~ Pergamon Soc. Sci. Med. Vol. 45, No. 7, pp. 1135 1138, 1997 ,~ 1997 Elsevier Science Ltd. All rights reserved

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SHORT REPORT

ROLE CONCEPTS AND EXPECTATIONS OF PHYSICIANS AND NURSES IN HOSPITALS

P. J. M. V E R S C H U R E N ' * and H. MASSELINK- '

'University of Nijmegen, Nijmegen, the Netherlands and :University of Eindhoven, Eindhoven, The Netherlands

Abstract The social environment in which hospitals in the Netherlands have to function nowadays is greatly changing. Over the last 10 years the policy of the Dutch government has become less directive, market mechanisms are gaining weight and the demand for services by patients is changing. As a result of these changes hospitals formulate their strategic goals in terms of improvement of quality of care and efficacy. A basic assumption in this article is that quality of care is to be gained by collaborative practice between physicians and nurses. A necessary condition for this is that there is a correspondence in role concepts and expectancies of physicians and nurses in hospitals. The object of this research is to describe the role concepts and role expectations of nurses, physicians and patients in two Dutch hospi- tals. In general, the research revealed considerable differences between role behaviour and role concepts amoung nurses. In the long run these differences may not be favourable for good understanding between them and physicians, or for their own job satisfaction. This may also have negative conse- quences for collaboration between nurses and physicians and, finally, for the quality of care and cure within the ward. There is a need for discussion of the role concepts of nurses in relation to their actual regular tasks in order to resolve this. A second discrepancy exists between the role behaviour of phys- icians and the expectations of nurses about this behaviour. This may also lead to a lower job satisfac- tion for nurses. Taking into account the fact that patients are satisfied with the way physicians and nurses pay attention to most aspects of care and cure, a discussion between physicians and nurses could be recommended. The aim is revising either the role behaviour of physicians, especially as regards their attention to the psycho-social needs of patients, or the expectations of nurses, or both. C' 1997 Elsevier Science Ltd

Key words--collaboration, role concept, role behaviour, role expectations

INTRODUCTION

The social env i ronment in which hospitals in the Nether lands have to funct ion nowadays is greatly changing. Over the last 10 years the policy of the Dutch government has become less directive, mar- ket mechanisms are gaining weight, and the demand for services by pat ients is changing. At the same time the kind of services hospitals deliver is becom- ing more diverse as a result of medical innovat ions. Moreover , the Dutch popula t ion is getting older and people are more knowledgeable and self- assured, increasingly asking for care as well as for cure. As a result of these changes hospitals formu- late their strategic goals in terms of improvement of quali ty of care and efficacy. Therefore, they concen- trate on the demands of the patients, they strive for high quality services and they try to reach an opti- mal balance between costs and benefits. In order to realize their strategic goals hospitals are having to take several measures. Many hospitals are going to merge or col laborate and they choose carefully the

*Author for correspondence. Meyboomlaan 1, 2242 PR. Wassenaar, the Netherlands.

kind of services they offer. Unti l now these changes have affected neither work in the hospital wards in general no r the col laborat ive practice between phys- icians and nurses in particular. And yet it is on the wards where physicians and nurses have to achieve goals, where they have to realize quality of care and efficacy as set by hospital managements .

COLLABORATIVE PRACTICE AND QUALITY OF CARE

A basic assumption in this article is that quality of care is to be gained by col laborat ive practice between physicians and nurses. Literature and research on this are scarce in the Nether lands (Nievaard, 1986). Nievaard points out tha t bo th nurses and physicians have a s trong social int imacy with patients when solving their problems. This goes along with strong feelings of a t t achment and mutua l concern. But at the same time there is a great difference in professional power between these groups of professionals. According to Nievaard, this is an impor tan t barr ier to col laborat ive prac- tice. Differences in the rewards and the educational level of the two groups also form a barr ier to col-

1135

1136 P.J.M. Verschuren and H. Masselink

laboration (Prescott, 1985). Katzman (1988) points out that the gender specific composition of both groups is another obstacle to collaboration. This may be due to the limited insight into the role of nurses obtained by medical students during the course of their training (Fondiller, 1986).

Little research has been done into organizational work in hospitals that describes and defines colla- borative practice between physicians and nurses as a solvable problem, or at least as a problem that can be reduced. Some recent literature on this sub- ject (Harteloh, 1991) does not even mention colla- borative practice as a means to improve the quality of care in hospitals.

A question which must be asked is what exactly is meant by "quality of care". According to Harteloh (1991), we can distinguish two aspects of this. From a professional point of view the first can be defined as "doing things in the right way". Physicians and nurses determine the standard of what is "the right way" and whether their work meets accepted professional standards. From the clients' point of view patients may also have opinions about the way professionals are acting. The other aspect of quality of care relates to the managerial point of view and can be defined as "'doing the right things". Here too nowadays the patient to a large extent sets the standards. A recent Dutch law (WGBO, 1995) highlights this, stating that patients must explicitly give their consent to receiving any planned diagnostic and therapeutic treatment. The philosophy behind this law is that a patient can only take the right decisions about treatment if he or she is informed about any side- effects, the possible complications and the way this treatment might influence his or her daily life. This is the welt-known criterion of informed consent.

As a further consequence of changes in the social and political environment of hospitals, modern management gives considerable weight to the opinion of patients and patient satisfaction. Moreover, the present generation of patients seems more ready to question the functioning of nurses and physicians, and also to question whether they are doing the right things (NP/CF, 1995).

Because the activities of physicians and nurses mutually influence each other, it is suggested that the "right things" can only be done "in the right way" if collaborative practice exists.

One of the most important conditions is that there should be a congruency between the actual behaviour of physicians and nurses and their role concepts, i.e. the way they see their own tasks, on the one hand, and (1) their actual behaviour as pro- fessionals, and (2) the expectations that physicians, nurses and patients have, on the other.

The role concept of physicians and nurses, the role concepts of patients is not considered here, refers to the opinion each group has about their own tasks and their functioning within the organiz-

ation. Their opinions concern both "doing the right things" and "doing things in the right way". So nurses, for instance, might be unsatisfied with the tasks they fulfil for several reasons. They may feel that they should not perform certain tasks because they believe those tasks are not relevant, or should be done by physicians. In contrast, they may feel that they should do tasks that are not (yet) defined as theirs. They may also be dissatisfied with the way they have to fulfil their tasks, for instance, because of protocols made by the physicians, or simply because of lack of time.

Role expectations refer to opinions that one group of actors has about the activities of another group. For instance, nurses have an opinion about the tasks physicians fulfil or should fulfil, as well as about the way they fulfil them. Role expectations then can be described as implicit or explicit ideas of one group about the total number of activities the other group should perform (doing the right things) and the way they should perform them (doing things in the right way).

RESEARCH DESIGN

The object of the research is to look at the role concepts and role expectations of nurses, physicians and patients in two Dutch hospitals. One is an aca- demic and the other a general hospital, both in the city of Nijmegen in the cast of the Netherlands. The wards involved are: a neurological, an urologi- cal and a cardiological ward, a combined heart and reconstructive surgery ward and finally a coronary care unit.

Data were gathered from medical and nursing dossiers and from a set of pilot interviews, followed by a written questionnaire for physicians, nurses and patients. These questionnaires focus on the fre- quency of activities physicians and nurses perform in the near vicinity of the patient and on the way they perform these activities in their own view as well as in the views of both other groups.

We distributed 294 questionnaires of which 246 were filled in adequately and returned by the three groups. The response rates were as follows: phys- icians 92% (n = 33), nurses 81% (n = 108) and patients 84% (n = 105). We were pleased with the very high response rate of the physicians, and con- sider it an indication of the interest and importance this group of professionals attaches to this subject.

RESULTS

Table 1 shows the results of the questionnaire. The first column shows the names of clusters of items, followed by the mean score for that cluster of each of the three groups. Each cluster contains between three and 14 items. For instance, cluster I1, "caring for patients' social needs", is built on six items in the questionnaire, containing the fol-

Role concepts and expectations of physicians and nurses 1137

Table I. Behaviour of physicians and nurses in their own views and in the views of other groups; mean scores for groups

Opinion Physicians Nurses Patients

Physicians' behaviour 01 Talking with patients about diagnosis and treatment 02 Talking with patients about psycho-social needs 03 Informing nurses about diagnosis and treatment 04 Informing nurses about physicians' talks with patients on diagnosis and treatment 05 Informing nurses about physicians' talks on on psycho-social needs 06 Physicians" style of communication with patients in general is all right 07 Physicians' style of communication with patients during rounds is all right 08 Physicians style of organizing their work is all right

3.02 2.33 2.87 2.29 1.87 2.49 2.94 2.53 2.86 2.16 2.60 1.76 3.31 2.61 3.35 3.62 2.83 3.67 3.81 2.60

Nurses' behaviour 09 Caring for patients' daily life 2.87 10 Caring for patients' mental well-being 3.09 I 1 Caring for patients' social needs 2.84 12 Talking with patients about diagnosis and treatment 2.76 13 Talking with patients about psycho-social consequences of diagnosis and treatment 2.82 14 Informing physicians about patients' daily life 2.84 15 Informing physicians about patients" mental well-being 2.98 16 Informing physicians about patients' social needs 2.61 17 Informing physicians about activities related to diagnosis and treatment 3.02

Informing physicians about nurses' talks with patients on activities related to diagnosis and 2.69 18 treatment

Informing physicians about nurses" talks with patients on psycho-social consequences of 2.82 19 diagnosis and treatment 20 Nurses' style of communication with patients in general is all right 3.39 21 Nurses' style of communication with patients during rounds is all right 3.01 22 Nurses' style of organizing the work at the ward is all right 3.07

2.87 2.98 2.51 2.66 2.77 2.48 2.58 2.28 2.61 2.51

2.67

3.09 2.96 2.90 2.84 2.79

3,96 3.29 3.47 3.33 3.82 3.53

lowing subjects: outlook on life, religion, contacts with relatives and friends, contacts with other patients in the ward, financial affairs and the employment of the patient.

The items were clustered at face value, in combi- nation with a check on the homogeneity of the clus- ter by means of Cronbach's alpha. On the basis of a critical value of 0.75 items were eliminated if necessary. The result was 22 clusters with alphas of at least 0.75, with the exception of cluster 10, "nurses' care for mental well-being of patients". This cluster contains the items "emotions" and "feelings" of patients, as well as their "experiences with the illness and period in the hospital". Although Cronbach's alpha (0.52) indicated this was not a homogenous cluster, we decided to use this set of items as the cluster is an important one.

The items in the questionnaires are of two differ- ent types. First are questions concerning the opinion of physicians, nurses and patients about the frequency of medical activities as indicated in the first column of Table 1 (clusters 1-5 and 9-19). These questions each have five response categories, from 1 "not nearly frequent enough" to 5 "far too frequent". For each of the two groups of pro- fessionals the mean score on each cluster was calcu- lated. Although it is difficult to give exact criteria, a mean score between 2.75 and 3.25 will be inter- preted as "normal". Lower scores are qualified as unfavourable or very unfavourable. As Table 1 shows, for these clusters we found no mean scores higher than 3.25, meaning that in the eyes of the three groups no activities were performed anywhere near too frequently. Second, the rest of the items in the questionnaires are statements about the working

style of the professionals (clusters 6, 7, 8, 20, 21 and 22). These items concern the communication between both categories of professionals and the or- ganization of their work. Each statement has five response categories, from 1 "strongly disagree" to 5 "strongly agree". A mean score between 2.75 en 3.25 means an indifferent opinion. A mean score lower than 2.75 can be interpreted as a negative judgement, whereas a mean score higher than 3.25 means a positive judgement of the working style of professionals.

Role behaviour vs role concept

In the opinion of both nurses and physicians themselves, the latter pay too little attention to the mental welfare and social needs of patients. Apart from this the actual behaviour of physicians corre- sponds in general to a large extent with their role concept. In contrast, there is a discrepancy between the actual behaviour of nurses and their own role concept. This is especially the case regarding their communication with physicians and with patients.

Role behaviour of physicians vs role expectations of others towards them

Generally speaking the performances of phys- icians come up to the expectations of patients, with the exception of the psycho-social domain. However, there are considerable differences between physicians' performances with respect to psycho- social needs of patients, and between the expec- tations of patients and nurses. There are also strong differences between several aspects of the role beha- viour of physicians and the expectations of nurses.

138 P. J. M. Verschuren and H. Masselink

As to the psycho-social needs of patients phys- icians are not providing an optimal care. However, managers in hospitals should be careful in reallocat- ing tasks as to psycho-social needs of patients. Despite nurses increasingly claim psycho-social care as their task and competence, the patients prefer physicians to fulfil these tasks.

Role behaviour o f nurses vs role expectations o f

others towards them

In the eyes of patients nurses generally do the right things to a sufficient degree. In contrast, the physicians are not fully convinced of this. Thus, physicians do not come up to the expectations of nurses, and nurses to an extent do not come up to the expectations of physicians. Nevertheless patients feel that most of the functioning of nurses and physicians meets the standards they expect.

GENERAL CONCLUSIONS AND RECOMMENDATIONS

In general there are considerable differences between role behaviour and role concepts amoung nurses. In the long run these differences may not be favourable for good understanding between them and physicians, or for their own job satisfaction. This may also have negative consequences for col- laboration between nurses and physicians and, finally, for the quality of care and cure within the ward. There is a need for discussion of the role con- cepts of nurses in relation to their actual regular tasks in order to resolve this.

A second discrepancy exists between the role behaviour of physicians and the expectations of nurses about this behaviour. Interestingly, this may also lead to a lower job satisfaction for nurses. Taking into account the fact that patients are satis- fied with the way physicians and nurses pay atten- tion to most aspects of care and cure, a discussion between physicians and nurses could be rec- ommended. The aim is revising either the role beha- viour of physicians, especially as regards their attention to the psycho-social needs of patients, or the expectations of nurses, or both. In this respect an experiment in one of the two hospitals with dis- cussions on concrete cases of care and cure recently provided to a patient seems to be successful.

As to the generalizability of our findings, it should be remarked that the fact that physicians and nurses largely meet patients' expectations does

not exclude latent tensions on this point. Expectations and behaviours can have become part of traditional ways of thinking and fixed routines in hospitals, whereas their changing social and politi- cal environment demands new orientations and practices of professionals in hospitals.

It can also be asked whether the results are corre- lated with characteristics of professionals such as age, gender, specialism, etc. Analysis of cross-tabu- lations showed that in some cases they are. For instance, older physicians are more positive than the younger ones about the exchange of infor- mation between the groups of professionals on patients' daily activities. It may be that experienced professionals find this kind of information more im- portant than younger ones. More experienced nurses felt more negative about the exchange of in- formation on this subject than the less experienced.

However, apart from this there was no strong re- lationship between the answers and characteristics of professionals and patients. This may mean that some basic differences in actual behaviour, role con- cepts and role expectations were revealed. These differences may in part be attributed to differences in training. As until now neither nursing nor medi- cal educators pay much, if any, attention to the im- portance and possibilities of collaborative practice in and outside hospitals, this can be strongly rec-

ommended.

Acknowledgements We are very grateful to Mrs Ann Simpson for making some editorial corrections and sug- gestions. This article was partly written during Verschuren's stay at the Netherlands Institute for Advanced Study in the Humanities and Social Sciences, Wassenaar, the Netherlands.

REFERENCES

Fondiller, S. H. (1986) The nurse-physician team, realities and relationships. NSNA 33, 39-41.

Harteloh, P. P. M. (1991) Kwafiteit van Zorg. Vuga, Gravenhage.

Katzman, E. M. (1988) Nurse-physician conflict as bar- riers to the enactment of nursing roles. Western Journal of Nursing Research 10, 576-590.

Nievaard, A. C. (1986) Triaden in het ziekenhuis. Ph.D. dissertation, University of Leiden, Leiden.

NP/CF (1995) De Kwaliteit van de Gezondheidszorg in Patientenper,spectief NP/CF, Utrecht.

Prescott, P. A. (1985) Physician-nurse relationships. Annals qf lnternal Medicine 103, 127-133.

WGBO (1995) Medisch Contact, Vol. 21. WGBO.