Perceived quality of interprofessional interactions between physicians and nurses in oncology outpatient clinics

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    European Journal of Oncology Nursing 18 (2014) 619e625Contents lists avaiEuropean Journal of Oncology Nursing

    journal homepage: www.elsevier .com/locate/ejonPerceived quality of interprofessional interactions between physiciansand nurses in oncology outpatient clinics

    Charlotte T. Lee a, *, 1, Diane M. Doran b, Ann E. Tourangeau b, 2, Neil E. Fleshner c

    a Daphne Cockwell School of Nursing, Ryerson University, 350 Victoria Street, Toronto, Ontario, Canadab Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canadac Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, CanadaKeywords:Integrated care deliveryInterprofessional collaborative practiceNurse-physician relationshipsRelational coordination* Corresponding author. Tel.: 1 416 979 5000x799E-mail addresses:, charlot

    1 This study is a part of Charlotte T. Lee's doctoraCapital and Relational Coordination in Outpatient Clinwas supported by Co-Investigator Small Grant Award aResearch Unit, University of Toronto. Charlotte T. Lsupported by the following funding sources: GovernmToronto Foundation Graduate Scholarship in Sciencelowships from the Ontario Training Program in Healthas well, the Wilson Centre for Research in EducatiNetwork.

    2 Ann Tourangeau is funded in part through a NursAward from the Ontario Ministry of Health and Long 2014 Elsevier Ltd. All rights reserved.a b s t r a c t

    Purpose: To evaluate the perceived quality of interactions between nurses and physicians in oncologyoutpatient clinics.Methods: A cross-sectional, observational survey involving 250 physicians and nurses was conducted atoncology outpatient clinics at two regional cancer centres in the province of Ontario, Canada. Eligibleparticipants were identified by administrators and invited to complete a one-time survey questionnaire.Quality of interactions was assessed using a seven-item survey of relational coordination, which mea-sures two factors of interaction: supportive relationships and quality communication. Descriptive ana-lyses and multivariate analyses of variance (MANOVA) were conducted to assess potential differencesbetween the two study sites and the two professional groups.Results: Overall, nurses and physicians at both study sites rated their interactions highly (mean 4.32and 4.51 out of 5 for supportive relationships and quality communication, respectively). No difference ineither factor was reported between physicians and nurses at either study site, but the two study sitesdiffered significantly in both factors [F(2, 245) 7.54, p < 0.001].Conclusions: Overall, oncology nurses and oncologists at outpatient clinics rated their levels of inter-professional interaction highly. Contextual factors may have contributed to the high interaction scoresand different ratings between the two cancer centres. The finding that nurses and physicians reportedsimilar levels of perceived interactions suggests that relationships in these outpatient cancer clinics arehighly collaborative and collegial.

    2014 Elsevier Ltd. All rights reserved.Introduction

    Teamwork is essential in healthcare, with multiple providersinvolved in every phase of a patient's illness trajectory. The per-formance of healthcare teams is known to strongly affect the2; fax: 1 416 979 (C.T. Lee).l dissertation entitled Socialics. The dissertation projectt the Nursing Health Servicesee's doctoral education wasent of Ontario/University of& Technology; Training fel-Services and Policy Research,on at the University Health

    ing Senior Career Researcher-Term Care.quality of patient care in all medical subspecialties, includingoncology (Baggs et al., 1999; Manojlovich, 2010; Mukamel et al.,2006; Ponte et al., 2010; Friese and Manojlovich, 2012). As aresult, more researchers have been focussing on various aspects ofinterprofessional teamwork and collaboration.

    This study was motivated by the awareness that high-qualityinteractions and relationships among care providers are crucialto improving interprofessional practice. Merriam-Webster (2012)defines interactions as mutual actions or influences. Theseinclude all types of contact among individuals (e.g., verbalcommunication, non-verbal communication, behavioural ex-changes) and are manifestations of interpersonal relationships.Research about interpersonal relationships builds on findings fromthe fields of psychology and sociology. Scholars have used varioustheories to explain different aspects of interpersonal relationships,and these have been applied to research about actions and in-fluences within healthcare teams. For example, social exchangetheory helps clarify leaderemember dynamics of a team (Brunetto


  • C.T. Lee et al. / European Journal of Oncology Nursing 18 (2014) 619e625620et al., 2013), relational dialectics helps clarify role conflicts withinteams (Apker et al., 2007), and sensitivity to equity appears to bepositively correlated with an individual's agreeableness at work(Bing and Burroughs, 2001). With regard to teamwork, researchinvolving these psychological or sociological theories suggests thatan individual's mindset affects his/her actions, so positive inter-personal interactions (attitudes and behaviour) are vital to pro-mote collaboration. However, few studies have focused on theattributes of interpersonal interactions among healthcareprofessionals.

    We conducted a literature review to assess current knowl-edge about interpersonal relationships, teamwork theories, andtheir applications in healthcare work environments. Within thefew relevant publications, two general frameworks were usedto integrate the concepts of interpersonal relationships andteamwork theories in healthcare: the nursing practice envi-ronment framework (Fox, 2000; Lake, 2002); and the inter-professional practice framework (D'Amour and Oandasan,2005; Interprofessional Education Collaborative Expert Panel,2011). Although the nursing work environment frameworkdoes not focus mainly on provider relationships, it includesnurseephysician relationships as one contextual factor. Pre-liminary evidence suggests that positive work environmentalfactors, as measured by the Practice Environment Scale (PES,which includes a measure of provider interactions), areassociated with a superior quality of care (Schmalenberg andKramer, 2009). The interprofessional practice framework(D'Amour and Oandasan, 2005; Interprofessional EducationCollaborative Expert Panel, 2011) helps clarify the factorsassociated with healthcare professionals' collaborative capacityat both pre- and post-licensure levels. This framework is basedon interactions among professionals and patients, and theseare expected to vary depending on the complexity ofcare. However, only a few studies have focused on providerrelationships or interactions beyond communication andof these, only one was conducted in an oncology setting usinga qualitative approach which limits generalizability (Hunt,1998).

    Our review of the available literature revealed several addi-tional gaps and limitations. Most published studies that examineinterprofessional interaction have been conducted in inpatientsettings (Manojlovich, 2005; Nadolski et al., 2006; Reeves et al.,2009). Because collaborative attitudes and behaviours are influ-enced by professional culture and context (Hall, 2005), in-teractions among healthcare professionals likely vary betweeninpatient and outpatient settings because the structures andprocesses associated with these settings are different (e.g., staffingstructure, patient schedule). It is important to study interprofes-sional interaction in oncology outpatient clinics because of thecomplexity of care and toxicity of treatment. Additionally, currentresource constraints have meant that acutely ill cancer patients,who used to be admitted for disease management, are increas-ingly likely to be treated as outpatients. Increasing complexity ofcare, patient acuity, and patient volume make the functioning ofan outpatient oncology team crucial in providing sensitive careand preventing errors and redundancy, which are key indicatorsof quality healthcare.

    Beyond the lack of studies conducted in outpatient settings,studies about interprofessional interactions are limited by meth-odological issues. For example, very few quantitative studies haveexamined interprofessional interactions beyond verbal commu-nication (Nadolski et al., 2006; Manojlovich, 2005). Quantitativetechniques can help advance knowledge in this area by usingreplicable measurement tools and generalizable findings. Addi-tionally, verbal communication is only one aspect of interpersonalinteractions. Among the studies that have examined actions andinfluences beyond verbal communication, most have used a globalmeasure of perceived collaboration (Lake, 2007; Schmalenbergand Kramer, 2009; Friese and Manojlovich, 2012). Althoughperceived collaboration is an integral element of quality in-teractions, global ratings cannot provide details about actions andinfluences among team members. Gittell et al.s (2000) RelationalCoordination Survey (used in the current study) is the only vali-dated instrument that assesses measurements for interpersonalinteractions. The authors proposed and validated the idea thatquality communication and supportive relationships are key teamattributes that lead to superior performance. Quality communi-cation is characterised by the presence of timely, frequent, andproblem-solving communication, while a supportive relationshipis characterised by the presence of shared knowledge, sharedgoals, and mutual respect.

    Finally, staff physicians are rarely included in surveys ofinterprofessional attitudes. This can hamper the validity ofresearch, because physicians are a key healthcare provider groupwho may have different perceptions about interactions withother professionals due to different roles and expectations. Validresearch about interprofessional perceptions should includemore than one professional group. In summary, existing knowl-edge of provider interactions at outpatient oncology clinics islimited by: a) a lack of empirical data in the outpatient envi-ronment; b) a lack of research utilising quantitative methodologywhich limits comparison; and c) the inclusion of only one pro-fessional group.

    The present study addressed some of these gaps by quan-titatively evaluating the quality of interactions between nursesand physicians in two oncology outpatient clinics. Nurses andphysicians were selected for inclusion because they are thehealthcare professionals most often involved in providing careat outpatient clinics: other allied health professionals werenot included because they are not involved in every patientvisit.

    The specific research questions addressed were: a) What arethe levels of perceived interaction between nurses and physi-cians, as reflected by perceived levels of supportive relationshipsand quality communication, in oncology outpatient clinics? b)Do nurses and physicians in oncology outpatient clinics differ intheir levels of perceived interaction, as reflected by theperceived levels of supportive relationships and qualitycommunication?


    Study design, setting, and sample

    This study was nested within a larger dissertation study thatwas conducted to validate a theoretical framework related tonurseephysician interactions in outpatient clinics (Lee, 2012).To address the current research questions, a cross-sectional,observational survey was conducted at the outpatient de-partments within two comprehensive, university-affiliatedcancer centres in the province of Ontario, Canada. Both cen-tres are located within the same metropolitan boundarieswithin the governance of the same regional cancer program.Centre A is an older institution that opened in the 1950s andcentre B opened approximately three decades later. At the timeof the study, both offered all modalities of cancer treatment forall kinds of cancer. Centre A was larger than centre B, but theyboth housed 10e20 radiation treatment machines. Centre Aadministered more than 25,000 chemotherapy treatmentsannually, and centre B administered more than 17,000

  • 3 University of Toronto REB approval number: 24758 (centre A) and 24550(centre B). Institution protocol and approval number: 09-0702CE (centre A). Insti-tution protocol and approval number: 265e2009 (centre B).

    4 This unique code allowed us to track individual participation or non-participation (for sending reminders). No participants in this study completedmore than one questionnaire.

    C.T. Lee et al. / European Journal of Oncology Nursing 18 (2014) 619e625 621treatments annually. Centre A treated more than 15,000 newpatients annually and centre B treated more than 10,000 newpatients annually. Centre A had a total of approximately400,000 patient visits per year, and centre B had approximately220,000. Both centres were amongst the 10 largest compre-hensive cancer centres in North America. Compared with centreB, centre A had more attending physicians (approximately 90versus 70) and more staff nurses (approximately 90 versus 45)employed in ambulatory services. Both centres employed asimilar model of care at the time of study.

    Data were collected from a study sample that included staffphysicians (n 150) and staff nurses (n 100). More physicianparticipants than nurse participants were included because thisproportion is consistent with the physician to nurse ratio at thetwo study sites. The sample size was determined based onexisting standards regarding the power requirements for con-ducting a multivariate analysis of variance (MANOVA), the mainanalysis method in this study. A minimum of 44 subjects perprofession per site was needed to achieve 80% power to detect asignificant difference in the level of interaction, assuming amoderate effect size with an alpha of 0.05 (Guilford and Fruchter,1978).


    Interactions between nurses and physicians were measuredusing a previously validated, seven-item survey of relationalcoordination (Gittell et al., 2000). The goal of the emergingtheory of relational coordination is to extend the conventionaltheory of coordination (management of task dependencies), butthe survey of relational coordination has been used to assessrelational aspects of teamwork, such as interprofessional in-teractions (Meyer, 2010; Warshawsky et al., 2012). As noted,this instrument measures two factors of interaction: supportiverelationships and quality communication. As notedearlier, shared knowledge, shared goals, and mutual respe...


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