Collaboration between hospital physicians and nurses: An integrated literature review

Collaboration between hospital physicians andnurses: An integrated literature review

C.J. Tang1 Candidate Bachelor of Science (Nursing) (Honour) program,S.W. Chan2 PhD in Nursing, W.T. Zhou3 Advanced Practice Nurse, Master inNursing & S.Y. Liaw4 Registered Nurse, PhD in Medical Education

1 Student, 2 Professor, 3 Lecturer, 4 Assistant Professor, Alice Lee Centre for Nursing Studies, National University ofSingapore, National University Health System, Singapore, Singapore

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

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

physicians and nurses and compromised the quality of patient care.

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

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

physician–nurse collaboration.

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

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

collaboration in the hospital setting.

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

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

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

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

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

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

inter-professional education and interdisciplinary ward rounds.

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

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

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

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

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

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

resolve workplace issues.

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

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

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Literature Review

© 2013 International Council of Nurses 291

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

Physician–Nurse Collaboration

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

Hostile and adversarial relationships between both profes-sions still largely exist in many Western countries such as theUSA, Italy, Germany, and Asian countries like China and Japan(Morinaga et al. 2008; Papathanassolgou et al. 2012; Rosenstein2002). Studies found that physicians tend to have rude andintimidating personalities (Robinson et al. 2010; Rosenstein2002; Rosenstein & O’Daniel 2005). They exhibited disruptivebehaviours such as yelling and using abusive language towardsnurses. Consequently, nurses experienced a lack of respect andautonomy (Robinson et al. 2010; Rosenstein 2002; Rosenstein &O’Daniel 2005). The ‘friendly stranger’ relationship was alsoevident in some studies where interactions between physiciansand nurses were solely characterized by formal exchanges ofinformation (Kramer & Schmalenberg 2003; Schmalenberg &Kramer 2009). Each party was fairly satisfied with only fulfillingtheir own tasks and responsibilities towards each other andpatients (Kramer & Schmalenberg 2003; Schmalenberg &Kramer 2009). Nonetheless, there is evidence suggesting thatphysician–nurse relationships are in fact improving and movingslowly towards a collegial or collaborative nature (Kramer &Schmalenberg 2003; Schmalenberg & Kramer 2009). Collegialrelationships are characterized by equal trust, respect and

autonomy over patient care. Both professions engage in opencommunication and value each other’s input about patient out-comes (Robinson et al. 2010; Schmalenberg & Kramer 2009).Collaborative relationships are based on mutual respect andtrust, though at times nurses are expected to cooperate withphysicians (Robinson et al. 2010; Schmalenberg & Kramer2009). Effective physician–nurse collaboration has been foundto greatly improve the quality of patient care and their healthoutcomes (Hughes & Fitzpatrick 2010; Messmer 2008; Rose2011). As described, the patterns of physician–nurse collabora-tion are diverse and this could be attributed to the different atti-tudes, values and interpersonal skills held by each individual(Rosenstein 2002; Vazirani et al. 2005). Furthermore, behav-iours of physicians and nurses are largely influenced by theirpre-licensure education and ward cultures, which differ acrossclinical settings and countries (Hughes & Fitzpatrick 2010;Robinson et al. 2010).

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

AimRecognizing that collaboration is a two-way interpersonalprocess, it is important to understand the attitudes of both phy-sicians and nurses towards collaborative practice. This will aidin identifying the areas of improvement for physician–nursecollaboration (Petri 2010; Seitz et al. 2007). This integratedliterature review therefore aimed to present the best available

292 C. J. Tang et al.

© 2013 International Council of Nurses

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

Methods

Search method and process

The search sought to identify published papers in Englishwhich reported primary research studies on physician–nurserelationship or collaboration in hospitals. Relevant studieswere searched via the following databases: CINAHL, PubMed,Wiley Online Library and Scopus. Key search terms includedsingly or in various combinations: ‘nurse-physician relations’,‘attitudes’, ‘inter professional collaboration’, ‘collaboration’,‘doctor’, ‘nurse’ and ‘hospital’. A manual search was carried outon Journal of Interprofessional Care and using the ancestryapproach, reference lists of each retrieved article were reviewedfor additional relevant journals. The search was limited tojournals published in the last 10 years, from January 2002 toDecember 2012.

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

Search outcomes

The search process, and total number of included and excludedarticles are illustrated in Fig. 1. A total of six articles wereexcluded for the following reasons: (1) focus of the studywas not largely based on physician–nurse collaboration;(2) explored relationships between physicians and advancednurse practitioners; and (3) inappropriate target group wheremedical students, nurses and nurse managers were recruited asparticipants. Finally, 17 articles were reviewed.

Of the 17 reviewed studies, three were qualitative studies thatused focus-group interviews or semi-structured interviews. Theother 14 articles were quantitative studies. Ten of them adopteddescriptive comparative designs, where questionnaires wereused to evaluate the different attitudes physicians and nurses

have towards collaboration. Four used experimental designsto evaluate the effectiveness of interventions in improvingphysician–nurse collaboration. Table 1 summarizes the method-ologies and findings of the reviewed studies. These findingswere pooled together and categorized into three key themes fordiscussion.

Results

Attitudes towards physician–nurse collaboration

The reviewed studies adopted different instruments to measureattitudes of physicians and nurses towards collaboration. The‘Jefferson Scale of Attitudes toward Physician-Nurse Collabora-tion (JSAPNC)’ has been used in four of the reviewed studies(Garber et al. 2009; Hojat et al. 2003; Hughes & Fitzpatrick2010; Thomson 2007). Other questionnaires used include‘Baggs Collaboration and Satisfaction about Care Decisions(CSACD)’, ‘Collaboration & Satisfaction with Patient Care Deci-sions (CSPCD)’, ‘Collaborative Practice Scale (CPS)’, ‘IntensiveCare Unit Management Attitudes Questionnaire (ICUMAQ)’,‘Nurse-Physician Collaboration Scale’ and ‘Nurse-PhysicianRelationship Survey’ (Messmer 2008; Nair et al. 2012;Nathanson et al. 2011; Nelson et al. 2008; Rosenstein 2002;Rosenstein & O’Daniel 2005; Thomas et al. 2003). The validitiesand reliabilities of all these abovementioned instruments werewell documented (Dougherty & Larson 2005; Thomas et al.2003).

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

Importance of physician–nurse collaboration

Several reviewed studies found that physicians and nursesvalued collaboration (Hughes & Fitzpatrick 2010; Robinsonet al. 2010; Rosenstein 2002). Both professions recognized thateffective collaboration is essential in bringing about betterquality patient care, which ultimately leads to improved healthoutcomes for patients (Hughes & Fitzpatrick 2010; Robinsonet al. 2010; Rosenstein 2002). Two studies supported that physi-cians and nurses recognized the importance of collaboration inensuring patient safety, satisfaction, faster recovery and lowermortality rates (Messmer 2008; Rosenstein & O’Daniel 2005).

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

Physician–nurse collaboration 293


(Garber et al. 2009; Hughes & Fitzpatrick 2010; Rosenstein2002; Thomson 2007). The aforementioned studies that useddescriptive comparative designs were conducted in variousparts of USA and all revealed statistically significant differencesbetween physicians and nurses in their attitudes towards col-laboration (Garber et al. 2009; Hughes & Fitzpatrick 2010;Rosenstein 2002; Thomson 2007). Hojat et al. (2003) conducteda cross-cultural study to compare attitudes towards collabora-tion between 2522 physicians and nurses from USA, Mexico,Israel and Italy. The study reported that despite differences inculture, nurses demonstrated a significantly more positive atti-tude than physicians towards the importance of collaboration(Hojat et al. 2003).

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

physicians and nurses have different training and they adoptdifferent care philosophies (Hughes & Fitzpatrick 2010; Sirota2007). While physicians were traditionally trained to developtechnical skills and focus on finding cure for diseases, nurseswere trained in developing interpersonal skills with patients andcolleagues, providing holistic care for patients and making deci-sions interdependently with physicians (Hughes & Fitzpatrick2010; Sirota 2007). As a result of the training that focused ondisease management, physicians were generally satisfied to prac-tice independently without much assistance from nurses(Hughes & Fitzpatrick 2010). In contrast, to achieve moreholistic care for patients including social and psychological well-being, nurses felt that their valuable perspectives should be con-sidered during times of decision-making (Dougherty & Larson2005). Nurses, therefore, see physician–nurse collaboration as

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

Search strategies:

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

2. Manual search on Journal of Interprofessional Care.

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

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

to December 2012 • Discuss about relationships or collaboration

between doctors and nurses in hospitals

23 potential journal articles were identified

and read in full to assess its relevance.

17 journal articles were included in the final

review

6 journal articles were

excluded

Reasons for exclusion: • Focus of study was not

largely based on physician–nurse collaboration (3)

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

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

• Target group included nurse managers (1)

14 quantitative studies3 qualitative studies

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

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

clinics, nursing homes and operating theatres (15)

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

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

Fig. 1 Flow chart describing details of literature search.



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

Quality of physician–nurse collaboration

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

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

Factors affecting physician–nurse collaboration

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

Communication

Effective communication is essential to building good workingrelationships between physicians and nurses (Petri 2010) andensuring patient care is delivered correctly and timely (Sirota2007). However, four reviewed studies found that communica-tion between both professions tends to be unclear and imprecise(McCaffrey et al. 2010; Robinson et al. 2010; Rosenstein 2002;Weller et al. 2011). This resulted in delayed delivery of patientcare and more frequent medical errors that ultimately jeopard-ized patients’ safety (McCaffrey et al. 2010; Rosenstein 2002).Such problematic communication issues between physiciansand nurses were reported to occur more commonly in medical–surgical wards than in ICUs (McCaffrey et al. 2010; Robinsonet al. 2010; Rosenstein 2002; Weller et al. 2011). Unlike inmedical–surgical wards, a continuous and regular presence ofdoctors in ICUs enabled nurses to clarify any doubts face-to-face and thereby improve the communication process(Schmalenberg & Kramer 2009). Furthermore, a higher acuityof patients in ICUs may have encouraged greater vigilanceamong physicians and nurses in ensuring their clarity of com-munication (Robinson et al. 2010; Sirota 2007).

Ambiguous communication between physicians and nurseshas led to unpleasant behaviours, especially among the physi-cians. A study by Rosenstein (2002) on the perceptions of 720nurses and 173 physicians from 84 hospitals in Northern Cali-fornia towards collaboration highlighted that nurses often failedto gather all relevant patient information before calling the phy-sicians. This unclear communication caused physicians to raisetheir voices rudely, which significantly affected the nurses’ atti-tudes towards patient care and hindered teamwork (Rosenstein2002). Moreover, Weller et al. (2011) observed that physiciansand nurses nowadays communicated more frequently throughwritten patient care records, where information was not alwaysconveyed accurately or read timely. The dependence on elec-tronic messaging systems has also caused more problems incommunication between physicians and nurses (Robinson et al.2010).

Respect and trust

Nurses in several reviewed studies perceived that their effort,professional assessments or inputs regarding patient care werenot valued by the physicians (Robinson et al. 2010; Rosenstein2002; Rosenstein & O’Daniel 2005; Thomas et al. 2003; Welleret al. 2011). This finding was evident across both medical–surgical wards and ICUs (Thomas et al. 2003; Weller et al.2011). Such dismissive attitudes caused nurses to experience alack of respect and trust, which significantly hampered thedevelopment of a more collaborative physician–nurse relation-ship (Thomas et al. 2003; Weller et al. 2011). The perceived



arrogance of some physicians further contributed to the hostileworking environment, making it difficult to establish respectfulrelationships (Sirota 2007; Weller et al. 2011). In contrast, aquantitative study conducted by Nelson et al. (2008) using ‘Col-laborative Practice Scale (CPS)’ revealed that physicians actuallyhighly valued and utilized the inputs contributed by nurses.Although this finding was incongruent to the other reviewedstudies, the possibility of research biases from single site studyand convenience sampling has been acknowledged by theauthors (Nelson et al. 2008).

Many reviewed studies found that physicians tended todisplay disruptive behaviours towards nurses, though some-times the reverse is observed as well (Robinson et al. 2010;Rosenstein 2002; Rosenstein & O’Daniel 2005). In a qualitativestudy using focus group interviews, nurses expressed that physi-cians often used words that were rude and humiliating. Thismade them feel incompetent and intimidated, which hadresulted in a lack of and fear of communication with physicians(Robinson et al. 2010). Other disruptive behaviours reportedincluded yelling, using condescending tones towards another,and berating patients and colleagues. These behaviours had sig-nificantly affected the nurses’ work satisfaction, their attitudestowards patients, and perceptions towards collaboration(Rosenstein 2002; Vazirani et al. 2005). It had also compromisedthe quality and safety of patient care delivered (Rosenstein2002; Rosenstein & O’Daniel 2005).

Understanding professional roles

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

Task prioritizing

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

affected by the different priorities physicians and nurses hadwith regard to patient care (Rosenstein 2002; Weller et al. 2011).The junior physicians in Weller et al.’s study (2011) reportedthat nurses did not always understand the rationale behindcertain treatments. As a result, given limited work time, nurseschose to complete other tasks that they perceived as moreimportant or urgent (Weller et al. 2011). These differences intask prioritizing not only caused physicians and nurses todevelop feelings of frustration towards each other, but in somecases led to delays in the delivery of effective patient care(Rosenstein 2002; Weller et al. 2011).

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

Unequal power

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



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

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

Improvement strategies for physician–nurse collaboration

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

IPE

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

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

Interdisciplinary ward rounds

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

Despite the effectiveness of ward rounds in improving col-laboration, the heavy patient workload and insufficient time tocomplete individual tasks had affected the doctors and nurses’willingness and sense of urgency to round as a team (Burns2011; Miller et al. 2008; Rosenstein 2002; Weller et al. 2011). InBurn’s study (2011), it was observed that participation rates inward rounds declined after the fourth week of implementa-tion. Vazirani et al. (2005) recommended that the implementa-tion and evaluation of interdisciplinary ward rounds beconducted over a longer period, for example, 2 years, in orderto observe any significant improvements in physician–nursecollaboration.

DiscussionPhysician–nurse collaboration is a complex interpersonalprocess between physicians and nurses. In reviewing the litera-ture on the attitudes of hospitals’ physicians and nursestowards collaboration, it was found that such attitudes havebeen explored mainly in the hospitals in Western countries,especially those within the USA. Little is known about the atti-tudes of physicians and nurses towards collaboration in hospi-tals beyond this region. As a result of possible cultural andsocial differences, findings of studies conducted in one countryor region may not be fully applicable to other countries. Amutual understanding of attitudes towards collaboration canserve as a first step for physicians and nurses to recognize spe-cific challenges both face in working together, and identifysolutions to enhance partnership (James et al. 2010). Morefuture studies are therefore needed to continue exploringthe attitudes of physicians and nurses towards collaborationin various settings. Besides exploratory studies, the review



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

Different types of questionnaires were adopted by thereviewed studies to measure attitudes of physicians and nursestowards collaboration. Although the validities and reliabilities ofthese questionnaires were well documented, each questionnairewas developed to only intentionally measure attitudes towardscertain aspects of collaboration in specific settings (Dougherty& Larson 2005). A broad rather than narrow focus is importantin enhancing the understanding of physician–nurse collabora-tion. Moreover, the findings of this review have identifiedseveral factors affecting physician–nurse collaboration in a hos-pital environment. Future research could aim to develop a com-prehensive instrument that explores attitudes in a greater depthand broader scope.

The review identified a considerable amount of literatureaddressing perceptions towards improving collaboration fromphysicians and nurses working on the ground level. There hasbeen little research that examined the role of senior physiciansand nursing administrators in facilitating collaboration. Jameset al. (2010) highlighted a need for the executive hospital com-mittee from both medicine and nursing to clarify perceptionsand define expectations for the two professions before takingthe lead to develop a partnered plan for enhanced workingrelationships.

In view of unequal power existing between physicians andnurses, policy makers could look more into regulation of thenursing profession whereby nurses are granted more autonomyin making clinical decisions on patient care. To furtherempower nurses with clinical knowledge and decision-makingskills, there could be hospital-based IPE programs for both phy-sicians and nurses to learn from one another. With greaterknowledge and capacity to make clinical decisions, it is believedthat nurses may become more confident in communication andsatisfied with the collaborative practice experience. Further-more, leaders of the hospital management boards could takemore concrete steps to deal with workplace issues such as con-flicts and disagreements between both professions, for instance,by creating an open forum and conducting regular discussionsessions for physicians and nurses to resolve differences or shareany unpleasant experiences related to collaboration (Rosenstein2002). Conflict management guidelines could also be drawn upand disseminated to both professions, so that any discontent-ment can be addressed promptly and effectively.

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

relatively small number of articles that met the inclusion criteriain this review and their methodological approaches could haveintroduced bias.

ConclusionThis integrated literature review has sought to present the bestavailable evidence on physician–nurse collaboration. The reviewfound that both physicians and nurses working in the hospitalsetting possessed differing attitudes towards the importance andquality of physician–nurse collaboration. Their attitudes werefound to be influenced by factors including communication,respect and trust, unequal power, understanding other profes-sional roles, and task prioritizing. The review also identifiedstrategies such as IPE and interdisciplinary ward rounds thatcould improve physician–nurse collaboration. More researchefforts, along with policy and practice implications, would bekey to improving collaborative practice between hospital physi-cians and nurses.

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

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Collaboration between hospital physicians and nurses: An integrated literature review