas et al., 2004, p. 15). Therefore interventions targeted at areas of

patient-care delivery (e.g., nurse-physician relationships) may be extremely useful in

improving nurses’ workplace environment, satisfaction, and concomitantly therecruitment and retention of nurses (Rosenstein, 2002). This is particularly important

as the “growing concern about the worldwide shortage of nurses will necessitatemore attention to recruitment and retention issues” (Laschinger et al., 2001, p. 10).

Zwarenstein and Bryant (2004) reinforce this theory by stating “if the lack of nurse-

doctor collaboration contributes to problems in quality and efficiency of patient care,

interventions to improve collaboration may impact positively on care” (p. 3). This

belief is based on current organizational theory (Andreason, 1995, as cited inZwarenstein & Bryant, 2004) from other industry sectors, which states that thequality of the product and the efficiency of production are dependent on successful

teamwork. Therefore if this theory is applied to the healthcare industry one couldassume that efficiency and quality of patient care, is dependent on the degree to

which inter-disciplinary relationships are collaborative.

IMPORTANCE OF NURSE-PHYSICIAN COMMUNICATION AND

COLLABORATION

There is evidence that communication and collaboration are central elements of good

nurse-physician relationships (Ryan, 1999; Coeling & Cukr, 2000). Boyle and

Kochinda (2004, p. 61) define collaboration as “nurses and physicians workingtogether cooperatively to achieve shared problem solving, conflict resolution,

decision making, communication and coordination”. Collaboration has also beendescribed as: “a process which allows the interaction of colleagues within a flat

hierarchy, with individuals being able to make decisions both independently and aspart of a team” (Burchell, Thomas, & Smith, 1983, as cited in Taylor-Seehafer, 1998,

p. 387); and “an interaction that includes consideration for all comments involved inthe interaction, and active integration of the perspectives and skills of various

participants” (Coeling & Cukr, 2000, p. 67). Keenan, Cooke, and Hillis (1998, p. 69)




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recalled the suggestion by Gray (1989) that “the essence of collaboration is balanced

power among participants who recognize each other’s mutual value”. Whereas the

Kilmann and Thomas (1977) model of conflict resolution (as cited in Dechairo-Marinoet al., 2001), states that collaboration involves a high level of concern for others

(cooperativeness), as well as a high concern for self (assertiveness).

Regardless of which description is used, the central element of collaboration seemsto be communication. Corser (1998) devised a conceptual model of collaborative

nurse-physician interaction based on the premise that the actual interaction which

takes place between the individuals involved, whether it is a telephone call, face toface meeting, or an email, is regarded as the fundamental aspect which is “required

to maintain the overall character of the relationship between the nurse andphysician” (Corser, 1998, p. 334). The other factors which contribute to collaboration

seem to be mutual trust, respect, and shared decision making responsibilities.

OUTCOMES OF COLLABORATIVE NURSE-PHYSICIAN

RELATIONSHIPS

Co l l a b o r a t i v e n u r s e - p h y s i ci a n r e l at i o n s h i p s a r e a ss o c ia t e d w i t h i m p r o v e d p a t i e n t , n u r s e , a n d p h y s i ci a n o u t c om e s (Corser, 1998). The significant patientoutcomes which have been noted include:

• Improved patient satisfaction (Baggs & Ryan, 1990; Devereaux, 1981; King,1990; McEwan, 1994; Liedtka & Whitten, 1998).

• Improved patient transfer and discharge decisions (Baggs, Ryan, Phelps,Richeson, & Johnson, 1992; Coluccio & Kindely Kelley, 1994; Fagen, 1992).

• Improved patient care or outcomes (Horak, Pauig, Keidan, & Kerns, 2004;Coeling & Cukr, 2000; Aiken, 2001; Gitell, Fairfield, Bierbaum, Head,

Jackson, Kelly, et al., 2000; Shortell, Jones, Rademaker, Gillies, Dranove,

Hughes et al., 2000; Dechairo-Marino et al., 2001; Baggs, Schmitt, Mushlin,Mitchell, Eldredge, Oakes et al., 1999; Lassen, Fosbinder, Minton, & Robins,

1997; Estabrooks et al., 2005).• Decreased risk-adjusted length of stay for patients (Shortell, Zimmerman,

Rousseau, Gillies, Wagner, Draper et al., 1994; Baggs et al., 1992; Aiken,2001; Lassen et al., 1997).

• Reduced medication errors (Sim & Joyner, 2002; Lassen et al., 1997).

• Interestingly, collaboration has also been found to be an integral factor inpositive patient outcomes regardless of the severity of the patient’s condition

(Barrere & Ellis, 2002).

Nursing outcomes associated with nurse-physician collaboration include:

• Improved job satisfaction (Baggs & Ryan, 1990; Baggs et al., 1992; Taylor,

1996).• Decreased job associated stress (Baggs & Ryan, 1990).

• Lower nurse turnover rates (O’Brien Pallas et al., 2004).

• Improved communication amongst caregivers (Liedka & Whitten, 1998;

Miccolo & Spanier, 1993; Lassen et al., 1997).

• Improved understanding of the nursing role (Liedka & Whitten, 1998).

• Improved efficiency (Aiken, 2001).




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Physician outcomes associated with nurse-physician collaboration include:

• Improved job satisfaction (Miccolo & Spanier, 1993).

• Improved communication amongst caregivers (Liedka & Whitten, 1998;

Miccolo & Spanier, 1993; Lassen et al., 1997).

• Decreased job associated stress (Miccolo & Spanier, 1993).

• Improved understanding of the nursing role (Liedka & Whitten, 1998).• Improved efficiency (Aiken, 2001).

Organizational outcomes associated with nurse-physician collaboration include:

• Decreased costs (Liedka & Whitten, 1998; Lassen et al., 1997).

• Improved efficiency of healthcare workers (Aiken, 2001).

Evidence emerging from the research available suggests that improving nurse-

physician collaboration is a way of attaining these favourable outcomes. Positive

nurse-physician relationships set the standard for healthy workplaces withinhealthcare organizations. Accordingly when these relationships are stressed it may

make communication with other health professionals equally difficult (Jansky, 2004).

Although collaboration has been identified as “an essential element of qualityhealthcare” (Coeling & Cukr, 2000, p. 63), with several positive outcomes as shown

above, the belief is that it is still not commonplace within the majority of healthcare

organizations (Coeling & Cukr, 2000; Barrere & Ellis, 2002). This may be due to anumber of different factors. Coeling and Cukr (2000) state that it is not enough to

insist that healthcare professionals collaborate more, as lack of collaboration in mostcases is due to a lack of relevant skills. Some research suggests that there may be

negative outcomes associated with collaboration, such as increasing healthcareprofessionals’ job stress, brought on by the responsibilities associated with increased

collaboration (Cape, 1986; Prescott, Dennis, & Jacox, 1987; as cited in Corser,

1998).

IMPETUS FOR INTERDISCIPLINARY COMMUNICATION/COLLABORATION

The recent impetus for improving interdisciplinary collaboration among healthcareprofessionals may be attributed to a number of different factors: increased patient

acuity and complexity, shorter lengths of stay, and more frequent interactions

among different healthcare professionals. Corser (1998, p. 325) states that as the “sicker and quicker” conditions that characterize modern healthcare practice

intensify, so will the requirement for effective communication, and complementaryrelationships between healthcare professionals.

“Collaboration is the healthcare buzzword of the 1990s. It improves patient care,enhances job satisfaction, boosts productivity, and helps to contain costs”

(Pavlovich-Danis, Forman, & Simek, 1998, p. 20). The development of understanding, respect, and trust amongst healthcare professionals, seems to be an

essential process in ensuring effective collaboration amongst healthcareprofessionals, and an appreciation of each individual’s strengths and limitations. “It

is becoming increasingly clear that now and in the future a healthcare modelconsisting of partnerships that build collaborative interventions is the approach that

will lead to improved health outcomes for the public at large and in particular to




13

vulnerable and at-risk populations” (Bolton, Georges, Hunter, Long, & Wray, 1998, p.

6).

Successful collaboration fosters quality, satisfaction, and enhanced productivity for

those who provide and those who receive healthcare (Korabek et al., 2004; Warren,Houston, & Luquire, 1998). As a result, collaboration has the potential to significantly

impact on healthcare organizations (Warren et al., 1998). The key to assembling asuccessful collaborative team within a healthcare organization is to put together “a

multidisciplinary team in which the healthcare professionals treat a patient

independently but share information, pool their knowledge, and jointly evaluate ordevelop an appropriate plan of care” (Warren et al., 1998, p. 95).

Following an extensive review of the literature from 1982 to 1998, surrounding

collaborative nurse-physician interactions, Corser (1998) observed that the majorityof work published focuses specifically on factors that contribute to collaboration. This

presents a major obstacle as non-clinical definitions of collaboration fail to take into

consideration the fact that nurses and physicians rarely possess the same viewregarding what collaborative interaction encompasses.

SCOPE OF THE PROBLEM

As mentioned earlier, research has shown a positive relationship between the quality

of nurse-physician relationships and the quality of patient care (Estabrooks et al.,2005). Combined with autonomy, decision-making ability and professional

development opportunities, these factors are major determinants of the work placeenvironment (Smith, 2004). Rosenstein (2002) conducted a survey targeting nurses,

physicians, and healthcare executives in a large network of hospitals. The majority of

respondents (92.5%) reported witnessing some degree of disruptive physicianbehaviour in their institutions, and both physicians and nurses agreed that it

influences nurses’ as well as other staff members’ attitudes towards patient care,inhibits teamwork, and affects the outcomes of patient care.

BARRIERS TO NURSE-PHYSICIAN COLLABORATION

Barriers to nurse-physician collaboration still exist in a variety of different healthcare

settings (Ryan, 1999; Resnick & Bonner, 2003; Neale, 1999; Taylor-Seehafer, 1998;

Rosenstein, 2002; Castledine, 2004). The barriers are reported to occur due to: rolemisunderstanding; real and perceived differentials in power (Corser, 2000), position

and respect; and varying perceptions of decision-making input and autonomy (Baggset al., 1997; Baldwin, Welches, Walker, & Eliastam, 1987; Pike, 1991; Knaus,

Draper, Wagner, & Zimmerman, 1986; Lo, 1995; as cited in Larson, Hamilton,Mitchell, & Eisenberg, 1998).

Patients are also becoming more knowledgeable about their conditions and possibletreatments, which has led to requests for more information from the healthcare

professionals treating them (Williamson, 2003). This greater involvement of consumers in their healthcare decisions demands increased inter-disciplinary

communication in order to provide the necessary information (Fox, 2000).




14

FACTORS AFFECTING NURSE-PHYSICIAN COMMUNICATION

Fox (2000) conducted a communications audit in the United Kingdom to determinethe factors which affect internal communication between nurses and physicians. The

results identified 5 key inter-related factors: awareness, experience, interaction,profession, and environment.

Awareness of protocols and regulations regarding communication were not common

knowledge amongst nurses or physicians within the healthcare organization.

Physicians and nurses at the lower levels (i.e., less experience) had the most limitedknowledge of procedures; however overall, nurses appeared to have a better

knowledge than the physicians. When questioned, it was noted that senior houseofficers (1 year post graduation and following registration with the General Medical

Council) and clinical assistants were the only groups which felt that no improvementsin communication were needed. It should be taken into consideration that clinical

assistants have limited time in the hospital and are not ward based. Experience alsohad a notable effect on the ability to communicate verbally; senior staff members

were more proficient than the less experienced members of both disciplines.

The general consensus was that better interaction between physicians and nurses

would improve the working environment. Additionally, as may be expected, thefindings indicated that interaction between the two disciplines was more difficult than

interactions within the disciplines. Interestingly, interaction seemed much moreeffective within nursing in comparison to medicine, which is perhaps due to the

hierarchical framework which is reported to exist within medicine.

Nurses and physicians were often unaware of each other’s issues and concerns

regarding communication, and nurses stated that they felt communication was muchmore of a problem than the physicians perceived. Absence of understanding of the

other discipline’s role within healthcare, and a lack of mutual respect were found tohave an extremely negative effect on communication.

Finally the work environment had a significant impact on communication, with staff

recognizing that communication was better in clinics than in wards. This is perhapsdue to the more clearly defined roles of each profession within a clinic environment

and increased interaction between different healthcare professionals. Although the

overall consensus was that while the work environment could have a significanteffect on communication, it was more likely that communication affected the work

environment to a greater extent.

EVOLVING NURSE-PHYSICIAN RELATIONSHIPS

Nurse-physician relationships have long been the focus of ongoing debate. In the

past it was assumed that “there was clear agreement between the two disciplinesthat the relationship was hierarchical with doctors being superior to nurses” (Stein,

Watts, & Howell, 1990, p. 546). This finding was reinforced by Tourish and Irving(1995) who described the medical profession as being traditionally hierarchical and

inward looking.

“The relationship between the doctor and the nurse is a special one, based on mutualrespect and interdependence, steeped in history, and stereotyped in popular culture”

(Stein et al., 1990, p. 546). In 1967 Stein compared the nurse-physician relationship




15

to a game model, with nurses making recommendations for patient care in such a

way that it appeared as if the physicians initiated them. The major drawback with

this sort of interaction is that it has an “inhibitory effect on open dialogue which isstifling and anti-intellectual. The game is basically a transactional neurosis” (Stein,

1967, p. 703). However, Stein (1967) reported that the game, like any other, wasnot without rewards and penalties. If the game was played correctly, both sides

would benefit; however, any divergence from this openly accepted method of interaction could result in severe penalties. As a result, nurses were commonly

treated as doctors’ handmaidens (Williamson, 2003; Trossman, 2003; Pavlovich-

Danis et al., 1998), and the interaction between the two disciplines was verycarefully structured so as not to disturb the hierarchy. The training of medical and

nursing students was believed to be the root of the problem, as this wasacknowledged as shaping the future attitudes of nurses and doctors (Stein, 1967).

The nurse-physician relationship is constantly evolving. Recent changes include the

fact that nurses are no longer exclusively female and physicians are more likely to be

female. In addition, public esteem for physicians has deteriorated, there is increasedpublic awareness of disease treatments and outcomes, and the commercialization of

medical care has undermined public confidence in the physicians’ commitment to

altruistic concerns (Stein et al., 1990; Williamson, 2003). However, according toPorter (1991, p. 728) some of the original problems still appear to exist as he states, “unproblematic subordination and the informal covert decision-making types of

interaction appeared superficially to be used frequently”. Although it should be noted

that his findings also indicated that “nurses were less dependent on thesesubordinate modes of interaction than much of the literature suggested” (p. 728).

Other factors that may influence nurse-physician relationships include culturalconditioning wherein men assume the power roles; and the media portrayal of

nurses as less intelligent, more irrational, and having less input in healthcaredecisions than physicians (Pavlovich-Danis et al., 1998).

NURSES & PHYSICIANS’ PERCEPTIONS OF NURSE-PHYSICIAN

RELATIONSHIPS

The current nursing shortage has focused public attention on the importance of nursing care (Williamson, 2003), and the unfavourable conditions in which most

nurses work: poor financial rewards, low professional autonomy, limited participation

in decision making processes (Stein et al., 1990), and at utilization levels of 93%and above (far higher than the 85% ±5% recommended by O’Brien-Pallas et al.,

2004). Nurses possess a unique set of skills which afford them a high level of knowledge and understanding when it comes to assessing a patient’s condition. They

spend the most time looking after patients and observing their gradual changes(Jansky, 2004). However nurses generally feel that physicians do not respect them

for their unique knowledge and skills, which has a negative effect on their

relationships (Jansky, 2004).

The growing body of literature suggests nurses and physicians have differentperceptions of collaborative interactions, which hinders future efforts to investigate

their significance (Corser, 1998; Larson et al., 1998). This is backed up by anexploratory study carried out by Larson et al. (1998) into nurse–physician

relationships. Results from questionnaires and interviews showed that while nursesand physicians share a similar opinion of the importance of communication within the

hospital, they have different views on their respective group’s contributions to the




16

process. Nurses perceived that they gave information to physicians more often than

they received it, they made suggestions as often as physicians, and they provided

information to physicians regarding nursing care as often as physicians providedinformation regarding medical care. Statistically the physicians did not agree with the

nurses’ perceptions. However, the majority of the difference in opinion regardingcontribution to the communication process was between the nurses and the house

officers (1 year post graduation and following registration with the General MedicalCouncil), rather than the more experienced attending physicians. Nurses felt that

their interactions with house officers required a number of improvements; this was in

contrast to their relationships with attending physicians. During the interviews,attending physicians expressed a greater respect for, and appreciation of the

contribution that nurses make to patient care. This greater respect and appreciationcould be attributed to physician experience, maturity, or an increased level of

interaction (Larson et al., 1998). Additionally the findings showed that nurses andattending physicians had better relationships, from the nurses’ perception. Finally the

findings indicated that the communication styles observed were most likely to stem

from social influences, as opposed to changes within the healthcare organization,such as re-structuring.

Traditional differences in views between nurses and physicians have not only heldback advancement in the nursing profession, but they have also affected researchinto nurse-physician relations. It is proposed that to improve both patient outcomes

and working conditions for nurses and physicians, further research is required

(Corser, 1998).

COLLABORATIVE VS COLLEGIAL

Kramer and Schmalenberg (2003) surveyed nurses from 14 magnet hospitals to

identify the underlying themes in nurse-physician relationships. They discovered that

power was the underlying theme, and based on this they developed a 5 categoryscale to characterize nurse-physician relationships with power as the underlying

variable:

1. Collegial - “excellent” with an emphasis on equality between the twodisciplines and with a focus on equal although different power and knowledge

to contribute to the interdisciplinary team.

2. Collaborative – “good” or “great” relationships based on mutual trust, respect,and power. The nurses described these relationships as having mutual but not

equal power.3. Student-teacher – “good”, “pleasant” and “courteous” are words that were

used to describe these types of relationships with physicians showingwillingness to discuss, explain, and teach. Power was unequal but overall they

felt the outcomes were beneficial.

4.

Neutral – absence of strong feelings in regards to these types of relationships.Information exchange may take place although nurses felt that physicians

rarely acknowledged receiving information, leaving nurses feeling that theydon’t contribute. Power is unequal and outcomes are neutral.

5. Negative – Frustration, resignation and hostility characterize theserelationships. Power is unequal and outcomes are negative due to power

plays.




17

Corser (1998) identified that one of the problems associated with researching

collaboration is the “myriad of incomplete, contradictory, or borrowed definitions of

collaboration that had been used” (p. 327). Kramer and Schmalenberg (2003) backthis up with their findings, which indicate that the terms ‘collegial’ and ‘collaborative’

are sometimes used interchangeably to describe ideal nurse-physician relationships.However, their study differentiates between the two by describing collegial as

“different but equal knowledge” and collaborative as “mutual power but not equal”.Kramer and Schmalenberg (2003) also mention that the dictionary definition of the

two terms makes the same distinction. In contrast, following a review of available

literature, Corser (1998) made the distinction that collegial was frequently describedas a “precursor to collaboration, most often derived from the involved parties’ formal

hierarchical status and organizational authority” (Baggs & Schmitt, 1988; Fieger & Schmitt, 1979; Nugent & Lambert, 1996; as cited in Corser, 1998, p. 327). In a

comprehensive study of the integration of Primary Care Nurse Practitioners (NPs)into Ontario’s healthcare system, IBM (2005, p. 8) characterized a collaborative

approach as one “based on establishing a collegial relationship that evolves over time

based on experience”. Thirty per cent of the NPs in the study expressed satisfactionwith the degree of communication and collaboration with the family physician. NPs

who identified being dissatisfied with the degree of communication and collaboration

with the family physician were more likely to indicate that the physician with whomthey worked had concerns regarding their scope of practice and/or liability. Otherauthors have described collaboration as involving “fewer formal behaviours related to

one’s organizational status or position” which was usually related to the participants’

inherent values and communication skills (Devereaux, 1981; Mailick & Jordan, 1977;Siegler & Whitney, 1994, as cited in Corser 1998, p. 328).

T h e o u t c om e i n a l l o f t h e 1 4 m a g n e t h o s p i t a ls w h e r e n u r s e s an d n u r s e

m a n a g e r s w e r e in t e r v i e w e d , r e g a r d l e s s o f t h e d e f i n i t i o n o f c o l la b o r a t i o n

u s e d , w a s a p o s i t i v e co r r e l a t i o n b e t w e e n t h e q u a l i t y o f n u r s e - p h y s i c i a n

r e l at i o n s h ip s a n d t h e r e p o r t e d q u a l i t y o f c a r e f o r p a t i en t s ( K r a m e r &

Sc h m a le n b e r g , 2 0 0 3 ) .

COLLABORATIVE VS CONSULTATIVE

The Primary Health Care NP Integration Study (IBM, 2005) set out to identify the

best approach to integrating primary health care NPs into healthcare settings in

Ontario, and more specifically, practice settings. NP is a term used to describe nursesin advance practice roles1.

The project working group identified the outcome variables (integration domains) for

the study, which included: the NP role within the practice setting, external influencesaffecting the scope of practice, role in decision making, workplace satisfaction, and

collaboration and team dynamics.

The researchers used a literature review; NP survey; physician surveys, both for

those working with a NP and those not working with a NP; site visits; patient surveysand population based surveys to gather data. The 27 site visits, which were

1 “In Ontario, the term NP is used interchangeably to describe a number of advanced practice nursingroles, such as primary health care NPs and acute care NPs. In this report, the term NP refers specifically toprimary health care NPs who are registered in the extended class (RN[EC]) with the College of Nurses of Ontario.” (IBM, 2005, p. 1)




18

conducted, covered a variety of different practice settings and the NP, physician and

other members of the healthcare team were interviewed. The information gathered

facilitated the identification of two structures for the NP-physician relationship,collaborative and consultative, based on the following key characteristics:

1. Collaborative – “collaborating MD had a formal and ongoing relationship with

the patient along with the NP, MD and NP share care of patients, MD notdirectly remunerated for collaboration” (IBM, 2005, p. 7).

2. Consultative – “consulting MD does not have a formal and ongoing

relationship with the patient population served by the NP, primary MD role isto consult with the NP, MD remunerated for consultation” (IBM, 2005, p. 7).

The results identified specific factors which enabled the successful integration of a NP

into the inter-disciplinary team: mutual respect, conflict resolution, understanding of each other’s role, willingness to help, and institutional memory of the organization’s

collaborative culture (IBM, 2005). This corresponds with the factors mentioned

earlier as major determinants of the work place environment and concomitantlynurses’ satisfaction which has been linked to improved patient health (O’Brien-Pallas

et al., 2004; Estabrooks et al., 2005).

On average the NPs reported that they were happy with the level of communicationand collaboration between the NP and physicians; however, “where physicians

expressed concerns regarding NP scope of practice and/or liability and the concerns

were not resolved, NPs reported higher levels of workplace dissatisfaction” (IBM,2005, p. 12). This is further backed up by results which showed that “40% of NPs

identified the top negative aspect of their role as a lack of understanding frommedical professionals” (IBM, 2005, p. 12).

The researchers stated that “while there is no doubt about the positive contribution

that NPs make to client care, they would be more highly used if those contributions

were better understood by patients and members of the interdisciplinary team” (IBM,

2005, p. 21). This is further backed up by the site visits where “very few patientsreported dissatisfaction with NPs” (IBM, 2005, p. 11), and dissatisfaction was a directresult of poor definition of NP’s role.

MAGNET HOSPITAL LITERATURE and NURSE-PHYSICIAN

RELATIONSHIPS

Definition of a magnet hospital

Magnet hospitals are organizational settings characterized by an emphasis on

professional autonomy, decentralized organizational structures, participatory

management, and self-governance (Upenieks, 2003). Magnet hospitals consistently

demonstrate three key characteristics: nurses have the status needed to influencepeople and to get the resources for good patient care (also known as ‘professionalautonomy over practice’); good collaboration exists between nurses, physicians, and

administrators; and established systems ensure nurses’ participation in policydecisions (autonomy within clinical practice) (Jones-Schenk, 2001; Scott et al.,

1999; Havens & Aiken, 1999).

The source of the definition of magnet hospitals was a policy study commissioned by

the American Academy of Nursing (AAN) in 1981 and published in 1983 (McClure et




19

al., 1983). The study was commissioned at a time of severe nursing shortages and

sought to identify the organizational characteristics that enable the attraction and

retention of qualified nurses (Buchan, 1999), and that support professional nursingpractice (Aiken, Havens, & Sloane, 2000; Upenieks, 2003). The magnet hospital’s

ability to recruit and retain nurses has been credited to their practice environmentsand their reputations for valuing nurses.

Overall, research has shown that nurses are attracted to hospital work environments

that promote autonomy, control over the practice environment, and foster good

nurse-physician relationships (Laschinger et al., 2003). Nurses in magnet hospitalshave lower levels of burnout and greater job satisfaction. Furthermore, magnet

hospitals have been shown to have better patient outcomes, including lowermortality rates (Aiken, Smith, & Lake, 1994; Laschinger et al., 2003).

Most magnet hospital literature to date has focused on identifying magnet hospital

characteristics and linking these characteristics with increased recruitment and

retention (McCLure et al., 1983; Kramer & Schmalenberg, 2002), and positivepatient outcomes (Aiken, Sloane, & Klocinski, 1997; Aiken et al., 1994; Aiken,

Sloane, Lake, Sochalski, & Weber, 1999). Some researchers have focused on

identifying particular strategies that will facilitate magnet hospital attributes (Kramer& Schmalenberg, 2002; Hinshaw, 2002; Laschinger et al., 2003), although thesehave yet to be tested empirically. Hinshaw (2002) has observed that even less

attention has been paid to establishing recommendations for strategic interventions

geared towards improving nurse-physician relationships overall.

The literature reflects an acknowledgement that part of what makes magnethospitals successful is the interrelationship and cumulative nature of the defining

characteristics (e.g., Kramer & Schmalenberg, 2002). Kramer and Schmalenberg(2002) themselves point to the fact that there is significant overlap amongst their

identified ‘essentials of magnetism’. For example, nurse-physician relationships (one

defining characteristic of magnet hospitals) is partially facilitated and fostered by

other magnet hospital characteristics, such as nurse clinical competency andorganizational support (Kramer & Schmalenberg, 2002). Moreover, good nurse-physician relationships are a form of organizational support as well as being fostered

by organizational support (Kramer & Schmalenberg, 2002).

Nurse-Physician Relationships

Good nurse-physician relationships have been repeatedly identified as a fundamentalcharacteristic of magnet hospitals (McClure et al., 1983; Kramer & Schmalenberg,

2002; Hinshaw, 2002). The magnet hospital literature has been less clear about howmagnet facilities come to achieve good nurse-physician relationships. Various

statements are made that infer a synergistic or cumulative association between thevarious magnet hospital characteristics, making a clear cause and effect process with

regard to nurse-physician relationships difficult, if not impossible, to identify/isolate.

Moreover, Hinshaw (2002) observes through her thorough appraisal of the magnetliterature, that the research is not as explicit in suggesting strategies for promoting

positive nurse-physician relationships as for other magnet characteristics. Whetheror not this truly reflects an inability to isolate a precise cause and effect relationship,

or that nurse-physician relationships are simply more multidimensional than othercharacteristics of magnet hospitals, is unclear. It could also be due to a lack of

sufficient measurement tools with regard to nurse-physician relationships, hinderingresearchers’ ability to reliably study the characteristic at this point in time. Kramer




20

and Schmalenberg (2003) have begun to develop a nurse-physician relationship

scale but argue that substantial refinement is still required. Perhaps measurement

complications arise because nurse-physician relationships are dependent and closelyinterconnected with other magnet characteristics. This last aspect will be discussed

below.

Aiken et al. (1997) note that magnet hospital units promote: greater autonomy fornurses to act within their areas of professional expertise; greater nurse control over

the support services and personnel necessary to provide high-quality care (e.g.

social services, discharge planning, housekeeping); and better communicationstructures between nurses and physicians that are well understood and result in

better relationships. Aiken (2002) argues that magnet hospitals achieve the aboveorganizational outcomes through managerial decision making at the top of the

organization that recognizes nurses’ key importance to the provision of high-qualitycare and thus ensures a level of status for nurses within the institution proportionate

with their high levels of responsibility for patients’ welfare. Therefore Aiken (2002)

attributes good nurse-physician relationships in part to shared governance, which isthe organizational structure most often used within magnet hospitals, and is

distinguished by having a nurse representative on every level of administration.

However, Aiken et al. (1997) fail to explicitly identify these communication structureswithin the paper.

The nurse-physician relationship characteristic has been included in Aiken and

colleagues refined conceptual model of the nurse work environment (Aiken, 2002),and Kramer and Schmalenberg (2002) suggest that it may be an intervening variable

between organizational characteristics, such as the type of delivery system andpositive patient outcomes. Regardless of how the influence occurs, it is clear that a

positive nurse-physician relationship is a consistent, important characteristic inmagnet hospitals (Hinshaw, 2002).

Interrelationship of Magnet Hospital Characteristics

In order to further illustrate the idea of synergy as it relates to magnet hospital

characteristics, it is useful to refer to a 2001 study by Kramer and Schmalenberg.During a survey of 279 staff nurses within magnet facilities, Kramer and

Schmalenberg (2002) isolated eight factors of magnetism that were consistently

chosen by nurses as being crucial to being able to provide high quality care.

These Essentials of Magnetism are:

● Working with other nurses who are clinically competent● Good nurse-physician relationships and communication

● Nurse autonomy and accountability● Supportive nurse manager-supervisor

● Control over nursing practice and practice environment

● Support for education (in-service, continuing education, etc.)● Adequate nurse staffing

● Concern for the patient is paramount(Kramer & Schmalenberg, 2002)

To articulate the interrelated nature of magnet characteristics the attribute of ‘nurse

clinical competency’ will be examined. Clinical competency is required fororganizationally sanctioned autonomy; for good nurse-physician relationships -




21

“…physicians will not trust or collaborate with nurses they do not perceive as

competent” (Kramer & Schmalenberg, 2002, p. 55); and for control over nursing

practice (Kramer & Schmalenberg, 2002, Hinshaw 2002). Furthermore, education iscritical for clinical competence (Kramer & Schmalenberg, 2002), and support for

education is another essential of magnetism (see Figure 1).

Figure 1: A conceptual model of the “Essentials of Magnetism” (selected)(Kramer & Schmalenberg, 2002): An illustration of their interrelated and inter-

dependent qualities.© This model was developed from a comprehensive literature

review and synthesis of the findings.

© O’Brien-Pallas & Cook, 2005

Another attribute of magnet hospitals is a supportive nurse-manager/supervisor.

There needs to be some form of institutional support that serves to promote goodnurse-physician relationships within the organization, and a supportive nurse-

manager/supervisor often fills this role. Once good nurse-physician relationships arein place, they will further reinforce the supportive network of the institution. It

becomes difficult to determine which characteristic should precede which, as they are

all interrelated, and certain characteristics of magnet hospitals clearly facilitate thedevelopment of other characteristics.

Adequate nurse staffing is another magnet characteristic that is highly contingent on

a few of the other essentials of magnetism (see Figure 2). For example, although

nurse staffing may be inadequate, other factors (magnet characteristics) may enablenurses to give quality care. These include skilled, experienced, competent nurses;collaborative nurse-physician relationships; control over nursing practice; and

adequate support services (Kramer & Schmalenberg, 2002).




22

Figure 2: Factors that Enable Adequate Staffing: A conceptual model of the

multiple organizational characteristics that have an impact on adequate staffing as

identified by Kramer and Schmalenberg, 2002.© (NB: The characteristics designated as “essentials of magnetism” [Kramer & Schmalenberg, 2002] are in bold).

Moving Forward To Create a Magnet Hospital Environment

A complete overhaul of a hospital’s organizational structure is rarely feasible;

therefore it may be useful to highlight potential cause and effect on a smaller scale inorder to slowly begin transformation of organizational structures. Aiken and Sloane

(1997) demonstrated that positive outcomes in the form of nurse job satisfaction and

lower mortality rates resulted from re-organization at the unit level. Dedicated AIDSunits were re-organized to give nurses on these units increased clinical autonomy –

an “essential of magnetism” - and this, in part, resulted in less nurse burnout. Inother studies Aiken and colleagues have shown that the same organizational features

associated with lower nurse burnout, such as nurse autonomy, are also associatedwith a safer work environment for nurses in terms of lower nurse-reported

needlestick injuries (Clarke, Sloane, & Aiken, 2002; Aiken et al., 1997), greater

patient satisfaction with care (Aiken, Sloane, & Lake, 1997; Aiken et al., 1999), and

lower risk-adjusted Medicare mortality (Aiken, Smith, & Lake, 1994; Aiken et al.,

1994).

A significant lesson to be learned from the magnet hospital literature is the fact thatit is crucial to keep the interrelated nature of magnet hospital characteristics in mind,

despite the fact that complete organizational transformation may not be possible. For





23

instance, the Quality Health Outcomes Model (Mitchell, Ferketich, & Jennings, 1998,

Figure 3) posits that the effects of healthcare interventions are mediated by the

characteristics of the organizations in which care takes place (Vahey, Aiken, Sloane,Clarke, & Vargas, 2004).

The Center’s [University of Pennsylvania School of Nursing’s Center for

Health Outcomes and Policy Research] series of large-scale studies of outcomes of hospital care suggest that features of the practice setting,

including n u r s e a u t o n om y , s t a f f i n g a d e q u a c y , a n d r e l a t i o n s h i p s

b e t w e e n n u r s e s a n d p h y s ic ia n s , as well as characteristics of thenurses, influence patient outcomes by their effects on care processes,

including nurse surveillance, continuity of care, patient centeredness,and preparation of patients and their families to successfully manage

their care after discharge. (Vahey et al., 2004, p. 58)

Figure 3: Quality Health Outcomes Model

(Mitchell, P., Ferketich, S., & Jennings, B., 1998)

To elucidate further, relationships between nurses and physicians will be able to

safeguard against inadequate staffing (see Kramer & Schmalenberg, 2002; and

staffing model above), and will therefore be able to impact on care processes, suchas nurse surveillance (Aiken, 2002). When nurses detect signs of a potentially

serious complication, rescuing the patient means they must be able to mobilizeresources quickly, including the ability to bring physicians to the bedside (Clarke &

Aiken, 2003). Therefore, nurses’ status within a hospital – as reflected by theircredibility and rapport with physicians and the support received from hospital

administration – influences the extent to which they can do so (Clarke & Aiken,2003). When a patient encounters a life-threatening complication, taking action

involves quickly instituting appropriate measures and activating a team response and

nurses must exert some control over the situation to ensure that such actions aretaken (Clarke & Aiken, 2003). This control must be officially sanctioned and

supported by the hospital organization as a whole, as is done within magnethospitals through ensuring nurse clinical autonomy and control over nursing practice

for nurses. Although a nurse can begin first-line emergency measures, saving thepatient is usually a team effort. High priority tasks include alerting the appropriate

members of the team and conveying the urgency with which they are needed at thebedside. Nurses must communicate clearly with other nurses, physicians and hospital




24

personnel, and for a nurse’s concerns to be heeded and acted upon, there must be

sufficient trust and regard among team members (Clarke & Aiken, 2003).

Overall, hospital nurse work environments that assign greater autonomy and control

to nurses at the bedside, provide administrative support for nursing care, haveadequate staff, and facilitate good relationships between nurses and physicians are

associated with several positive outcomes:

From an organizational perspective, magnet hospitals gain on a

number of fronts: empowered nursing leaders and staff who arecommitted to high-quality care and to the organization because of the

environment that exists; decreased costs due to low turnover of nurses; stronger relationships among nurses and physicians; and a

flexible professional workforce that can initiate and work with change.(Hinshaw, 2002, p. 84)

Magnet Environments in Non-hospital Settings:Although hospitals have been the focus for research and evaluation of “magnet”

attributes since the 1970s, other settings are now using the magnet attribute

framework to evaluate the work environment. For example, one study asked homecare nurses to identify the extent to which 10 magnet attributes were present intheir agencies (Smith-Stoner, 2004). In addition, the American Nurses Credentialing

Centre (ANCC) makes its “Magnet Recognition Program” available to any healthcare

setting (ANCC, 2005).

Strategies to Foster Positive Nurse-Physician Relationships and MagnetHospital Attributes

Having now explored the literature findings in depth (for inclusion criteria see

Appendix 2), the following section presents a summary of the recommendations tofoster positive nurse-physician relationships and magnet hospital attributes compiled

from the synthesis work by Kramer and Schmalenberg (2002) and Hinshaw (2002).For a conceptual representation of the strategies that can foster the ‘essentials of

magnetism’ see Appendix 6.

Hinshaw (2002):

• Development of explicit communication structures for nurse-physician dialogue on

patient care planning and decisions. Such dialogue cannot be taken for granted orleft to “just happen.”

Examples of communication structures include:• Grand rounds for patients, interdisciplinary seminars for common areas of

knowledge, and informal planned unit forums to discuss immediate patient careissues.

• A common committee structure for interdisciplinary decision making about patientcare policies and procedures at the organizational level; for example, developing

critical pathways for clinical care.

• Development of collegial teams of nurses and physicians who work togetherconsistently and can therefore develop trust and respect for each other over time.




25

These strategies require that both nursing and medicine, as professions, learn better

how to value and respect each other’s knowledge and expertise (Hinshaw, 2002).

Kramer and Schmalenberg (2002): • Foster and promote collaborative practice programs.

• Provide educational support and encouragement for nurses to develop collegialrelationship with physicians.

• Reward the establishment of collegial relationships by interpreting the

professional nurse role to physicians’ at all different levels, for example, residentsand attending physicians.

• Create and nurture the cultural value of collegial and collaborative relationships.

• Further develop the nurse-physician relationship scale described in this research.

• Continue to research the impact of interdependent nurse-physician relationshipon patient outcomes.

• Investigate the correlation, if any, between collegial nurse-physician

relationships, clinical autonomy and control over nursing practice, and nurse jobsatisfaction and actual and intended turnover.

Laschinger, Almost, and Tuer-Hodes (2003):

These researchers sought to test Kanter’s Workplace Empowerment theory – linking

nurses’ perception of workplace empowerment, magnet hospital characteristics, and

job satisfaction in three independent studies. (Kanter argues that social structureswithin the work environment that provide employees with access to information,

support, resources (essentials of magnetism), strong interpersonal relationships, and opportunities to learn and grow (essential of magnetism) otherwise known as

“professional development” (see Hinshaw, 2003 and Kramer & Schmalenberg, 2002),increase a worker’s sense of empowerment).

NB: In this study, structural empowerment closely resembles organizational support

as discussed by Hinshaw (2002), and “Administrative Support” as discussed by Aikenand Sloane (1997).

Key Findings: Greater access to workplace empowerment structures resulted inhigher perceptions of autonomy, increased control over the practice environment,

and positive nurse-physician relationships. All empowerment structures wereimplicated as being important influences on magnet characteristics.

(NB: The empowerment structures as defined in this study are magnet

characteristics [Kramer & Schmalenberg, 2002; Hinshaw, 2002])

Recommendations for nursing administration:1. Examine workplaces for structural factors that act as barriers to staff nurses’

access to empowerment structures

2. Managers should focus less on control and more on:¾ The coordination, integration, and facilitation of nurses’ work

¾ Providing access to information, resources and support¾ Implementing strategies to enable access to information about organization

policies




26

COLLABORATIVE INTERVENTIONS TO FOSTER NURSE-PHYSICIAN RELATIONSHIPS

The body of literature surrounding nurse-physician relationships is sizeable;

however, while the literature may comment on, editorialize, or encourage the use of collaboration, very few studies have been carried out which seek to improve

collaboration within healthcare organizations through intervention focused research(Corser, 1998; Zwarenstein & Bryant, 2004; Lassen et al., 1997; Boyle & Kochinda,

2004; Horak et al., 2004).

The term intervention encompasses a variety of activities such as: inter-disciplinary

workshops, organization of interdisciplinary ward teams, home healthcare nurse-practitioner partnerships, interdisciplinary education within universities, self-paced

learning modules, classes to teach communication skills and styles, introduction of shadowing programs for nursing and medical students, role playing case scenarios,

and team building meetings. Additionally the interventions may be targeted to anumber of different groups: nursing students, medical students, nurses, physicians,

nurse and physician leaders, and healthcare administrators. The following table

provides a summary of intervention studies located in the literature (for inclusioncriteria see Appendix 2).

Researchers Intervention Implemented Study Participants Target

Audience

Coeling & Cukr

(2000)

Communication class Nursing graduate

students

All healthcare

professionals

Barrere & Ellis

(2002)

Shadows program Medical students Medical &

nursing students

Boyle & Kochinda(2004)

6 learning modules Nurse & physicianleaders

Nurse & physician leaders

Buback (2004) Self-paced learning modules OR Nurses OR Nurses

Dechairo-Marino etal. (2001) Operating principles forcollaboration and quality

patient outcomes & class

focussing on components of collaboration

Medical-surgical & ICU Nurses Not identified

Korabek et al.(2004)

Partnering groups set up,team building exercises,

partnership forums & anewsletter

Community basedphysicians & nurses

Communitybased nurses &

physicians

Foley, Nespoli, & Conde (1997)

Case scenarios usingstandardized patients and

standardized physicians

Medical-care nurses Nurses

Keenan et al.

(1998)

Nine vignettes Emergency room

nurses

Nurses &

physiciansHorak et al. (2004) Team building meetings,

ground rules for

collaboration.

Nurses, physicians,nurse & physician

leaders

Nurses & physicians

Trossman (2003) Procedure for reporting

disruptive behaviour

Nurses & physicians Nurses &

physicians

Zwarenstein and Bryant (2004) conducted a systematic review of the interventions

that have been carried out in the current literature up to October 1999. Systematic




27

reviews are “reviews of a clearly formulated question that use explicit methods to

identify, select, and critically appraise relevant research and to collect and analyse

data from the studies that are included in the review” (Grimshaw, McAuley, Bero,Grilli, Oxman, Ramsay, et al., 2003, p. 298). Current literature suggests that

systematic reviews are increasingly being seen as providing the best evidence onwhich to base future healthcare decisions (Grimshaw et al., 2003; Irwig,

Zwarenstein, Zwi, & Chalmers, 1998). Systematic reviews should be carried out priorto quality improvement research, in order to confirm that all the relevant evidence

available informed the research, and to ensure that the proposed research questions

have not been previously answered.

Zwarenstein and Bryant (2004) applied extremely rigorous criteria for inclusion of studies within their review; they only included studies which were randomized trials,

controlled before and after studies and interrupted time series. As a result theyfound only two which fit their criteria, and they concluded that in future, researchers

must find a way to analyse the data in a statistically valid way which corrects for

possible clustering effects. However, they acknowledged the difficulties that areassociated with this particular area of research such as the complexity of

interventions, and the intermediate processes, which are difficult to measure.

Dechairo-Marino et al. (2001) also stated that “it is unlikely that rigorous studies willbe undertaken without major funding. Therefore, advancing the field may occurthrough multiple exploratory studies in a variety of settings undertaken by different

investigative teams” (p. 224).

Summary of Interventions

Interventions to optimize nurse-physician collaboration reported in the literature

include training workshops in collaboration and communication skills, jointinterdisciplinary staff meetings, case scenarios, co-ordination of care, and patient

centred care efforts. Interventions directed towards establishing professional practiceenvironments are also linked to nurse-physician collaboration. Attributes of a

professional practice environment include evidence-based practice, clinicalcompetency, and systems and processes that facilitate practice and professional

development (Matthews & Lankshear, 2003). Matthews and Lankshear (2003)identified sixteen “essential elements of a professional practice environment” (p. 65).

These include formal communication lines that promote the involvement of all

stakeholders in decision-making, structures and roles that reflect theinterprofessional nature of the staff, collaborative practice principles and strong

physician linkages. The authors share strategies reported as having been successfulin strengthening these elements. These include implementation of the principles of

shared governance and continuous quality improvement, and the identification andarticulation of expectations, systems, and processes that support consultation and

collaboration. Ultimately, interventions that enhance nurse-physician relationshipspromote a quality work environment—one which positively influences nurses’ job

satisfaction, promotes retention of the nursing workforce and recruitment of new

graduates, and decreases healthcare costs. Appendix 3 contains a summary of selected research studies; the summary of the literature on nurse-physician

collaboration in Appendix 5 also includes related interventions.




28

CONCLUSION AND RECOMMENDATIONS

This report has documented the strong evidence that exists about the importance of

positive nurse-physician relationships. It is clear that these relationships are anessential attribute of “magnet” healthcare organizations and promote optimal

outcomes for nurses, patients, and healthcare organizations. These outcomes include

quality patient care, job satisfaction for nurses and associated retention andrecruitment benefits, and cost effectiveness for healthcare organizations. Selected

policy implications arising from this report include:

• The need to raise awareness of the importance of positive nurse-physicianrelationships with such individuals or associations as the Ontario Ministry of

Health and Long-Term Care, Ontario Ministry of Training, Colleges and

Universities, Ontario Hospital Association, Ontario College of Physicians andSurgeons, Council of Universities, Joint Provincial Nursing Committee, Joint

Provincial Planning Committee, etc.

• The need to measure nurse-physician relationship indicators as part of the

hospital report card system and RFP Template for Community Care AccessCentres (or contract monitoring protocols).

• The need to incorporate collaborative education models and curricula for nurses

and physicians.

As previously mentioned, Appendix 5 provides a detailed list of interventions toinfluence positive nurse-physician relationships. The following recommendations

are directed toward the Research Unit and Nursing Secretariat of theMinistry of Health and Long-Term Care and have been developed with the

goal of raising awareness of the importance of positive nurse-physician

relationships throughout the healthcare system, and informing policy anddecision-makers about initiatives and interventions that strengthen and

optimize nurse-physician relationships.

1. As part of the NHSRU University of Toronto site’s ministry-directed researchfor 2005-2006:

• Write a feasibility study proposal (i.e., intervention group, demonstration

study).

• Develop fact sheets on nurse-physician relationships, and magnet healthcare

organization attributes to be used for clinical and policy direction.

• Develop a distribution/dissemination plan for the fact sheets.

• Summarize findings from the nurse-physician relationship focused questionscontained in the Health Human Resource Modelling: Challenging the Past,

Creating the Future study (project 3), scheduled for distribution in September

2005 (see Appendix 7).• Conduct an environmental scan on nurse-physician relationships (e.g., nurse-

physician relationship awareness and/or activities of organizations such as theCanadian Council on Health Services Accreditation, Canadian Health Care

Association, Canadian Association for Schools of Nursing, Canadian NursesAssociation, Ontario Nurses Association, Registered Nurses Association of

Ontario, Registered Practical Nurses Association, College of Physicians andSurgeons of Ontario etc).




29

2. Develop strong indicators that are valid and reliable and then measure nurse-

physician relationship indicators as part of the hospital report card systemand RFP Template for Community Care Access Centres (or contract

monitoring protocols).

3. Explore the feasibility of including initiatives related to nurse-physicianrelationships and magnet hospital attributes in the strategic plan of the Joint

Provincial Nursing Committee:

• Commission (RFP process or alternate) a research project to test a 360 o intervention(s) designed to positively influence nurse-physician relationships:

• Use an intense dose of intervention

• Test specific outcomes such as degree of shared decision making, risk adjusted

length of stay, patient satisfaction and out system comes, nurse satisfaction,and physician satisfaction.

• Include both physicians and nurses if possible

• Use a large sample size• If possible incorporate a randomized block design

• Apply a validated and statistically reliable measurement tool (see Appendix 4).

4. Following additional research and the implementation of an interventionstudy, a nurse-physician collaboration component could be added to the

funded Ontario Nursing Strategy Initiatives. A Request for Proposal could be

developed for healthcare organizations to submit their project ideas tooptimize nurse-physician collaboration that could then be considered for

funding to a level established by the MOHLTC.

5. Encourage the Canadian Association for Schools of Nursing and the Council of Ontario Universities to develop curricula for their health discipline programs to

build communication skills and foster optimal collaboration between nursingand medical faculties, students, and graduates.

6. Commission a best practice guideline on nurse-physician collaboration as partof the Registered Nurses Association of Ontario’s “Best Practice Guidelines”

program funded by the MOHLTC.

Upon review of this nurse-physician report by the Ministry of Health and Long-

Term Care, the draft nurse-physician workplan for the period of April 01, 2005 –

March 31, 2006 will be finalized based on Ministerial feedback.

—————




30

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2(3), 95-98.

Wilkinson, C.S. & Hite, K.J. (2001). Nurse-physician collaborative relationship on

nurses’ self-perceived job satisfaction in ambulatory care. Lippincott’s Case

Management , 6(2), 68-78.

Williamson, M. (2003). Challenging doctors’ orders. Nursing New Zealand , 9, 26-27.

World Health Organization. (2000). The world health report 2000. Health Systems:

Improving Performance. Geneva: Author.

Zwarenstein, M. & Bryant, W. (2004). Intervention to promote collaboration between

nurses and doctors. The Cochrane Database of Systematic Reviews, 4.




37

APPENDIX 1Client Care Delivery Model (O’Brien-Pallas, Doran, et al., 2001)

(Donabedian, 1966; Leatt & Schneck, 1981; Jelinek, 1967; O’Brien-Pallas, 1994)




38

APPENDIX 2Inclusion Criteria for Review of Interventions for Nurse-Physician

Relationships and For Magnet Hospital Literature Review

INTERVENTIONS FOR NURSE-PHYSICIAN RELATIONSHIPS

Phase 1

Initial keyword search of multiple databases: PubMed, Medline, CINAHL, EMBASE, Healthand Psychosocial Instruments, and all EBM reviews (Cochrane, DSR, ACP, Journal Club,

DARE, and CCTR). This was completed using keywords related to nurses and physicians:nurse-physician relations, nurse-physician relationships.

Original searches produced approximately 2000-3000 references. After combining the

original search with a search for solutions and recommendations the results were reduced to

approximately 700, and from that we found approximately 40 relevant articles.

Each article retrieved from the database search was checked for additional references withrelevance to nurse-physician relationships, and solutions and recommendations. A final

reference list of 40 articles related to nurse-physician relationships, with solutions andrecommendations for change, from 1997-2004 was compiled. Articles were collected from

online databases or resources at the University of Toronto.

Inclusion Criteria

All articles which discussed the implementation of an intervention aimed at improving or

enhancing nurse-physician relationships, regardless of the setting, were included in the listof accepted articles.

Note: the rejected articles discussed nurse-physician relationships generally, without any

evidence of interventions which improved/enhanced nurse-physician relationships. An

observation made by Corser (1998) was that the majority of work which has been publishedfocuses on specific factors which the researchers believe contribute to collaboration,

however an obstacle is that non-clinical definitions of collaboration fail to take intoconsideration the fact that nurses and physicians rarely posses the same view regarding

what collaborative interaction encompasses.

The majority of articles agreed that better nurse-physician relationships will improve theoverall worklife for healthcare workers, and may improve patient outcomes but very few

give concise recommendations of how to achieve this, or evidence of methods which have

worked.

MAGNET HOSPITAL LITERATURE REVIEW SEARCH STRATEGY

Phase 1

Keyword search of multiple databases: PubMed, Medline, CINAHL, and All EBM Reviews(Cochrane DSR, ACP Journal Club, DARE, and CCTR) using keyword: ‘magnet hospital.’ The




39

reference lists for each article retrieved through the database search was also perused toensure that major contributors and other relevant articles were not overlooked. A reference

list was compiled, and all articles pertaining to magnet hospitals from 1997 to 2004 were

retrieved, either from online databases or the library.

Inclusion Criteria

All articles that made suggestions and/or identified strategies for improving nurse-physician

relationships were included.

Note: Most of the magnet articles had little to contribute regarding interventions or

suggestions to improve nurse-physician relationships, let alone suggestions on how toimplement magnet characteristics (in particular those related to good nurse-physician

relationships) into non-magnet facilities. Most of the magnet hospital articles simply statedthat good nurse-physician relationships were a characteristic of magnet facilities.




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APPENDIX 3Selected List of Interventions

Educational Interventions

Coeling and Cukr (2000) conducted a study with graduate nursing students that was

designed to increase awareness of nurse-physician collaboration, and determine if threespecific communicator styles (dominant, contentious, and attentive), were utilised in

interactions which the students believed were collaborative in nature. The study participantsattended a communication class, in which they were asked to come up with a definition of

collaboration. Once this was formulated they were asked to record the details of their firstinteraction with a physician each day. The criteria to define the first interaction of the day

stated that it must involve at least three back and forth communicative interactions.

Participants were required to note if the interaction was collaborative, if it improved thequality of patient care, and if it increased nurse satisfaction from their perspective. Similarly

Buback (2004) specifically targeted nurses as a result of reports in the literature suggesting

nurses are regularly subjected to abuse within operating rooms, however the interventionwas still underway when the article went to press. A self paced learning module focussingon conflict resolution and communication skills, formed the basis of the module, which

included current articles on assertiveness, and relevant case studies.

Boyle and Kochinda (2004) implemented a collaborative communications intervention

targeting nurse and physician leaders, in order to enhance collaborative communication,and optimize unit outcomes. The intervention consisted of six modules targeting specific

dimensions of nurse-physician collaboration. Each module was comprised of learningactivities, skill practice, and problem solving sessions. Dechairo-Marino et al. (2001)

implemented an action research design, which included an interactive session involvingnurses and physicians. First the participants produced operating guidelines for collaboration;

this was followed up by a 4-hour class specifically targeting nurses, and designed to

enhance their status as decision makers and teach them conflict management techniques.Korabek et al. (2004) set up partnerships between family physicians and community based

nurses, following the identification of gaps in the primary health care system in the CalgaryHealth Region. The participants attended an orientation session where they met their

partners and took part in exercises to encourage team building. The orientation session wasalso used to encourage the participants to arrange follow up meetings 2 to 3 weeks after

the initial orientation. Horak et al. (2004) evaluated an intervention which targeted bothnurses and physicians in response to recommendations from a quality improvement (QI)

consultant. The intervention consisted of team building meetings between nurses and

physicians, then the group split into the separate disciplines in order to allow each group tostate what they required from the other. Following the meeting, the QI consultant

formulated a list of acceptable behaviours on which to base ground rules for collaboration.

Finally a second team building meeting was arranged to follow up on the list of behavioursagreed upon during the first meeting.

Case Scenarios & Observational Interventions

Barrere and Ellis (2002) implemented a ‘shadows’ program as part of a quality improvement

project within a hospital. Medical and physician assistant students were assigned to anexperienced




41

registered nurse, whom they would shadow for a full 8-hour shift in an attempt to improvetraditional attitudes towards collaboration with nurses. The students received an orientation

package consisting of program objectives and selected articles discussing the importance of

communication and collaboration.

Foley et al. (1997) specifically targeted nurses to participate in their evaluation research.The study participants took part in interactive case scenarios with standardized patients and

standardized physicians, in order to enhance their interactive skills. The case scenarios werevideotaped with a nurse educator watching the scenarios as they were happening in an

adjacent room. Immediately following the case scenarios the nurse educator and theparticipant reviewed the interaction. Keenan et al. (1998) specifically targeted emergency

room nurses to take part in their cross-sectional study. The intervention consisted of nine

vignettes assessing the strength of the nurses’ intentions to use conflict managementstyles.

The majority of studies, which we included, focussed on teaching collaborative or

communication behaviours to nurses and or physicians (Coeling & Cukr, 2000; Buback,

2004; Boyle & Kochinda, 2004; Dechairo-Marino et al., 2001; Korabek et al., 2004; Horaket al., 2004)

Unfortunately as observed by Coeling and Cukr (2000), there is a distinct lack of reliable

validated tools and instruments available in the current literature to test the impact of collaborative interventions especially at the behavioural level.




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APPENDIX 4Summary of Instruments & Tools Reported in the Literature

1.

Investigator developed instrument based on Norton’s Communicator Style (Norton,1978, as cited in Coeling & Cukr, 2000) combined with investigator developed outcome

indicators (e.g., nurse perception of collaboration, quality of care, and satisfaction with

the interaction).

2. Oral debriefings for study participants, to verbalize lessons learned and compare andcontrast experiences.

3. Qualitative written evaluations.

4. Jefferson Survey of Attitudes towards Physician-Nurse Collaboration (Hojat et al., 1999,as cited in Barrere & Ellis 2002). This survey contains 15 statements related to

physician-nurse roles and interactions involving: authority, autonomy, responsibility for

patient monitoring, collaborative decision making, and role expectations. Participantsindicate their level of agreement with each statement using a 4-point Likert scale, witha higher score indicating a more favourable attitude towards collaboration. In previous

studies this instrument has demonstrated satisfactory construct validity and internal

consistency reliability.

5. Investigator developed Collaboration Skills Simulation Vignette test (Boyle & Kochinda,2004). Collaborative communication was conceptualised using the elements of the

interaction process: communication skills of the different stages (open, clarify, develop,agree, close), processes (procedural suggestions, check for understanding), and

relationship skills (key principles of esteem, empathy, involvement, sharing, support).

The vignette was comprised of seven sequenced situations, to test all elements of theinteraction process. Content validity of the test was established before it was

implemented.

6. A modification of the ICU Nurse-Physician Questionnaire (Shortell, Rosseau, Gillies,Devers, & Simms, 1992). This questionnaire measures 12 aspects of unit leadership,

communication, coordination, and problem solving/conflict management. Previous

research confirmed content validity, factor analysis, and construct validity.

7. An adaptation of the Verbal Abuse Survey (Araujo & Sofield, 2003 as cited in Buback,2004). This survey consists of 15 questions used to identify the effectiveness of an

intervention implemented to prevent verbal abuse in the OR.

8. An adaptation of the Collaboration and Satisfaction About Care Decisions instrument,

designed by Baggs (1994). This survey measures collaboration and satisfaction with thegeneral decision making processes in the unit. The original survey had previously shown

reliability and validity in other hospital settings.

9. Interviews were conducted with participants during some of the studies to identify anychanges in behaviours or attitudes.




43

10. The Wilder Collaboration Factors Inventory (Mattessich, Murray-Close, & Monsey, 2001,as cited in Korabek et al., 2004) identifies 20 factors which influence the success of

collaboration. The factors are then grouped into the following categories: environment,

membership, characteristics, process and structure, communication, purpose, and

resources.

11. The Performance Assessment Checklist was used to provide immediate feedback to

participants acting out case scenarios. This checklist identified and assessed actions andbehaviours, which were apparent in the subjects during the case scenario. The checklist

was piloted, however there was no formal testing of reliability and validity.

12. Nurse-Physician-Patient Interaction/Communication Survey; part A was based on a

previous survey of communication skills, and part B was based on the NursingBehaviour Supportive Checklist (Gardner & Wheeler, 1981; Gardner & Wheeler, 1987 as

cited in Foley et al., 1997). The survey was used to assess the intermediate changes innurses’ interactions with physicians and patients. Part A of the survey had no previous

reliability information, however it was piloted for face validity prior to the beginning of

the intervention study. Part B had demonstrated internal consistency and face validityduring an earlier study.

13. Video equipment was used in some studies to record interactive case scenarios. This

technique allowed the participants to view the interaction and review it with someoneelse at a later date.

14. An abridged version of the Organizational Culture Inventory (OCI) (Cooke & Lafferty,

1989, as cited in Keenan et al., 1998) was used to record nurses’ beliefs in regards tothree types of work group norms. The full OCI has been previously tested for reliability

and validity.

15. Vignettes, which are descriptions of hypothetical conflict situations, were used in somestudies to assess the strength of the nurses’, and physicians’ intentions to use conflictmanagement styles in their interactions.

16. Team building meetings with nurses, residents/interns, nursing clinical supervisors and

chief residents were initiated to increase the understanding and appreciation of thedifferent roles of healthcare professionals within the healthcare organization.

17. The Physician-Nurse Communication Scale developed by Jones (1994, as cited in Larson

et al., 1998) was designed to test the degree of mutual power-control communication

between physicians and nurses. This tool has demonstrated reliability and validity underpsychometric testing.




44

APPENDIX 5Summary of Literature Findings Related to Nurse-Physician

Relationships

To create the following list of interventions and recommendations, an exhaustive literature

review of over 80 articles was conducted with a focus on nurse-physician relationships and

recommendations and solutions for improvement. Whenever a specific intervention wasimplemented to improve nurse-physician relationships a separate list was kept.

The complete list was then subdivided into themes and the matching interventions or

recommendations were listed.

EDUCATION

Healthcare Professionals

1. Implement training classes within healthcare organizations to teach:

• Appropriate communicator styles

• Collaborative behaviours

• Listening skills and sensitivity training for physicians

• Teamwork and relationship building

• Conflict management

• Stress management

• Time management

• Phone etiquette

• Communication issues such as patient legislation and official communication

procedures

2. Implement assertiveness training classes in order to provide nurses with the skillsneeded to deal with disruptive physicians. Knowing techniques that work for dealing

with difficult doctors and difficult situations can boost confidence, improve

competence at work, reduce stress and anxiety, and increase enthusiasm fornursing.

3. Introduce interactive case scenarios for nurses to assist with techniques for dealing

with physicians, patients, family members, and other healthcare professionals.

4. Use case scenarios for all healthcare professionals to develop knowledge and skills

in:

• Creative problem solving

• Crisis resolution in clinical practice and management

• Nurses’ responsibilities and workflow

This could contribute to the production of a rich database of qualitative data from all

the participants.

5. Ensure appropriate nurse competencies.




45

6. Hold forums to enhance physician awareness of current issues and factors, whichaffect nurses’ satisfaction.

7. Highlight the link between increased collaboration, communication, teamwork, and

improved patient care for nurses and physicians.

8. Provide organizational support for further education of nurses including financial

support and flexible work arrangements.

9. Provide nurses with guidelines to follow when consulting a physician in regards to apatient’s care. For example providing checklists to follow before placing a call to a

physician, thus ensuring that the nurse has all the information that may be required

during the call.

10. Introduce shared practical training for doctors and nurses in order to facilitategreater understanding of each other’s roles and trust in each other’s competencies.

11. Develop and introduce more effective pain management practices with guidelines ondealing with barriers, tailored to each specific institution.

12. Examine and shift the power base underlying collegial relationships:

• Have one nurse manager orientate all new residents, interns, and staff physicians to the concept that nurses’ knowledge is different but equal.

• Promote awareness amongst nurses and physicians of how each groupmaintains their practice as current.

13. Ensure that regulations and guidelines are available to junior medical and nursing

staff in regards to written and verbal communication.

14. Provide clinical experiences that allow each profession to experience and understandthe responsibilities and work of the other (e.g., role modelling and shadowinghealthcare professionals).

15. Educate physicians and consumers about the contribution that nursing brings to

healthcare.

16. Create opportunities for collaboration through open forums, group discussion, andcollaborative workshops.

Nursing & Medical Students

1. Expose students to interdisciplinary education in order to foster positive attitudes to

collaboration at a later date.

2. Introduce interdisciplinary care planning mechanisms for nursing and medical

students.

3. Introduce training and education of nursing and medical staff in collaborative skillsduring professional education settings within universities.




46

4. Provide collaborative interdisciplinary clinical experiences for students as well as rolemodelling of collaborative relationships in nurse-physician practice.

Other

1. Educate hospital administrators on the effects of nurse-physician collaboration onnurses’ self perceived job satisfaction (Wilkinson & Hite, 2001).

RESEARCH

1. Examine

• Specific providers’ collaborative behaviours (e.g., frequency and patterns of communication, degree of shared decision making) in order to match these

with positive patient outcomes, and provider satisfaction.

• Multidimensional factors of both the nurse-physician relationship and job

satisfaction, to allow a weighting of influencing factors.

• Differences in nurses’ and doctors’ perceptions of doctors’ attitudes.• The many factors and variables in any intervention undertaken such as the

type and size of hospitals, nursing system used in the unit. This will give abetter picture of variables affecting nurses’ participation in decision making

(Krairish & Anthony, 2001).

• The communicative underpinnings of clinical practice, including interactive

styles, how they are perceived by others, and how they may be modified.

• Communication styles prospectively over time, so that the impact of

organizational changes on the interactions between healthcare professionals

can be identified.

• The relationship between, nurse-physician collaboration, nurses’ participation

in decision making, and specific patient outcomes. This will help to elucidatethe relationship between structure, process, and outcome.

• Care delivery models which are designed to facilitate interdisciplinary teamwork.

• The use of new language to communicate and record methods of treatment.

One suggestion was the use of nursing minimum data sets, which provide datato facilitate decision-making.

• The different health outcomes for patients cared for in the traditional andcollaborative models of healthcare delivery, identification of the product of

collaborative practice models and further identification of the type of attitudinal climate in which collaborative relationships can be nurtured should

be undertaken if the elusive nature of collaboration is to be captured (Taylor-

Seehafer, 1998).

2.

Implement• Intervention study designs which have a more intense dose of intervention,

include all subjects, use a larger sample size, and incorporate a randomizedblock design.




47

• Recommendations for better collaborative partnerships which include morechoice given to participants so that they have more say in whom they partner

with.

• Data collection instruments which create the least amount of burden with the

maximum value.• A pre-partnership conflict resolution process that supports the dissolution of

ineffective partnerships.

• Research designs and tools at the onset of interventions designed to measurechange (Dechairo-Marino et al., 2001).

3. Focus research

• In three areas: identification of nurse-physician conflict area amenable to

collaboration, design of collaborative interventions, and evaluation of theeffectiveness of an intervention in relation to improved patient outcomes and

enhanced collaboration.• On nurses and doctors who are motivated to collaborate with each other as

participants in interventions to test the effects of collaboration.

• With more specific outcomes in mind (e.g., improved collaborativecommunication about advance care planning, goals or care, prognosis,withholding and withdrawing of life sustaining treatments within ICUs) (Boyle

& Kochinda, 2004).

4. Devise a tool with a demonstrated ability to measure change (Dechairo-Marino et al.,

2001).

OTHER

Policy Implications for Organizations

1. Implement organizational policies to support collaboration and coordination of patient care (e.g., in one hospital the nurse manager orients new physicians to the

equal but different knowledge base concept, and informs them that within the

organization nurses respect physicians and vice versa; evaluate staff nurses on howwell they work with physicians, putting the patient care first; and some nurse

managers are evaluated on how much assistance they provide for nurses andphysicians, in order to help them work well together) (Kramer & Schmalenberg,

2003).

2. Implement a zero tolerance policy for disruptive behaviour. Disseminate a “code of conduct” policy and reporting guidelines to both nurses and physicians. Apply policies

consistently and quickly and provide feedback to those involved.

3. Ensure physicians sign a code of conduct policy when they are credentialed or re-

credentialed.

4. Develop, implement, and enforce appropriate policies, remove barriers to reportingdisruptive behaviour, and implement a feedback process on the outcomes of

reporting.




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Nurse/Physician Managers

1. Appoint a physician leader who will take charge of training and educationalprograms.

2. Introduce performance related goals, where each member of staff has part of their

compensation tied to achieving measurable goals within their organization. The Chief Nursing Officer (CNO) and Chief Medical Officer (CMO) could collaborate on

improving these relationships and administer surveys to measure nurse and

physician satisfaction, with the overall scores relating to the current progress.

3. Deal with complaints made by physicians regarding nursing care in a proactivemanner. For example, if a physician states that a nurse did not follow the dressing

change order, follow up with the nurse, but ask the physician to present a programon dressing wounds post-surgery.

4. Bring together the appropriate leaders from each discipline to collaborate and sharethe responsibility of dealing with complaints from patients. This sends a powerful

message to the staff that the two disciplines are equals, should work as a team, andultimately are accountable to the patients.

5. Combine the chart notes of nurses and physicians in order to improve

communication between nurses and physicians, with staff informing the relevantpeople of changes in the notes which will affect patient care.

6. Introduce multidisciplinary meetings at the ward and management level.

Healthcare Administrators/Managers

1. Encourage hospital administrators to take a more proactive role in avoiding possible

confrontations related to staffing, scheduling, and equipment.

2. Include physicians on nurse recruitment teams, this will allow them to gain a betterunderstanding and appreciation of the things which are important to nurses when

they look for a job.

3. Set up collaborative practice teams (CPTs); multidisciplinary health care teamsaimed to ensure that quality, cost-effective, research-based care is provided to

patients.

4. Allocate additional time and resources to raise the awareness of official

communication procedures, to ensure staff members are more aware of theregulations that should guide their interactions.

5. Implement quality circle meetings, allowing representatives of all levels to meet and

discuss communication problems, and possible solutions.

6. Examine workplace design and layout in relation to environmental factors which

impact on written and verbal communication.




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APPENDIX 6A Conceptual Model Representing Strategies Identified by Kramer &

Schmalenberg (2002) and Hinshaw (2002) as Fostering Magnet

Hospital Characteristics





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APPENDIX 7Nurse-Physician Focused Survey Questions From Health Human

Resources Modelling: Challenging the Past, Creating the Future

Study (Project 3)

We are pleased to have the opportunity to include nurse-physician focused questions within

our ongoing research projects. This will give us the opportunity to generate useful data froma multitude of nurses.

There are two surveys within the project 3 study, which contain nurse-physician focused

questions. The first survey is aimed at nurses who are currently working in nursing

(stayers) and will apply to the following groups:

• Nurses working in nursing – employed on a regular basis

• Nurses working in nursing – employed on a casual basis

The second survey is aimed at nurses not working in nursing (leavers) and will apply to the

following categories of nurses:

• Nurses employed in other than nursing and seeking employment in nursing

• Nurses employed in other than nursing and not seeking employment in nursing• Nurses not employed in nursing and seeking employment in nursing

• Nurses not employed in nursing and not seeking employment in nursing

For all six provinces included in the study the researchers will be sampling RNs. In addition

for Ontario only, the researchers will be sampling practical nurses. Two of the questionsfrom each survey appear below:

Stayers Survey

1. You have indicated either that you have no plans to leave nursing as a career or that

you plan to retire within the next year. How much of a problem do you consider eachof the following in your current position?

• Relationship with physicians2. If (Yes) think of your professional relationships with physicians in your current

nursing position. To what extent do you agree or disagree with the followingstatements?

• The overall atmosphere of nurse-physician relationships in your workplace is good

• The physicians you work with are aware of the importance of nurse-physicianrelationships to nurse satisfaction

•

Physicians value and respect nursing collaboration and input• There is administrative support of nurses in conflict with physicians

• There is physician support for nurses in conflict with physicians




Leavers Survey

1. In your last nursing position, did you work or communicate with physicians?2. (If Yes) Think back to your professional relationships with physicians in your last

nursing position. To what extent do you agree or disagree with the followingstatements?

• The overall atmosphere of nurse-physician relationships in your workplace is good

• The physicians you work with are aware of the importance of nurse-physician

relationships to nurse satisfaction

• Physicians value and respect nursing collaboration and input• There is administrative support of nurses in conflict with physicians

• There is physician support for nurses in conflict with physicians

This research has been generously funded by a grant from the Government of Ontario. The views expressed in this report do notnecessarily reflect those of the Government of Ontario

23634605 nurse physician relationships solutions and recommendations for change

Documents

nursephysician communication

nursephysician collaboration

nurse staffing

importance of nurse

magnet hospital literature

magnet hospital environment

ministry of health

quality health outcomes