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Abstract
Objective: Using the theory of relational coordination, which holds that in high-pressure settings such as hospitals, high-quality communication and strong relationships are necessary for coordinated action, we sought to determine the quality of the nurse-physician relationship by examining the communication and interaction between nurses and residents from the residents' perspective.
Methods: A sample of 20 medical and surgical residents, selected by a snowball sampling technique, were interviewed about the quality of their communication and relationships with nurses in the workplace.
Results: Residents' responses were influenced by their perceptions of nurses' cooperativeness and competence, and their impressions of nurses' professional preparation and demeanor varied widely. Although 19 of 20 residents reported instances of poor communication or problematic relationships with nurses, most believed that this posed no significant threat to patient care because the nurses' role, as they saw it, was one of simply following orders.
Conclusions: Given the strong doubts some residents expressed about nurses' cooperativeness and competence, the nursing profession should consider strengthening nursing education and clearly delineating nurses' roles and competencies.
How to improve the nurse-physician relationship is a frequent topic in nursing journals. But despite the interest in this issue among nurses and patient-safety advocates, most literature is still, as Sweet and Normal described in a 1995 review, either "prescriptive or anecdotal." Some work on this topic also has the limitation of focusing on nurses' reports or experiences and not taking into account physicians' experiences. Further, nurses and physicians may have a different understanding of what it means to work together effectively. Physicians have historically embraced a hierarchical model of giving orders that nurses carry out, whereas nurses have increasingly come to desire a more egalitarian, collaborative interaction.
The 'doctor-nurse game.' In 1967 the psychiatrist Leonard Stein described a "game" in which nurses make recommendations in such a way that their suggestions appear to be initiated by physicians; thus they participate in decision making while still preserving their subordinate place in the hierarchy.1 In 1990 Stein and colleagues suggested that the move away from hospital-based diploma programs to academic education, in the form of associate's and bachelor's degrees, was a "principal vehicle" behind a shift in nurse-physician relations: "Instead of being told to defer to physicians, [nursing] students are told that nurses are equal to other health care providers, in a relationship that is collegial, not subservient, and that nurses are professionals and thus obligated to make decisions and take responsibility."2 The shift in nurse-physician relations likely reflected broader social influences as well, including the dramatic changes in women's social status that allowed greater opportunities for their participation in the workforce. But these social changes have hardly changed nurses' structural position in health care, which is often subordinate to physicians and to administrative bureaucracies. For nurses, therefore, attempts at collaboration may be alienating rather than empowering.
A study by Kramer and Schmalenberg suggests that nurses believe "nurse autonomy and control over nursing practice" to be an important contributor to a "good" nurse-physician relationship and to the quality of care.3 In their study, the highest relationship rating given by nurses was "different but equal." Positive nurse-physician collaboration has been associated with good patient outcomes in ICUs.4-8 In other settings, problems with nurse-physician collaboration or communication have been associated with medication errors,9 patient safety issues,10 and patient deaths.11
In order to see how physicians themselves view the nurse-physician relationship, we performed a qualitative study of nurse-physician interactions from the perspective of medical and surgical residents.
OBJECTIVE
We set out to examine the nurse-physician relationship through the lens of relational coordination, a theory that holds that work is successfully accomplished when high-quality relationships and communication exist among participants in the work process. The theory of relational coordination was first developed and validated in the context of commercial airline flight departures12 and then was shown to have significant effects on quality and efficiency outcomes in a number of health care contexts.13-15 Gittell's theory of relational coordination suggests that coordinated action is based on factors related to
* frequent, high-quality communication (which is timely, accurate, and problem solving).
* high-quality relationships (in which shared goals, shared knowledge, and mutual respect are present).
Relational forms of coordination are important in acute care, where tasks are often interdependent, uncertain, time constrained, and performed under conditions of great complexity.
We focus here on nurses' relationships with residents for several reasons. We anticipated that residents, who are still in training and are therefore lower in the health care hierarchy than physicians, might be more open to collaborating with nurses and including them in decision making. On the other hand, inexperienced residents may find their judgments and decisions scrutinized by nurses and may perceive a lack of respect or even hostility from nurses who question their competence. Residents may also have more frequent interactions with nurses because there are more of them than there are attending physicians. Finally, whether inclusive and collaborative or hostile and disrespectful, residents' interactions with nurses may contribute to their future attitudes toward working with nurses.
METHODS
The data for this analysis came from a larger study of medical and surgical residents' duty hours and handoffs. The larger study examined residents' work hours; workload and work intensity; and communication with and support from other residents and attending physicians, nurses, and other care providers in the hospital. This article presents the findings related to the general relationship and communication between nurses and residents.
The Queens College (Flushing, New York) institutional review board approved this project. Using a snowball sampling technique, we asked our contacts and interviewees to provide names of residents who might be willing to talk with us about their daily work experiences. We conducted telephone interviews with 20 medical and surgical residents (11 men and nine women) in academic health centers and community hospitals in New York, California, Ohio, Massachusetts, and Michigan. Fourteen were in medical specialties, and six were in surgical specialties. Interviews followed a structured, open-ended questionnaire protocol and lasted 45 minutes on average. With few exceptions, interviews were conducted over the telephone, recorded, and transcribed. The questions on communication and relationships with nurses, which are the focus of this analysis, were one of seven sections in the interview protocol. As shown in Table 1, these questions correlate with the seven dimensions of relational coordination:
 | TABLE 1. Mapping Interview Questions on Residents' Communication and Relationships with Nurses |
* frequency
* timeliness
* accuracy
* problem solving
* mutual respect
* shared knowledge
* shared goals
Our questions were open ended rather than multiple choice because we wanted to understand how often high levels of relational coordination occurred and what, in the residents' view, accounted for it. These seven dimensions of relational coordination provide the concepts used in the initial coding of the data. Two independent raters examined each respondent's statements, looking for the presence of a "highly positive" response, one that indicated that the dimension in question occurred "all of the time," "always," "frequently," "usually," "often," or "most of the time." We then categorized other types of responses as "negative" or "weak" (occurring "rarely" or "never") or "contingent" (identified by phrases like "it depends" or "sometimes"). There was extremely high interrater reliability, with no disagreements about typology.
Next, we analyzed the residents' statements accompanying these typologies, in particular their descriptions of interactions with nurses and the concepts or themes that emerged from these descriptions. We conducted this analysis first within each dimension and then across dimensions. As we describe below, several prominent themes related to competence, cooperation, and roles emerged.
RESULTS
The most common response to our questions on aspects of relational coordination was a variant of "it depends." What it depended on, according to residents, was whether nurses had these two qualities:
* cooperativeness
* competence
As one resident summed up, "It all depends. Some are very nice. Some are not very nice. Some are very smart and knowledgeable, and some are not." Cooperativeness referred to how congenial and hardworking residents perceived the nurses to be. Competence referred to how smart or experienced the residents perceived the nurses to be. Most residents associated experience with competence, as in the following observation: "You have more older nurses that know how the system runs; they know what to do with a patient." But experience was not synonymous with competence; many residents pointed to the importance of education, either on its own or combined with experience. For example, one resident said, "The day-shift nurses, some of them have a lot of experience and have actually been working for 20 years and, you know, [have] been educating themselves the whole time and getting better and learning from their experience, and then others have been doing the same things incorrectly for 20 years." These themes were central in every interview. No systematic, observable relationship appeared to exist between residents' views on nurses' cooperativeness and competence and residents' sex, specialty, region, or hospital type.
Frequent, high-quality communication was the first of the two aspects of relational coordination we explored; it encompasses four of the seven dimensions.
Frequency. When asked, "How often do you talk to nurses about your patients?" most residents answered "quite a bit" or "a lot." Only five residents described communication with nurses as rare. But whether regular or rare, the frequency of communication was not perceived as an important issue by residents, one of whom said, "Whenever I need them or I want to go over something with them, I find whoever it is. It's not really an issue." The key concern for residents seemed to be frequency relative to need. For example, one resident said that she didn't have much interaction with nurses because of her limited need to exchange information with them: "I tell them tests that I need, but I don't give them much information. They're not making decisions about treatment or anything."
Most residents sought or initiated contact with nurses to tell them which orders to fill or to give instructions related to patient care. But not all interactions between residents and nurses were about patient care. Some were purely relational, like chit-chat or exchanges of niceties. Yet residents described this type of interaction as also having an instrumental purpose. As one explained, such interactions keep the nurses happy, and they will work harder for you, and they'll do a better job."
Only two residents said that frequent communication was important because of what the nurse had to say. One said, "Nurses' feedback is essential and important. Very, very important. Many times we may miss out on things and patients' condition[s] that the nurse may pick up and bring to our attention.... Without a smooth communication and good rapport it wouldn't be possible for us to pick it up or treat that." Working in the same location and going on rounds together also contributed to the frequency of residents' and nurses' interactions.
Timeliness. About half of the residents said nurses gave them the information they needed in a timely way "most of the time," but only three had unqualified responses. Other respondents were more tentative and—in general—presented one of two types of complaints:
* Nurses did not give them enough information.
* Nurses gave them too much trivial and unnecessary information.
For example, one said, "Sometimes you wish they would have told you, but you find out when you're in with the patient." Another said, "Some might tell you way too much, and it's like there is no processing of it first ... and others know exactly what to say and only call you when they really need you." In the residents' view, whether they received the information they needed when they needed it depended on the nurses' ability to discern what constituted crucial information as well as on the nurses' willingness to communicate with them—what residents referred to as "personality." For example: "Some nurses don't talk, some do. It's personality," or, "It is part of their personality. They like to talk about the patients longer, they give me more information than I care to have at a certain time, or they want to talk longer than I might have time for."
Accuracy. Whether residents trusted patient information from nurses was strongly related to their perceptions of the nurses' competence. Only one resident stated outright that she didn't trust nurses ("I look into whatever they tell me just to know what's the truth"); the majority of residents gave qualified answers. For some, trust depended on which nurse gave the information: "It totally depends who it is. Some of them are very good, and then some of them are not."
Being trustworthy or "good" depended on the nurses' ability to discern the important facts and make a case with them. For example, "There are some nurses who I felt I could trust more of what they say. You know, 'This patient has been exhibiting X, Y, and Z ... and I'm concerned about these things because of it.' And this is a really sharp nurse who ... in the past has been right on." In contrast, other nurses "were not as good at reading patients and reporting appropriate things. They would be reporting things that are minor and making it into a bigger deal than it was. Or the reverse." Another resident connected the nurses' reporting with their education: "It depends on the academic level, I mean, whether whatever information they give is ... right or not."
Residents felt that nurses' clinical judgment and ability to distinguish crucial from trivial information was related to their experience and training. Said one, "I think it just depends on the nurse and their experience. Some of them are really good at this kind of picking up something that doesn't look right or doesn't smell right. Then some of them call you every five minutes, so you never trust them.... Those types of nurses ... start losing their credibility." Residents distinguished nurses' presentation of facts about a patient from their assessment of the patient. One said, "I trust factual things they tell me.... I trust less, you know, their opinions or their interpretations of what's happening." Another emphasized the need to "see for yourself and make your own judgment.... I don't feel like that's their job, to diagnose what's wrong with the patient or what this acute situation is all about. I'm happy if they recognize one and just tell me." Residents' estimation of the accuracy of information provided by nurses reflected their opinion of the nurses' clinical judgment. This suggests that residents perceived variation in nurses' abilities and didn't take competence as a given.
Problem solving. Fifteen residents recalled situations in which nurses helped them solve problems. Nine of these felt that nurses made a positive contribution to problem solving. One said, "They usually have ideas [about] what they think is going on, and they are good about being open about that so that we are sure that we don't miss anything." Two of six residents who gave qualified answers took issue with the idea that nurses helped them solve problems. Said one, "Many times I think it's the reverse.... They already have a plan of action in their mind and would get very upset if you didn't go along with it." Some residents noted that nurses were more likely to help out in acute situations. One said, "Usually nurses help me solve problems, especially the better nurses, and always when acute attention is required."
Residents' examples of how nurses helped them solve problems underscored a division of labor between nurses and physicians in which nurses had their own distinct responsibilities. In most cases, the problems nurses solved pertained to communication with the patient and the patient's family or to coordination with other hospital functions, as in this example: "They're very good about setting things up and communicating with other departments in the hospital and orchestrating transfers, [computed tomographic] scans, studies, anything that we need to get done."
Residents were more positive about problem solving than about other aspects of their communication with nurses. Throughout the interviews, residents emphasized that successful communication was contingent upon the nurse (competent or incompetent, able or unable to communicate important information), the situation (acute or nonacute), and the type of information communicated (factual or subjective). In terms of the quality of the communication, only four of the 20 residents experienced high-quality communication with nurses.
High-quality relationships was the second of the two aspects of relational coordination we explored. If residents' communication with nurses couldn't be characterized as "high quality," what about their relationships? The other three dimensions of relational coordination relate to this aspect.
Mutual respect. Residents' descriptions of nurses were indicative of whether they respected the nurses and of the qualities that garnered their respect. Generally, residents couldn't say whether the nurses they worked with had diplomas, associate's degrees, or bachelor's degrees, although they tended to single out as exceptional those with master's degrees, such as advanced practice nurses (APNs). They didn't otherwise differentiate RNs from unlicensed assistive personnel or from LPNs, all of whom they called "nurses." One resident noted the confusion inherent in the term: "Of course, there's always the good apples and the bad apples. There are some that are wonderful, that I know are RNs, and there are some that are LPNs or patient care technicians.... They don't seem to be highly educated people. I think most of them have an associate's degree or maybe a bachelor's degree." Residents considered themselves "lucky" to work with exceptional nurses, and didn't take them for granted: "In our case, we're very lucky because our floor nurses, they're very well trained. They know exactly how people need to be taken care of. They know our routine procedures and follow-up care that's mandated, and they're very good at it." Said another, "They're wonderful.... We have really good nurses here, but I've heard horror stories from the other clinic on the service."
Residents understood that respect is "a two-way street"—"You don't treat them like crap, and they respect the fact that you don't treat them like that." They also noticed that their colleagues didn't always show proper respect for nurses. About half the residents said they felt respected by the nurses, especially when the nurses were cooperative—when, in other words, nurses observed the medical hierarchy. One said, "I feel like they do respect me. They come to me when they need to, and they don't argue with my decisions."
But residents recognized that just as their opinion of nurses depended on which nurse they were work ing with, so nurses' respect for them was dependent on the resident in question. "They usually have an idea of which residents to trust." Residents told us they had to prove their competence to the nursing staff and that respect from nurses was not always forthcoming. "You earn that respect. You don't expect them to follow your orders as a first-week intern. They obviously know a lot more of clinical medicine than you do." Residents noted that some nurses even abused or hazed interns or new residents. One said: "Just the way that they speak to you.... Most of the time it's very disrespectful.... It's like an initiation type of thing. I think that they try to see how far they can push you sometimes, especially if you're new."
Shared knowledge, in our study, pertains to how well residents understood the interdependence of residents' and nurses' roles. Residents repeatedly characterized this interdependence as a pattern in which residents gave orders that nurses carried out: "We make the decisions; they follow the orders, essentially." Most residents emphasized the one-way flow of information, in which they communicated treatment plans and orders to nurses. Some residents recognized that nurses did more than carry out orders, but their descriptions of nurses' roles didn't place nurses at the center of the care process or consider them full partners in care. One resident characterized nurses as handling "ancillary miscellaneous aspects of health care" like obtaining "the social work intervention or the special intervention." Another described nurses as handmaidens: "The nurses take the patients to the rooms and do blood pressure and vitals. They pull the charts and get everything ready for us. They also do blood draws and the tests we request.... They're good about getting everything ready and getting us what we need."
But some residents did recognize the important role nurses play in promoting patient safety: "The nurses are seeing them more often.... So if there's really an acute problem, the nurse is probably going to be the one to catch it first. Then us. That's why you do have to take what they say seriously."
Overall, the residents' comments suggest a pervasive tendency to treat nurses as if they don't need to understand what's happening with patients because they merely follow orders. But four residents said that communication with nurses should consist of more than giving orders. They saw an advantage in sharing with nurses their thoughts or decision-making processes, either for their own convenience or the patients' benefit. One said, "I want to explain to the nurse what's happening to the patient and not just give orders and go.... Because if she understands what's going on ... there's a better chance the next time the patient develops something that she has some idea what might've been the case. And then she may not bother you. Also ... she might be able to help the patient more because she knows what's going on.... And then, I mean, you know, all said and done, they have education too; so they should not be treated like they don't know what's going on." These residents are aware that nurses who receive an explanation are more likely to follow orders and "not bother" them, that if they demonstrate to nurses the accuracy and trustworthiness of their treatment decisions, they will gain the nurses' cooperation, and that, in some cases, nurses can make useful contributions to developing care plans. This minority in our sample recognized that building up or drawing upon nurses' training can benefit patients.
But even if sharing information with nurses can improve trust and care, a key concern for residents was time. For some, whether to spend time explaining treatment plans or decisions to nurses depended on their impression of the nurses' competence: "It's individual. If you have a very competent nurse who is very knowledgeable, who is professional enough to understand the situation, she knows what I am doing and carrying out, that's fine. Then again, on an average, the nurses are competent, but then you have those nurses who may not be up to the task, [with] whom you will have to spend more time, you know, explaining what you are planning to do for the patient."
Sharing information with "less competent" nurses might require more time than a resident thinks is worthwhile. One resident who advocated having extensive discussions with nurses about pathophysiology and treatment also noted that he worked with nine APNs "and all of them have at least a master's degree. They have all worked with neurosurgeons ... anywhere from one to 20 years. A lot of them have taken medical school classes in neuroanatomy, and a lot of them have at least partial and some extensive critical care training." He explained that these APNs "play a huge role in helping us comanage our routine floor issues, ... and are a good, good, good bridge between us and the nursing staff while we're in the operating room." The education and qualifications of the nursing staff may underlie this resident's views about the value of discussing patient care with nurses. This resident was the only one in the sample who described a high-quality relationship with nurses.
Shared goals. For the most part, residents didn't feel that nurses shared their goals. In particular, they felt frustrated that they lacked the power to compel nurses to cooperate. One emphasized the shift-worker mentality of some nurses, observing that some are "intelligent" and "would give you suggestions themselves," but others "just are there for the hours, and they don't really, you know, care what the patient gets or what, you know, what happens to the patient. They're just doing their hours and doing their duty and getting out of there." Another noted, "Sometimes they get kinda surly and roll their eyes at us ... they're usually pretty good, unless it's 4:30. They like to leave on time. They get a little testy when it's near the end of the shift and you need something from them.... You better only request tests that you really need when it's 4:30." These examples point to the potential differences between residents and nurses in their orientation to work, as well as to residents' inability to compel nurses to pass information on to other nurses or to complete tasks, even when these are in the best interests of patients.
Many comments concerned time, and residents were aware that sometimes their priorities were at odds with those of nurses. Residents, for example, spoke of nurses "abusing" residents by off-loading tasks or failing to alert residents of new admissions. A resident explained, "Your time is valuable, and why should you be here till eight o'clock at night? ... You know, when their shift ends, they're out the door. And they didn't seem to value your time." Another resident noted that nurses might place their priorities ahead of residents' and "be working on a trivial matter when this important issue has to be addressed." A surgical resident complained, "They'll page you 10 times for a Tylenol order and nothing for a temperature or ... something else that needs to be communicated. And it's all written out, too, in the orders.... I don't want to be running up there if the patient's like, 'Oh, I'm just in pain.'" These statements point to the fact that nurses and residents have some incongruent goals.
Residents didn't feel that nurses valued residents' time or made an effort to minimize requests—particularly for things that could have waited or should have been automatic—when residents were exhausted or overburdened. But residents' examples also illustrate the differences in how residents and nurses value priorities related to patient comfort. Although pain control and food were low on the residents' lists of priorities or reasons for pages or emergency floor visits, these issues are very important to patients and nurses.
DISCUSSION
The interviews point to a number of positive aspects of communication and productive relationships between residents and nurses. Residents prized nurses who were knowledgeable and collaborative, focusing specifically on nurses'
* depth of understanding of patients' health and social issues.
* ability to anticipate and respond to patients' medical needs.
* partnership in identifying problems and courses of treatment.
* help in getting work done.
Although most of the 20 residents interviewed said that they'd had positive interactions with nurses and valued them, only one resident had frequent, high-quality communication and high-quality relationships with nurses. Are high levels of relational coordination among nurses and physicians the exception rather than the rule?
Our findings also point to the critical importance of physicians' and nurses' willingness to cooperate and to their ability to shape positive communication and relationships. Residents' descriptions of their attitude toward nurses are consistent with nurses' frequent complaints that physicians tend to see nurses as implements or tools16 and to have a "We decide; you carry it out" approach to collaboration.17 Although residents' medical training may be partly to blame for their disparaging view of nurses, their comments suggest that obstacles to nurse-physician collaboration are related to
* residents' and nurses' styles of communication and availability to communicate.
* the lack of standardization in nursing education.
* residents and nurses not sharing goals or understanding each other's roles.
These findings raise questions about the ability of nurses to overcome obstacles to good communi cation and relationships on their own. Although an individual nurse may be able to handle herself professionally, her efforts may be undermined by other nurses' behavior and by the nursing profession's shortcomings. Residents judged nurses not just on prior interactions with them but on their experiences with other nurses. The oft-repeated answer "it depends" and the references to "bad apples" and "horror stories" point to negative experiences that made residents wary of trusting nurses or of expecting their cooperation.
Our study's limitations include its qualitative design and small sample size. Our findings can't therefore be generalized to other physicians or residents. At the same time, the internal consistency among our interviews warrants some attention, given the diversity of residents' specialties and hospital and clinical settings.
Residents' general impressions of nurses underscored the variability in the education level and demeanor of nurses and fell short of an endorsement of the average nurse's potential role in care—a role that most nurses would argue should extend beyond following orders and arranging for ancillary services. At the same time, by underestimating or overlooking nurses' contributions to patient care, residents could consider breakdowns in communication and relationship as mere annoyances; as long as nurses carried out their orders, there was no threat to patient care. Two authors, including one of us (DBW), have pointed out that even highly educated nurses have failed to articulate the critical role nurses play, to the detriment of nurses' status in hospitals and patient care.16, 18 The ubiquitous confusion about nurses' roles that also emerged in these interviews identifies a far-reaching problem for nurses in explaining what they actually do and in making their contributions visible.
Residents were often unaware of the education of the nurses with whom they worked—unless they had master's degrees, which overtly changed a nurse's role. Some residents couldn't differentiate the unlicensed assistive personnel in hospitals from LPNs or RNs, although they differentiated the APNs and described them as "excellent."
Nurses' interest in having an egalitarian relationship with physicians seems at odds with nurses' status as the least educated group of licensed health care professionals in the country. While other professions such as pharmacy, physical therapy, and occupational therapy are moving toward requiring doctoral degrees for entry-level jobs, nurses still have primarily associate's degrees, and debate about whether to mandate the baccalaureate (specifically, the bachelor of science in nursing [BSN]) for entry-level nursing or for maintaining licensure is ongoing. Our finding that residents regarded even nurses with baccalaureates as "not highly educated" raises questions about whether an associate's degree or a BSN would make a more egalitarian collaboration possible—or whether such a collaboration would require nurses with a master's-level or even higher education. At the same time, residents' perceptions that better-educated nurses are better communicators as well as more competent nurses, seem consistent with the observed relationship between greater proportions of nurses with BSNs and lower patient mortality rates.19-22 It may be that physicians have closer relationships and communicate better with nurses in hospitals that favor higher educational pre paration for nurses, and that the resultant benefit to relational coordination promotes better patient outcomes.
Our findings highlight some of the problems between nurses and physicians that need to be solved before relational coordination, let alone collaboration, can occur with any consistency. Though qualitative, these findings are further evidence of the rift between nurses and physicians over the importance of collaboration. Although residents' concerns about nurses' cooperativeness and competence might be seen as professional posturing, still they represent an enduring critique of the nursing profession, particularly as it relates to professionalism and standardized education. Whereas some physicians grudgingly collaborate with nurses, surely some nurses—though eager for collaboration—actively withhold the communication and cooperation it requires. To the extent that nurses play a role in perpetuating undesirable nurse-physician interactions, perhaps the nursing profession has the power to change the rules of the nurse-physician game.
For more than 29 additional continuing nursing education articles related to the topic of professional issues, go to www.nursingcenter.com/ce .
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