Journal of General Internal Medicine

, Volume 24, Issue 2, pp 198–204

“What is Found There”1: Qualitative Analysis of Physician–Nurse Collaboration Stories

  • Kathleen A. McGrail
  • Diane S. Morse
  • Theresa Glessner
  • Kathryn Gardner
Original Article

Abstract

Background

Effective physician–nurse collaboration is an important, but incompletely understood determinant of patient and nurse satisfaction, and patient safety. Its impact on physicians has not been described. This study was undertaken to develop a fuller understanding of the collaboration experience and its outcomes.

Methods

Twenty-five medical residents, 32 staff nurses, 5 physician and 5 nurse faculty wrote narratives about successful collaboration; the narratives were then qualitatively analyzed. Narrative analysis was the initial qualitative method iteratively employed to identfy themes. A phenomenological approach was subsequently used to develop a framework for collaborative competence.

Results

Collaboration triggers, facilitative behaviors, outcomes and collaborative competence were the themes identified. Affect was identified in the triggers leading to collaboration and in its outcomes. Practioners typically entered a care episode feeling worrried, uncertain or inadequate and finished the interaction feeling satisfied, understood and grateful to their colleagues. The frequency of affective experience was not altered by gender, profession, or ethnicity. These experiences were particularly powerful for novice practioners of both disciplines and appear to have both formative and transformative potential. Collaborative competence was characterized by a series of graduated skills in clinical and relational domains. Many stories took place in the ICU and afterhours settings.

Conclusions

Despite the prevailing wisdom that nursing and medicine are qualitatively different, the stories from this study illuminate surprising commonalities in the collaboration experience, regardless of gender, age, experience, or profession. Collaborative competence can be defined and its component skills identified. Contexts of care can be identified that offer particularly rich opportunities to foster interprofessional collaboration.

KEY WORDS

collaboration competency relationship-centered practice teamwork 

References

  1. 1.
    Williams WC. Asphodel. New Directions Publishing Corporation; 1962.Google Scholar
  2. 2.
    Knaus W, Draper E, Wagner D, Zimmerman S. An evaluation of outcome from intensive care in major medical centers. Ann Int Med. 1986;104:410–8.PubMedGoogle Scholar
  3. 3.
    Baggs JG, Schmitt MH, Mushlin AI, et al. Association between nurse–physician collaboration and patient outcomes in three intensive care units. Crit Care Med. 1999;27(9):1991–8.PubMedCrossRefGoogle Scholar
  4. 4.
    Gittell JH, Fairfield KM, Bierbaum B, et al. Impact of relational coordination on quality of care, postoperative pain and functioning, and length of stay: a nine-hospital study of surgical patients. Med Care. 2000;38(8):807–19.PubMedCrossRefGoogle Scholar
  5. 5.
    Rosenstein AH. Nurse–Physician relationships: impact on nurse satisfaction and retention. Am J Nurs. 2002;102(6):26–34.PubMedGoogle Scholar
  6. 6.
    Baggs JG, Ryan SA. ICU nurse–physician collaboration and nursing satisfaction. Nurs Econ. 1990;8(6):386–92.PubMedGoogle Scholar
  7. 7.
    Larrabee JH, Ostrow CL, Withrow ML, et al. Predictors of patient satisfaction with inpatient hospital nursing care. Res Nurs Health. 2004;27(4):254–68.PubMedCrossRefGoogle Scholar
  8. 8.
    Nadolski GJ, Bell MA, Brewer BB. Evaluating the quality of interaction between medical students and nurses in a large teaching hospital. BMC Med Educ. 2006;6:23.PubMedCrossRefGoogle Scholar
  9. 9.
    Rosenstein AH, O’Daniel M. Disruptive behavior and clinical outcomes: perceptions of nurses and physicians. Am J Nurs. 2005;105(1):54–64.PubMedGoogle Scholar
  10. 10.
    Benner AB. Physician and nurse relationships, a key to patient safety. J Ky Med Assoc. 2007;105(4):165–9.PubMedGoogle Scholar
  11. 11.
    Horak BJ, Pauig J, Keidan B, Kerns J. Patient safety: a case study in team building and interdisciplinary collaboration. J Health Qual. 2004;26(2):6–12.Google Scholar
  12. 12.
    Sim TA, Joyner J. A multidisciplinary team approach to reducing medication variance. Jt Comm J Qual Improv. 2002;28(7):403–9.PubMedGoogle Scholar
  13. 13.
    ACGME Outcomes Project: General Competencies http://www.acgme.org/outcome/comp/compFull.asp; Accessed November 2008.
  14. 14.
    Baggs J, Schmitt MH. Nurses and resident-physicians’ perceptions of the process of collaboration in a MICU. Res Nurs Health. 1997;20:71–80.PubMedCrossRefGoogle Scholar
  15. 15.
    Baggs JG. Development of an instrument to measure collaboration and satisfaction about care decisions. J Adv Nurs. 1994;20(1):176–82.PubMedCrossRefGoogle Scholar
  16. 16.
    Hojat M, Fields SK, Veloski JJ. Psychometric properties of an attitude scale measuring physician–nurse collaboration. Eval Health Prof. 1999;22(2):208–20.PubMedCrossRefGoogle Scholar
  17. 17.
    Hojat M, Nasca TJ, Cohen MJ, et al. Attitudes toward physician–nurse collaboration: a cross-cultural study of male and female physicians and nurses in the United States and Mexico. Nurs Res. 2001;50(2):123–8.PubMedCrossRefGoogle Scholar
  18. 18.
    Yildirim A, Akinci F, Ates M, et al. Turkish version of the Jefferson Scale of attitudes toward physician–nurse collaboration: a preliminary study. D.Contemp Nurse. 2006;23(1):38–45.Google Scholar
  19. 19.
    Hojat M, Gonnella JS, Nasca TJ. Comparisons of American, Israeli, Italian and Mexican physicians and nurses on the total and factor scores of the Jefferson scale of attitudes toward physician–nurse collaborative relationships. Int J Nurs Stud. 2003;40(4):427–35.PubMedCrossRefGoogle Scholar
  20. 20.
    Stein L. The doctor–nurse game. Arch of Gen Psychiatry. 1967;16:699–703.Google Scholar
  21. 21.
    Lingard L, Espin S, Evans C, Hawryluck L. Crit Care. The rules of the game: interprofessional collaboration on the intensive care unit team. Crit Care. 2004;8(6):R403.PubMedCrossRefGoogle Scholar
  22. 22.
    Larson EB, Yao X. Clinical empathy as emotional labor in the patient–physician relationship. JAMA. 2005;293(9):1100–6.PubMedCrossRefGoogle Scholar
  23. 23.
    Thesen J, Kuzel AJ. Participatory inquiry. In: Crabtree BF, Miller WL, eds. Doing Qualitative Research. Thousand Oaks, CA: Sage Publications; 1999:269–92.Google Scholar
  24. 24.
    Cooperrider D, Whitney D. Collaborating for Change: Appreciative Inquiry. Berrett-Koehler Communications; 1999.Google Scholar
  25. 25.
    Bushe G. Appreciative inquiry with teams. Organ Dev J. 1998;16(3):41–50.Google Scholar
  26. 26.
    Bushe G. Five theories of change embedded in appreciative inquiry. In: Cooperrider D, Sorenson P, Whitney D, Yeager T, eds. Appreciative Inquiry: An Emerging Direction for Organization Development. Champaign, IL: Stipes; 2001.Google Scholar
  27. 27.
    Burke K. A Grammar of Motives. Berkeley: University of California Press; 1969.Google Scholar
  28. 28.
    Creswell JW. Five qualitative approaches to inquiry. In: Qualitative Inquiry and Research Design: Choosing Among the Five Traditions. Thousand Parks, CA: Sage Publications Inc; 2007:53–84.Google Scholar
  29. 29.
    Moustakas C. Phenomenological Research Methods. Newbury Park, California: Sage Publishers; 1994.Google Scholar
  30. 30.
    Groenewald T. A phenomenological research design illustrated. Int J Qual Methods. 2004;3(1)1–26.Google Scholar
  31. 31.
    Hitzler R, Reiner K. On sociological and common sense verstehen. Curr Sociol. 1989;37:91–101.CrossRefGoogle Scholar
  32. 32.
    Crabtree B, Miller W. Doing Qualitative Research. Thousand Oaks, California: Sage Publications; 2007.Google Scholar
  33. 33.
    Creswell JW. Qualitative Inquiry and Research Design: Choosing Among the Five Traditions. Standards of Validation and Evaluation. Thousand Parks, CA: Sage Publications Inc; 2007:207–9.Google Scholar
  34. 34.
    Gilcrist VJ, Williams RL. Chap 4, key informant interviews. In: Crabtree BF, Miller WL, eds. Doing Qualitative Research. Thousand Oaks, CA: Sage Publications; 1999:71–88.Google Scholar
  35. 35.
    Ashworth P. Nurse–doctor relationships: conflict, competition or collaboration. Intensive Crit Care Nurs. 2000;16(3):127–8.PubMedCrossRefGoogle Scholar
  36. 36.
    Mason DJ. MD-RN: a tired old dance. Am J Nursing. 2002;102(6):7.Google Scholar
  37. 37.
    Thomas EJ, Sexton JB, Helmreich RL. Discrepant attitudes about teamwork among critical care nurses and physicians. Crit Care Med. 2003;31(3):956–9.PubMedCrossRefGoogle Scholar
  38. 38.
    Coombs M, Ersser SJ. Medical hegemony in decision making: a barrier to interdisciplinary working in intensive care. J Adv Nurs. 2004;46(3):245–52.PubMedCrossRefGoogle Scholar
  39. 39.
    Hawryluck LA, Espin SL, Garwood KC, Evan CA, Lingard LA. Pulling together and pushing apart: tides of tension in the ICU team. Acad Med. 2002;77(10 suppl):S73–6.PubMedCrossRefGoogle Scholar
  40. 40.
    Thomson S. Nurse–Physician collaboration: a comparison of the attitudes of physicians and nurses in the medical surgical setting. MedSurg Nurs. 2007;16(2):87–91.PubMedGoogle Scholar
  41. 41.
    Fiscella K, Roman-Diaz M, Lue BH, Botelho R, Frankel R. ‘Being a foreigner, I may be punished if I make a small mistake’: assessing trans-cultural experiences in caring for patients. Fam Pract. 1997;14(2):112–6.PubMedCrossRefGoogle Scholar
  42. 42.
    Apker J, Propp KM, Zabava Ford WS, Hofmeister N. Collaboration, credibility, compassion, and coordination: professional nurse communication skill sets in health care team interactions. J Prof Nurs. 2006;22(3):180–9.PubMedCrossRefGoogle Scholar
  43. 43.
    Kramer M, Schmalenberg C. Securing “good” nurse–physician relationships. Nurs Manage. 2003;July 34–8.Google Scholar
  44. 44.
    Beach MC, Inui T. Relationship-centered care a constructive reframing. the Relationship-Centered Care Research Network J Gen Intern Med. 2006;21(S1):S3–8.PubMedCrossRefGoogle Scholar
  45. 45.
    Tresolini C. Relationship-Centered Care: Report of the Pew-Fetzer Task Force on Advancing Psychosocial Health Education, 1994. http://futurehealth.ucsf.edu/pdf_files/RelationshipCentered.pdf, accessed, 7/08.
  46. 46.
    Watson J. Caring theory as an ethical guide to administrative and clinical practice. Nursing Admin Q. 2006;30(1)48–55.Google Scholar
  47. 47.
    Sumerel MB. Parallel Process in Supervision. ERIC Digest 1994-04-0015.Google Scholar
  48. 48.
    Canadian Inter-professional Health Collaborative. Inter-professional Education & Core Competencies Literature Review. May 2007. Accessed July, 2008. http://www.cihc.ca/about/curricula.html.
  49. 49.
    Rabow M, Gargani J, Cooke M. Do as I say: curricular discordance in medical school end-of-life care education. J Palliat Med. 2007;10(3):759–69.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2008

Authors and Affiliations

  • Kathleen A. McGrail
    • 1
    • 2
    • 5
  • Diane S. Morse
    • 3
    • 4
  • Theresa Glessner
    • 2
  • Kathryn Gardner
    • 2
  1. 1.Department of MedicineUniversity of Rochester School of Medicine and DentistryRochesterUSA
  2. 2.Rochester General HospitalRochesterUSA
  3. 3.Fulbright ProgramWashingtonUSA
  4. 4.Department of Medicine and PsychiatryUniversity of Rochester Medical CenterRochesterUSA
  5. 5.RochesterUSA

Personalised recommendations