Nurse-physician Relationships Research Articles

Excellence Through Evidence

Multiple nurse-physician (RNMD) relationships coexist on hospital units; collegial and collaborative (C/C) relationships positively impact, more than others, patient outcomes. The goal of this multisite evidence-based management practice initiative was to identify structures that enable C/C RNMD relationships. In part 1, the authors discuss the methodology and selection of the sample of 141 physicians, managers, and staff nurses from 44 clinical units in 5 hospitals that had previously demonstrated extensive C/C RNMD relationships. These 141 experts were interviewed to identify structures enabling C/C RNMD relationships. Part 1 presents the structures that enable C/C RNMD relationships as described and tested in the literature, as well as a description of the characteristics of the clinical units, experts, and C/C RNMD relationships found in this study. In part 2, the structures identified by the experts as needed for securing C/C RNMD relationships will be presented, along with suggestions for attainment.

The Perfect Storm: Nursing In Twenty-First-Century America

The Perfect Storm: Nursing In Twenty-First-Century America

Nurse Practice Environments and Outcomes: Implications for Oncology Nursing

To examine practice environments and outcomes of nurses working in oncology units or Magnet hospitals and to understand the association between the two. Secondary analysis of survey data collected in 1998. Medical and surgical units of 22 hospitals, of which 7 were recognized by the American Nurses Credentialing Center Magnet program. 1,956 RNs, of whom 305 worked in oncology units. Chi-square tests compared nurse-reported outcomes by work setting, analysis of variance tested practice environment differences by setting, and logistic regression estimated the effects of practice environment, specialty, and Magnet status on outcomes. Practice environments, emotional exhaustion, job satisfaction, and quality of care. Oncology nurses had superior outcomes compared with nononcology nurses. Emotional exhaustion was significantly lower among oncology nurses working in Magnet hospitals. Scores on the Collegial Nurse-Physician Relations subscale were highest among oncology nurses. Outcomes were associated with Practice Environment Scale of the Nursing Work Index scores and Magnet status. Oncology nurses with favorable collegial nurse-physician relations were twice as likely to report high-quality care. Oncology nurses benefit from working in American Nurses Credentialing Center Magnet hospitals. Adequate staffing and resources are necessary to achieve optimal outcomes. Collegial nurse-physician relations appear to be vital to optimal oncology practice settings. In addition to pursuing American Nurses Credentialing Center Magnet recognition, nurse managers should assess practice environments and target related interventions to improve job satisfaction and retention. High-priority areas for interventions include ensuring adequate staff and resources, promoting nurse-physician collaboration, and strengthening unit-based leadership.

The Impact of Hospital Nursing Characteristics on 30-Day Mortality

Evidence indicates that hospital nursing characteristics such as staffing contribute to patient outcomes. Less attention has been given to other hospital nursing characteristics central to optimal professional practice, namely nurse education and skill mix, continuity of care, and quality of the work environment. To assess the relative effects and importance of nurse education and skill mix, continuity of care, and quality of work environment in predicting 30-day mortality after adjusting for institutional factors and individual patients characteristics. A cross-sectional analysis of outcome data for 18,142 patients discharged from 49 acute care hospitals in Alberta, Canada, for diagnoses of acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, pneumonia, or stroke between April 1, 1998, and March 31, 1999, was done. Mortality data were linked to patient demographic and comorbidity factors, institutional characteristics, and hospital nursing characteristics derived from a survey of all registered nurses working in acute care hospitals. Using multilevel analysis, it was determined that the log-odds for 30-day mortality varied significantly across hospitals (variance = .044, p < .001). Patient comorbidities and age explained 44.2% of the variance in 30-day mortality. After adjustment for patient comorbidities and demographic factors, and the size, teaching, and urban status of the study hospitals in a fixed-effects model, the odds ratios (95% confidence interval) of the significant hospital nursing characteristics that predict 30-day mortality were as follows: 0.81 (0.68-0.96) for higher nurse education level, 0.83 (0.73-0.96) for richer nurse skill mix, 1.26 (1.09-1.47) for higher proportion of casual or temporary positions, and 0.74 (0.60-0.91) for greater nurse-physician relationships. The institutional and hospital nursing characteristics explained an additional 36.9%. Hospital nursing characteristics are an important consideration in efforts to reduce the risk of 30-day mortality of patients.

Estudio piloto para la validación de una escala sobre el entorno de práctica enfermera en el Hospital San Cecilio

Objectives To adapt the Practice Environment Scale (PES) questionnaire to the sociocultural context of Spain through peer review. To analyze the psychometric properties of the PES at San Cecilio Hospital with a bureaucratic practice model.To compare these psychometric properties with those found in an American context with a professional practice model. Method We performed an observational, descriptive, cross-sectional study at the San Cecilio Hospital. Systematic consecutive sampling of 112 nurses was performed. Results The total variance explained in the American context was 48% compared with 37.849% in the present study.Factors 4 and 5 (staffing and resource adequacy, and collegial nurse-physician relations) from the American study were identical to factors 2 and 5 in the present study. Reliability analysis showed that the Cronbach's ??of the PES in the present study was higher than that of the American study. Conclusions The psychometric properties of the PES in a bureaucratic practice model in San Cecilio Hospital were inadequate for validation. Nevertheless, these properties were close to those found in a professional practice model in the American study. Staffing and resource adequacy and collegial nurse-physician relations seem to have a stable significance for any nursing environment and practice mode.

Disruptive Behavior &amp; Clinical Outcomes: Perceptions of Nurses &amp; Physicians

Overview: Providing safe, error-free care is the number-one priority of all health care professionals. Excellent outcomes have been associated with procedural efficiency, the implementation of evidence-based standards, and the use of tools designed to reduce the likelihood of medical error (such as computerized medication orders and bar-coded patient identification). But the impact of work relationships on clinical outcomes isn’t as well documented. Overview: The current survey was designed as a follow-up to a previous VHA West Coast survey that examined the prevalence and impact of physicians’ disruptive behavior on the job satisfaction and retention of nurses (see “Nurse–Physician Relationships: Impact on Nurse Satisfaction and Retention,”American Journal of Nursing, June 2002). Based on the findings of that survey and subsequent comments on it, the follow-up survey examined the disruptive behavior of both physicians and nurses, as well as both groups’ and administrators’ perceptions of its effects on providers and its impact on clinical outcomes. Overview: Surveys were distributed to 50 VHA hospitals across the country, and results from more than 1,500 survey participants were evaluated. Nurses were reported to have behaved disruptively almost as frequently as physicians. Most respondents perceived disruptive behavior as having negative or worsening effects, in both nurses and physicians, on stress, frustration, concentration, communication, collaboration, information transfer, and workplace relationships. Even more disturbing was the respondents’ perceptions of negative or worsening effects of disruptive behavior on adverse events, medical errors, patient safety, patient mortality, the quality of care, and patient satisfaction. These findings suggest that the consequences of disruptive behavior go far beyond nurses’ job satisfaction and morale, affecting communication and collaboration among clinicians, which may well, in turn, have a negative impact on clinical outcomes. Strategies aimed at reducing the incidence and impact of disruptive behavior are recommended.

Original Research: Disruptive Behavior and Clinical Outcomes: Perceptions of Nurses and Physicians

Providing safe, error-free care is the number-one priority of all health care professionals. Excellent outcomes have been associated with procedural efficiency, the implementation of evidence-based standards, and the use of tools designed to reduce the likelihood of medical error (such as computerized medication orders and bar-coded patient identification). But the impact of work relationships on clinical outcomes isn't as well documented. The current survey was designed as a follow-up to a previous VHA West Coast survey that examined the prevalence and impact of physicians' disruptive behavior on the job satisfaction and retention of nurses (see "Nurse-Physician Relationships: Impact on Nurse Satisfaction and Retention," June 2002). Based on the findings of that survey and subsequent comments on it, the follow-up survey examined the disruptive behavior of both physicians and nurses, as well as both groups' and administrators' perceptions of its effects on providers and its impact on clinical outcomes. Surveys were distributed to 50 VHA hospitals across the country, and results from more than 1,500 survey participants were evaluated. Nurses were reported to have behaved disruptively almost as frequently as physicians. Most respondents perceived disruptive behavior as having negative or worsening effects, in both nurses and physicians, on stress, frustration, concentration, communication, collaboration, information transfer, and workplace relationships. Even more disturbing was the respondents' perceptions of negative or worsening effects of disruptive behavior on adverse events, medical errors, patient safety, patient mortality, the quality of care, and patient satisfaction. These findings suggest that the consequences of disruptive behavior go far beyond nurses' job satisfaction and morale, affecting communication and collaboration among clinicians, which may well, in turn, have a negative impact on clinical outcomes. Strategies aimed at reducing the incidence and impact of disruptive behavior are recommended.

Work‐Related Disability in Canadian Nurses

To determine factors contributing to high registered nurse (RN) injury claim rates in Canadian hospitals. Cross-sectional study of secondary 1998-99 data for RNs (N = 8,044) in Ontario, Canada, linked at the hospital level (n = 127). Descriptive statistics, correlations, and logistic regression analyses were conducted. The odds of a high RN lost-time claim rate increased by 70% for each quartile increase in the percentage of RNs reporting more than 1 hour of overtime per week. The odds of a high RN musculoskeletal lost-time claim rate decreased by 64% for every one unit increase in the hospital-level score on the nurse-physician relationship subscale. To retain and optimize scarce hospital nursing resources, strategies to address overtime, sick time, and nurse-physician relationships might provide fiscal and human benefits.

Recruitment and Retention of Nurses: Challenges Facing Hospital and Community Employers

Understanding nurses' perceptions of their workplaces underpins successful recruitment and retention initiatives, particularly in this time of global nursing shortage. The American Nurses Association and the American Academy of Nursing have identified "magnet characteristics"--organizational factors that support excellent practice and working conditions in hospital settings. Using selected magnet characteristics, this exploratory study examined nurses' perceptions of their work experiences in both hospital and community settings. Mail surveys were completed by community and hospital nurses (n = 1248) selected randomly from a provincial registry in Ontario, Canada. Scales measured organizational factors (organizational and immediate supervisor support, decentralized decision-making, nurse-physician relationships and work-group cohesiveness) and job-related factors (autonomy, job challenge, work demands, fair treatment, work-status congruence; satisfaction with career, salary, working conditions) of nurses' experiences in their work settings. Nurses in both sectors wanted more opportunities to participate in decision-making and recognition for their contributions to their organizations. In the hospital sector, nurses reported significantly lower levels of perceived organizational and supervisory support and autonomy, and were less satisfied with working conditions and scheduling. Nurses in the community sector were most dissatisfied with salary. No cross-sector differences were reported on nurse-physician relationships, degree of job challenge or career satisfaction. Successful recruitment and retention initiatives hinge on the ability (and willingness) of healthcare organizations to attend to the concerns expressed by nurses and create work settings that are attractive to both new recruits and nurses currently in their employ.

Cutting-edge Discussions of Management, Policy, and Program Issues in Emergency Care

Cutting-edge Discussions of Management, Policy, and Program Issues in Emergency Care

Enhancing and Enriching the Nurse-Physician Relationship

For most of my career as a physician, 1 had been involved in what 1 Thought were ideal situations: nurses and physicians got along beautifully. A few years ago, I moderated a breakout session at a conference of nurses, where I heard stories of frustration and anger, lack of respect of one for the other, horror stories of nurse-physician interactions, some of which had an impact on patient care and professional satisfaction. That's the background of this conversation, in which a respected nurse-educator and physician-educator address the dilemma and draw on their own experiences. More optimistically, they spoke in detail of important initiatives to enhance relationships between the two professions. We began our discussion as 1 asked them to describe what experiences contributed to their interest in nurse-physician relationships.

On the Nurse-Physician Relationship: "A problem defined is a problem half solved."

On the Nurse-Physician Relationship: "A problem defined is a problem half solved."

Physician as Healer, Leader and Partner: Tackling the Nursing Shortage.

Physicians have been notably silent on the nursing shortage in spite of articles that have suggested that physician behavior is one of the causes of job dissatisfaction among professional nurses. In addition to the role of healer, the physicians of the Colorado Permanente Medical Group (CPMG) are expected to have the additional responsibilities of being both leaders in health care and strong clinical partners with the nursing staff. CPMG has embarked upon a program to leverage physician leadership to address the nursing shortage through multiple avenues. We expect not only to increase the number of nurses in the future, but also to enhance their careers by being their "Preferred Clinical Partner." To describe a model for engaging physicians in becoming active participants in solving the nursing shortage through leadership and partnering. The Preferred Clinical Partner Program has been developed to address the nursing shortage in multiple ways. We have significantly increased the number of scholarships available for nursing students as well as funding and developing additional educational programs to meet the needs of nurses entering from various points in their lives and educational journeys. We have also enhanced programs around physicians serving as teachers and mentors in the education and long-term development of health care team members. And finally, we are clarifying leadership and partnership expectations for physicians and developing very specific physician-nurse relationship training programs to try to solidify the long-term sustainability of careers of these important members of our health care team. Physician groups that take an active role by "opting-in" to nursing shortage issues will benefit by having an engaged, professional, compassionate nurse on their health care team.

Workplace empowerment and magnet hospital characteristics: making the link.

To test a theoretical model linking nurses' perceptions of workplace empowerment, magnet hospital characteristics, and job satisfaction in 3 independent studies of nurses in different work settings. Strategies proposed in Kanter's structural empowerment theory have the potential to result in work environments that are described in terms of magnet hospital characteristics. Identifying factors that contribute to work conditions that attract and retain highly qualified committed nurses, such as those found in magnet hospitals, that can be put in place by nursing administrators is extremely important for work redesign to promote professional nursing practice. Secondary analyses of data from 3 studies were conducted--2 of staff nurses and 1 with acute care nurse practitioners working in Ontario, Canada. The Conditions of Work Effectiveness Questionnaire-II, the NWI-R, and measures of job satisfaction were used to measure the major study variables.RESULTS The results of all 3 studies support the hypothesized relationships between structural empowerment and the magnet hospital characteristics of autonomy, control over practice environment, and positive nurse-physician relationships. The combination of access to empowering work conditions and magnet hospital characteristics was significantly predictive of nurses' satisfaction with their jobs. These findings suggest that nursing leaders' efforts to create empowering work environments can influence nurses' ability to practice in a professional manner, ensuring excellent patient care quality and positive organizational outcomes.

Home health care nurses' perceptions of physician-nurse relationships.

This work is a sociological analysis of the physician-nurse relationship in home health care. Data include observation, interview, and survey sources. Results confirm that, largely because of the physician's distance both physically and symbolically, home care nurses take on a more primary care role with patients than do nurses in hospitals. There are fewer instances of conflict between physician and nurse in this setting, as doctors yield more responsibility to nurses than they may in hospitals. In the end, though nurses claim higher levels of autonomy, patients appear to be the true beneficiaries of the in situ shift in nursing responsibility.

Health correlates of autonomy, control and professional relationships in the nursing work environment.

Internationally, nursing is facing a variety of challenges including changes in health systems, an ageing workforce and escalating shortages of Registered Nurses. New Zealand is no exception. Here as elsewhere these challenges are taking their toll on the resources and demands of hospital environments, on the health and well-being of nurses themselves and most certainly on the people for whom they care. In the United States of America (USA), three aspects of the nursing work environment--autonomy, control and nurse-physician relations--have been identified as linked to staff retention, levels of staff burnout and needlestick injury, as well as to a range of patient outcomes. To examine the New Zealand nursing situation and to see whether aspects of the work environment are associated with health status. A total of 225 Registered Nurses in a general hospital completed the Revised Nursing Work Index (NWI-R) and Medical Outcomes Study (MOS) 36-Item Short-Form Health Survey (SF-36). Ratings indicated that the New Zealand hospital environment was characterized by less autonomy and control and better nurse-physician relations than in USA hospitals. Results of correlations demonstrated that more positive ratings of the three workplace attributes were associated with better health status amongst the nurses. The results of regression analyses were indicative either of a confounding relationship or of a mediating relationship such that nurses' relations with physicians, administration and other departments mediate the associations between autonomy, control and health status. The study offers an insight into a New Zealand hospital environment and suggests the importance of good relationships with physicians and other departments for the health of nurses.

The impact of the nurse-physician relationship on barriers encountered by nurses during pain management

The aim of the current investigation was to examine the barriers encountered by Tasmanian registered nurses when attempting to provide optimal pain management. The impact of nurse satisfaction with their professional relationship with physicians during pain management on the types of barriers encountered was also examined. A total of 1,015 registered nurses completed a 21-item survey that examined the types of barriers encountered during pain management. In addition, data were gathered on nurses' satisfaction with their professional relationship with physicians during pain management. More than one-third of the respondents indicated that they had encountered at least one type of barrier to providing optimal pain relief, including insufficient cooperation by physicians and inadequate prescriptions of analgesic medications. Nurses who did not feel adequately consulted by physicians were significantly more likely to encounter barriers such as insufficient cooperation by patient's physicians and inadequate prescription of analgesic medications. The barriers to effective pain management encountered by nurses were affected by their relationship with physicians. Education, for both nurses and physicians, concerning the role of the nurse in the workplace will help to ensure that nurses encounter fewer barriers during pain management. Optimal pain management practice will result if guidelines for dealing effectively with barriers are tailored to the specific type of institution and the unit within those institutions. © 2003 by the American Society of Pain Management Nurses

RN–MD RELATIONSHIPS

Editor's note: “Nurse–Physician Relationships” (June), by Alan H. Rosenstein, reported the author's research of disruptive physician behavior and its effect on nurse satisfaction. The study received widespread news media attention, including coverage in U.S. News & World Report, The Philadelphia Inquirer, Modern Healthcare, Modern Physician, and Marketplace (Public Radio International). To follow are comments from AJN’ s readers in reaction to both the study and my accompanying Editorial, “MD–RN: A Tired Old Dance.” Readers were generally supportive of the study results and wanted to know how to address the problem of disruptive physician behavior (and some offered their own suggestions). A good start would be to share this article with your nurse colleagues and the physicians and administrators at your facility, which might provoke a discussion about the relevance of these issues at your institution. Editor's note: When I wrote the editorial, I was mindful that it might appear that I was blaming the victim. In my experience, nurses go out of their way to develop good working relationships with physicians. Nevertheless, as I noted, nurses too often put up with abusive behavior and perpetuate the inequalities in nurse–physician relationships. Physicians must recognize their role in this dance, but nurses should not wait for them to do so.

RN–MD RELATIONSHIPS

Staten Island, NY Editor's note: “Nurse–Physician Relationships” (June), by Alan H. Rosenstein, reported the author's research of disruptive physician behavior and its effect on nurse satisfaction. The study received widespread news media attention, including coverage in U.S. News & World Report, The Philadelphia Inquirer, Modern Healthcare, Modern Physician, and Marketplace (Public Radio International). To follow are comments from AJN’ s readers in reaction to both the study and my accompanying Editorial, “MD–RN: A Tired Old Dance.” Readers were generally supportive of the study results and wanted to know how to address the problem of disruptive physician behavior (and some offered their own suggestions). A good start would be to share this article with your nurse colleagues and the physicians and administrators at your facility, which might provoke a discussion about the relevance of these issues at your institution. Editor's note: When I wrote the editorial, I was mindful that it might appear that I was blaming the victim. In my experience, nurses go out of their way to develop good working relationships with physicians. Nevertheless, as I noted, nurses too often put up with abusive behavior and perpetuate the inequalities in nurse–physician relationships. Physicians must recognize their role in this dance, but nurses should not wait for them to do so.

RN–MD RELATIONSHIPS

Peoria, AZ Editor's note: “Nurse–Physician Relationships” (June), by Alan H. Rosenstein, reported the author's research of disruptive physician behavior and its effect on nurse satisfaction. The study received widespread news media attention, including coverage in U.S. News & World Report, The Philadelphia Inquirer, Modern Healthcare, Modern Physician, and Marketplace (Public Radio International). To follow are comments from AJN’ s readers in reaction to both the study and my accompanying Editorial, “MD–RN: A Tired Old Dance.” Readers were generally supportive of the study results and wanted to know how to address the problem of disruptive physician behavior (and some offered their own suggestions). A good start would be to share this article with your nurse colleagues and the physicians and administrators at your facility, which might provoke a discussion about the relevance of these issues at your institution. Editor's note: When I wrote the editorial, I was mindful that it might appear that I was blaming the victim. In my experience, nurses go out of their way to develop good working relationships with physicians. Nevertheless, as I noted, nurses too often put up with abusive behavior and perpetuate the inequalities in nurse–physician relationships. Physicians must recognize their role in this dance, but nurses should not wait for them to do so.