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Nurse-Physician Relationships in Hospitals: 20 000 Nurses Tell Their Story

2009; American Association of Critical-Care Nurses; Volume: 29; Issue: 1 Linguagem: Inglês

10.4037/ccn2009436

1940-8250

Claudia Schmalenberg, Marlene Kramer,

Nursing Roles and Practices

Why "good" relationships between nurses and physicians are important to high-quality patient care.In this article, 20 000 staff nurses tell their story about how they perceive, assess, and develop high-quality relationships with physicians in hospitals with the goal of improving patient care. This story is based on a synthesis of findings from 6 research studies, outlined in Table 1, as they pertain to nurse-physician relationships. In the Dimensions of Magnetism study1–6 and in the psychometric studies7,8,17 described, 20 616 staff nurses identified and described 5 types of nurse-physician relationships that prevail on almost all clinical units. In the 4 interview studies,13–16 721 staff nurses, 334 nurse managers, 229 physicians, 46 other health professionals, and 29 nurse and hospital administrators who were interviewed about nurse-physician and interdisciplinary relationships described not only the different types of relationships but most importantly why "good" relationships were important to patient care and what organizational structures and leadership practices promoted the "best" relationships— collaboration and collegiality. The distribution of interviewees among professional groups may seem, and is, somewhat lopsided. Our intention was to focus on staff nurses' perceptions of the quality of unit work environments. All excerpts are from staff nurse interviews unless otherwise noted.Throughout the 1990s, a great deal was written about the importance of "good" nurse-physician relationships, about how high-quality nurse-physician relationships were 1 of the 3 cornerstones of excellent (magnetic) work environments, about how the quality of nurse-physician relationships is more of a concern to nurses than to physicians, and about how physicians consistently rate the quality of these relationships higher than do nurses.18–21 In all of these writings, what constitutes good or high-quality relationships between physicians and nurses is seldom defined, and when an attempt is made to assess goodness, nurse-physician relationships are measured as though all interactions between nurses and physicians on the unit or in the clinic result in the same kind of relationship. Staff nurse interviewees had this to say about the problem:Relationships between nurses and physicians are important to study because how well these 2 groups work together affects the quality of care that patients receive.18 In a now classic study of all intensive care units (ICUs) in 13 large hospitals nationwide, Knaus et al22 reported that ICU patients cared for by nurses and physicians who worked collaboratively had lower "acuity-adjusted" mortality rates than did patients cared for by less collaborative nurses and physicians. Fewer deaths and transfers back to the ICU are positive outcomes for patients that have been cited in other studies.23,24 Collaborative nurse-physician relationships also lead to better patient and organizational outcomes such as decreased length of stay and net reduction in treatment costs without reduction in functional levels or decrease in satisfaction among patients.25 In addition to patient outcomes, high-quality nurse-physician relations result in increased satisfaction among nurses and physicians and increased autonomy for nurses.9–12,26,27Before the Dimensions of Magnetism study in 2001 (see Table 1), 3 types of nurse-physician relationships were described in the literature. The earliest was a manipulative relationship termed the "Dr-Nurse Game." In this relationship, the nurse was permitted to indirectly suggest changes or modifications in a patient's treatment or care plan but only if proper deference was shown to the physician and if nurses maintained their subordinate position.28 These Dr-Nurse Game relationships were assessed through observation and a compilation of anecdotes; they were not measured as such. A second, frequently described type was abusive-hostile-adversarial nurse-physician relationships. Rosenstein et al29 have conducted an extensive study of adversarial-abusive relationships, measured by numerical count of instances of abusive behavior and numbers of nurses who left employment because of abusive-hostile incidents with physicians.Concern about adversarial relationships gave rise to the formation of the National Joint Practice Commission on collaborative relationships supported by the American Nurses Association and the American Medical Association in 1971.30 The demonstration-evaluation projects associated with this endeavor showed some successes, for example, more collaborative nurse-physician relationships and perceived improvements in patient care. These projects also served as an impetus for development of tools to measure "collaborative" nurse-physician relationships.31,32 A measurement problem discovered almost immediately was that physicians perceived the degree of nurse-physician collaboration to be much greater than what nurses perceived it to be. And the differences were quite large. Thomas et al33 reported that 73% of physicians but only 33% of nurses in their study thought that their relationships were collaborative; Ferrand et al19 found that 50% of the physicians but only 27% of the nurses identified relationships with physicians as collaborative. Studies also reported that nurses' perceptions of the degree and quality of collaboration were a more accurate predictor of patient outcomes—deaths and transfer back to the ICU—than were physicians' perceptions.23,32 On the basis of the preceding findings, we concluded that physicians and nurses may not define collaborative nurse-physician relationships the same; measurement tools that fit one group's definitions and conceptions may not fit those of the other group; and because of these factors, multiple nurse-physician relationships most likely exist on the same clinical unit/clinic.In 2001, we set out to explore what staff nurses working in magnet hospitals meant by good nurse-physician relationships. We interviewed 279 staff nurses in 14 magnet hospitals1 and discovered some interesting facts. Throughout the 1990s, good nurse-physician relationships were assessed by having the 2 groups complete the Weiss and Davis collaborative practice scales,31 which operated on the principle that all nurse-physician relationships on a clinical unit were the same or highly similar. Staff nurses quickly informed us that such is not the case. Multiple relationships coexist on a clinical unit.9,10 A nurse may have a collaborative relationship with one physician, a hostile relationship with another, and a student-teacher type of relationship with a third. Moreover, relationships are dynamic. They change over time.From the examples of nurse-physician interactions described by the interviewees, we constructed the nurse-physician relationship subscale of the Essentials of Magnetism.1,7,9,10,17 This scale defines and measures the 5 types of nurse-physician relationships identified by the staff nurse interviewees:The nurse-physician relationship unit climate is a composite of the interactions and relationships of nurses and all physicians who visit or care for patients on the unit—physicians who admit and care for many patients as well as physicians who admit and visit only periodically. All 5 relationships can and do exist on a clinical unit at the same time.1,5,9,10 Respondents complete each scale item by indicating their perception of relationships on a 4-point scale ranging from "most physicians, most of the time" to "not true for any physicians." The first 3 categories are the more positive relationships, have a positive-feeling tone, and were weighted the heaviest by the 392 nurses from 7 magnet hospitals who participated in an item-weighting study7 based on which nurse-physician relationship was most beneficial to quality patient care. The friendly stranger relationship is a neutral one that can go either way. If left alone, it often deteriorates. Hostile/adversarial nurse-physician relationships are more common than might be expected. In a large, nationwide study, 96% of the 714 nurses surveyed indicated that they had either experienced or witnessed abusive behavior; 31% indicated that hostile nurse-physician relationships existed.29,35 The nurse-physician subscale of the Essentials of Magnetism measures the nurse-physician unit climate, the proportion of positive relationships to neutral or negative relationships.The preceding picture is based primarily on the literature9,10 and on facts garnered from the 2001 interviews with staff nurses in 14 magnet hospitals,1 namely that it is the unit nurse-physician relationship climate that affects outcomes for patients and nurses, the quality of patient care, and nurses' job satisfaction. The unit climate is composed of some combination of the 5 relationships explained in the previous paragraphs. What does the nurse-physician unit climate look like in excellent hospitals? Does the nurse-physician climate in magnet hospitals differ from that in comparison hospitals? What changes do staff nurses report over time? Table 2 presents a summary picture of the nurse-physician relationship climate on clinical units in magnet and comparison hospitals as evidenced by the percentage of staff nurses in agreement with the each type of nurse-physician relationship. It is a picture at 2 different periods, 2003 and 2007, and is based on the 2 psychometric studies of the Essentials of Magnetism outlined in Table 1.7,17In a 2003 study7 of 3602 staff nurses in 16 magnet and 10 comparison hospitals, the dominant unit climate (ie, an affirmative, weighted response to the 2 highest points on the 4-point scale) reported by staff nurses in magnet hospitals was collegial (86%) and collaborative (82%); the dominant unit climate reported by staff nurses in comparison hospitals was collaborative (64%) and friendly stranger (63%). In the magnet sample, 69% of the nurses reported that student-teacher relationships also existed with many physicians on their units; 54% cited friendly stranger relationships, and 13% reported that hostile/adversarial relationships with many or some physicians contributed to the unit nurse-physician relationship climate. In the comparison hospital sample, about half of the nurses (49% and 54%) reported student-teacher relationships, 61% reported collegial relationships, and 29% reported adversarial relationships. The last figure is more than double that found in the magnet sample (Table 2).In the 2007 study17 of 10 514 staff nurses in 18 magnet and 16 comparison hospitals, the magnet hospitals nurses still reported predominately collegial (81%) and collaborative (85%) relationships, although the percentage of friendly stranger (59%) and adversarial (17%) relationships had both increased by about 5% over the 2003 testing. Student-teacher relationships were slightly higher in 2007 than in 2003, and a shift toward physicians, rather than nurses, as teacher was apparent. Some of the largest percentage shifts in the 2007 study occurred among the comparison hospitals, which gained in all 3 of the positive relationship categories (collegial, collaborative, and student-teacher) and declined in the neutral (friendly stranger) and negative (hostile/adversarial) relationship categories (Table 2).The total, weighted score for the 5 types of relationships on the nurse-physician subscale of the Essentials of Medicine provides a nurse-physician relationship unit climate score that permits statistical comparison of magnet and comparison hospitals for both 2003 and 2007. In 2003, staff nurses in magnet hospitals reported significantly higher unit climate scores than did their counterparts in comparison hospitals. The F ratio was 21.279, significant at P<.001.7 In 2007, staff nurses in magnet hospitals again reported significantly higher unit climate scores than did their counterparts in comparison hospitals. However the F ratio had decreased to 14.446, significant at P<.001.17The 2007 psychometric and construct validity study (comparison and analysis of subscale scores will test the construct that nurses in magnet hospitals with excellent work environments will score higher than will their counterparts in comparison hospitals) had a larger overall sample than did the 2003 study, and the comparison hospitals were selected differently than they were selected in the 2003 sample. Specifically, 3602 nurses in the 16 magnet and 10 comparison hospitals in 2003 were compared with 10 514 nurses in 18 magnet and 16 comparison hospitals in 2007. In 2003, the comparison hospitals were from a convenience sample of hospitals invited to participate on the basis of regional representation. In 2007, the 16 comparison hospitals were all hospitals that had requested Essentials of Magnetism testing because they were preparing or considered themselves ready to apply for some mark of excellence—Magnet, Baldrige, or Employer of Choice. Within the group of 16 comparison hospitals, the proportion of academic medical centers was higher than in the 10-hospital sample in 2003. Also, a significantly greater percentage of participants were critical care nurses (Pearson χ2=244.29; df=10; significant at P<.001) in the 2007 16-hospital comparison sample than in the 18-hospital magnet sample.17 These differences might well explain some of the findings when the 2003 and 2007 samples were compared.The impact of the larger percentage of critical care nurses in the 2007 comparison hospital sample and its positive effect on unit nurse-physician relationship scores cannot be directly assessed because we did not obtain the same sort of information from the 2003 sample. However, we do have some comparative information. In both the 2003 and the 2007 samples, specialized units, particularly ICUs, in both magnet and comparison hospitals scored higher in nurse-physician relationships than did less specialized units.7,17 Of the 44 high-scoring clinical units in 5 high-scoring hospitals in the nurse-physician structure-identification study (see Table 1), 3 were magnet, 1 was a Veterans Affairs hospital, and the other was 1 of 5 hospitals in a corporate group.9,10 Many specialized units were represented among the 44 high-scoring units but not a single general medical/surgical unit in any of the 5 hospitals scored high enough on the nurse-physician sub-scale to qualify as a "high-scoring" unit for the interview part of the study.10A difference noted between the findings in the 20059,10 and the 200713–16 structure-identification studies with respect to the reported nurse-physician relationship climate on the unit was the increased emphasis on interdisciplinary interactions and collaboration rather than just interactions and collaboration between physicians and nurses. By 2007, regularly scheduled interdisciplinary rounds, particularly on medical ICUs and trauma, rehabilitation, and stroke units that included the active participation of all disciplines including staff nurses, were much more common.In addition, when physicians, administrators, and representatives from other professional departments were interviewed, they were asked to rate the quality of interdisciplinary interactions on a scale of 1 to 10 with the following benchmarks provided: 1=direct and teach others; 5=collaborative planning and evaluation; and 10=collegial interactions, a true partnership. Ratings ranged from 4 to 10, with a mean of 8.28. No significant rating differences were found between physicians (mean, 8.5) and representatives from other departments (mean, 8.1), although physicians' ratings of the quality of interdisciplinary interactions were slightly higher.For the physician group, 75% of the ratings were 8 or higher, 51% were 9 or higher, and 26% were at 10, the maximum benchmark. The picture for other departments was similar, with 70% of the ratings 8 or higher, 48% at 9 or higher, and 18% at 10. In situations in which therapists had a continuous and regular presence (eg, on orthopedic, rehabilitation, or critical care units), interdisciplinary interactions were reported to be particularly collaborative, almost collegial. When therapists provided care on a large number of units, the ratings of quality of interdisciplinary interactions were lower.One last finding from analysis of the interview transcripts was an increased understanding and recognition by physicians of the concept of unique and overlapping spheres of practice that is so vital for autonomous nursing practice and for collegial/collaborative relationships. A medical director demonstrates this feature in his orientation session with residents:When synthesizing results from several studies over time, the information may become overwhelming, suggesting the need for a summary. In the preceding section on the status of nurse-physician relationships on clinical units in hospitals and comparison of these relationships between magnet and comparison hospitals over time, the following major points are evidenced:The purpose of the nurse-physician structure-identification study was to ascertain from nurses, managers, and physicians on units that had previously confirmed high-quality nurse-physician relationships9 what the organizational structures and best practices were that enabled staff nurses and physicians on that unit to develop collegial/collaborative relationships. Several of the structures supporting development of collegial/collaborative relationships that were identified by the 141 interviewees in the nurse-physician structure-identification study9,10 are particularly relevant to clinical nurses on the front line.The increased reporting of adversarial relationships in magnet hospitals from 11% in 2001 to 14% in 2003 to 17% in 20074,9,10,17 is disconcerting, discouraging, and worrisome. Definitive steps must be taken to reverse this trend. The first step in constructive conflict resolution is to get the conflicting parties to talk with one another. As a staff nurse explained,Effective and constructive conflict resolution can also be done on a unit basis. In a unit operations or other interdisciplinary meeting, staff nurses and others can initiate a general discussion on approaches and best practices to use in handling disagreements, conflicts, and differences of opinion. Seek guidance from peers on how they approach situations that involve difficult interactions. It is well to particularly seek out those peers who seems to have "good" relationships with a "difficult" physician and ascertain how they approach the situation and initiate resolutions that work. Planned deliberative action is often successful in altering relationships.The best practice of regular, interactive interdisciplinary patient rounds is facilitated when a medical director or physician such as a hospitalist or an intensivist is designated as responsible for the medical practice of the unit. This person is then responsible for organizing and conducting interdisciplinary patient rounds, eliciting everyone's participation, and transmitting the group's decision to private physicians who may or may not be in attendance.For interdisciplinary patient rounds to truly be effective, physicians must shift their view of themselves from "customers" of the organization, to "stakeholders." As a physician explained,One community hospital that participated in the nurse-physician structure-identification study10 devised a plan to make interdisciplinary patient rounds truly effective and beneficial. This hospital was staffed 98% by physicians in group practices. Every 2 or 3 months, the practice designated 1 member of their group to be the medical director for the unit, responsible for conducting interdisciplinary collaborative patient rounds and communicating results and information to the appropriate practice physician. Nurses reported that this method worked quite well.10Staff nurses can also take steps to make effective collaborative practice rounds happen and to build collaborative relationships with physicians and other professionals. It is the responsibility of all professionals to attend and participate in such rounds.11 Because rounds are regularly scheduled, nurses can institute a system of "round coverage" so that all can attend and participate when their patients are being discussed.10 Through knowledgeable participation, staff nurses can ensure high-quality interdisciplinary patient care rounds so that the best possible patient care results. Staff nurses do a superb job of representing patients and interpreting physicians' comments to patients and patients' families.12 By coming to interdisciplinary rounds prepared, nurses are in a better position to represent the nursing-unique sphere of practice in the developing plan of care for a patient.10,12It is well to remember that the R in the acronym SBAR (situation-background-assessment-recommendation) stands for recommendations to the physician and to the interdisciplinary team.35,36 SBAR invites collaborative participation. By making evidence-based, thoughtful recommendations, nurses are not only helping the patient but building the cornerstones of future collegial, collaborative practice.Patient safety and high-quality patient care outcomes demand that clinical nurses engage in the practice of clinical autonomy and that physicians, nurses, and other professionals practice collegially and collaboratively. In the preceding article in this series,37 the structures and best practices related to autonomous practice were described. In this article, staff nurses, managers, and physicians have identified organizational structures and best practices conducive to building collegial/collaborative nurse-physician relationships. Many of these overlap. The structures and practices with particular relevance for clinical nurses were presented in this and in the preceding article.37 Staff nurses can participate in improving the work environment by seeking clarification of the parameters, dimensions, and definition of clinical autonomy and by availing themselves of the opportunities offered or seeking new opportunities to participate in dialogue sessions to renegotiate scope of practice.Nurse-physician relationships of any kind are forged by the day-to-day interactions on the clinical unit and can be shaped by staff nurses. Nurses must seek out and build collegial and collaborative relationships with physicians. The American Nurses Association noted in their 1980 social policy statement that clinical autonomy and nurse-physician collaborative relationships are true partnerships in which power is held and valued by both participants with recognition and acceptance of separate and combined spheres of activity, responsibility, and accountability.34(p7) Results indicate that physicians and nurses in the magnet hospitals involved in the structure-identification studies outlined in Table 1 have learned this important principle.