Running head: IMPROVING NURSE-PHYSICIAN RELATIONSHIPS IN THE
Improving Nurse-Physician Relationships in the Neonatal Intensive Care Unit
Karen Fugate
University of Central Florida
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Improving Nurse-Physician Relationships in the Neonatal Intensive Care Unit
Background
Collaboration has been described as a process that allows interaction between colleagues
within a flat hierarchy (Johnson & King, 2012). In healthcare, it is described as a complex
process requiring deliberate information sharing between disciplines and mutual responsibility
for patient care (Johnson & King, 2012). Kramer and Schmalenberg (2003) describe the
collaborative nurse-physician relationship as a “good” relationship based on mutual trust and
respect with shared but not equal power; the collegial relationship is described as an “excellent”
relationship based on different but equal power. So, although both are positive relationships,
collaborative and collegial relationships have different power bases; collegial relationships are
higher on the hierarchical scale. Of interest, nursing places more value on the nurse-physician
relationship and rates the quality of the relationship lower (Schmalenberg et al., 2005a). Indeed,
one of the Forces of Magnetism is collaborative “interdisciplinary relationships” based on mutual
respect ("Forces of Magnetism," 2013).
Positive nurse-physician relationships are critical in facilitating improved patient care
outcomes including decreased mortality and morbidity, better patient care, decreased cost,
improved efficiency, and decreased length of stay (Johnson & King, 2012; Schmalenberg et al,
2005a) . Benefits to nursing include improved communication, increased nurse autonomy,
improved physician understanding of the nursing role, increased nurse satisfaction, and
decreased nurse turnover rate (Johnson & King, 2012; Schmalenberg et al, 2005a). Benefits are
more pronounced in Magnet facilities where more positive nurse-physician relationships exist
(Kramer & Schmalenberg, 2003).
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Despite the clear benefits of collegial/collaborative nurse-physician relationships,
reported relationships are not ideal. Historically, the relationship has been an unequal one with
the physician dominating the relationship and the nurse assuming a lower status (Johnson &
King, 2012). Given the higher acuity of the patient and the closer work relationship between
nurses and intensivists in intensive care units (ICUs), intuitively one would expect enhanced
collaboration. Johnson and Kring (2012) did not find this to be the case when comparing
perceptions of medical-surgical versus ICU nurses in a large Magnet facility. Intensive care
nurses’ perceptions of the nurse-physician relationship were very similar to the medical-surgical
nurses and demonstrate relationships are not optimal:

Sixty-one percent of nurses perceive they are subordinate to physicians.

Only thirty-two percent report having a collegial relationship with physicians.

Fifty-seven percent of nurses have seen disruptive physician behavior.

Only nineteen percent report disruptive physician behavior.
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Eighty percent report unprofessional physician behavior.

Fifty-one percent report physicians do not understand the nurse’s role.

Forty-eight percent report physicians do not listen to nurses about patients.

Forty-three percent report physicians do not communicate with nurses.
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Thirty-nine percent report physicians treat nurses like handmaidens.

Sixty-four percent of physicians call nurses by their first name, yet only one percent of
nurses address physicians by their first name.
Scores on the NDNQI Practice Environment Scale of the Nursing Work Index (PES-NWI)
measuring the collegiality of the nurse-physician relationship in the Neonatal Intensive Care Unit
(NICU) at this writer’s Magnet facility support these findings. Scores on the PES-NWI have
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trended down over the past two years and are significantly lower than the academic medical
center mean (Figure 1).
Figure 1. NDNQI PES-NWI scores of nurse-physician collegiality in the NICU from 2011 to
2013 compared to NDNQI Academic Medical Center Mean.
Problem
Power distance and ineffective communication remain significant barriers to achieving
true, collaborative/collegial relationships in the ICU. Given that collegial/collaborative nursephysician relationships affect patient outcomes, increase nurse job satisfaction, and decrease
nurse turnover, this concerning trend needs to be reversed and overall commitment to improving
this critical relationship needs to be a priority. Nurse leadership, in collaboration with physician
leadership, can develop, nurture, and support equal power nurse-physician relationships using
evidence-based management practices. Evidence-based management practice takes the emphasis
off of ritualistic, isolated, and unsupported structures as the basis for nursing management and
focuses on identifying and adapting structures that work (Schmalenberg et al., 2005a, p. 451).
Evidence-based Practices to Support Development of Nurse-Physician Relationships
Schmalenberg et al (2005a) determined the structures that support the nurse-physician
relationship by using three sources of evidence-based practice: analysis of research findings,
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consensus of recognized experts, and operational and evaluation data. The following is a
summary of the evidence-based structures that enable collegial/collaborative nurse-physician
relationships as described by Schmalenberg et al (2005b).
Interdisciplinary Rounds/Meetings
Joint RN/MD rounds and meetings contribute significantly to defining the unique and
overlapping scopes of practice that create the basis for autonomous decision making
(Schmalenberg et al., 2005b). Rounds and meetings vary in structure and intensity. Daily bedside
rounds involving all disciplines as well as the family to discuss plans and establish goals are
characteristic of ICUs. Weekly meetings to discuss patient progress and plan of care are also
defined as well as regular interdisciplinary meetings to discuss general management of the unit
Schmalenberg et al., 2005b).
Competence/Continuity/Longevity
Physicians and nurses repeatedly mention competence as critical to trust, respect, and
autonomous practice (Schmalenberg et al., 2005b). Several decades of research has shown
competence in one’s own role is a key determinant in collaborative/collegial nurse-physician
relationships. A measure of competence is national certification and to a lesser extent, having a
minimum four year nursing degree. Nurses should be provided with educational opportunities to
enhance their skills. The basis of the “equal power” relationship is clinical competence. Nurses
must keep their practices current and physicians must know this (Kramer & Schmalenberg,
2003).
Physicians judge nursing competence by how well the nurse is able to report a critical
change in patient condition in an emergent situation (Schmalenberg et al., 2005b). In fact, the
more crisis oriented a unit is, the more the physician must rely on the nurse to provide constant
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surveillance and “rescue” the patient thus the greater the need for autonomous nursing practice
(Schmalenberg et al., 2005b). Nurses judge physician competence by patient outcomes and
complications, whether or not the physician seeks out the nurse before writing an order, and how
well the physician listens to and collaborates with other members of the team regarding the plan
of care (Schmalenberg et al., 2005b).
A consistent group of nurses and physicians provides continuity and longevity. Longevity
helps nurses and physicians get to know each other so they are better able to communicate
regarding patient needs and their actions and patterns are more predictable (Schmalenberg et al.,
2005b). Longevity and continuity also contribute to a phenomenon called “trust banking”
(Schmalenberg et al., 2005b). “Trust banking” occurs when a new nurse or physician joins the
team; the new team member uses “banked trust” until they prove themselves on their own. Team
members with longevity will assist the new team member until they are secure and competent
thereby trust is never jeopardized. In order to “bank trust”, trust must exist in the first place and
staff turnover must be minimal.
The frequent turnover in residents and fellows at teaching hospitals can create a challenge
for the nurse-physician relationship secondary to the brief tenure of the physician (Schalenberg
et al., 2005b). Nurses must prompt residents or fellows to call the attending physician in
situations where the resident or fellow is overwhelmed or uncertain and if they do not respond
appropriately to the nurse’s recommendations, the nurse should feel comfortable calling the
attending physician directly. Nurses must be supported and empowered by nursing and physician
leadership to call the attending directly any time they feel the situation warrants this type of
action.
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Culture Where Patient Concern is Paramount
Units reporting high levels of collegiality cite specific core hospital cultural values as
vital to the nurse-physician relationship (Schmalenberg et al., 2005b). It is not enough to merely
talk about trust, respect, teamwork, and collegiality; these values must be embedded in the
culture. Physician and nursing leadership must model a collaborative approach to solving
practice issues. Mission and vision statements and employee evaluations must value
collaboration. Concern for the patient comes first, personalities and differences are set aside, and
nurses and physicians work together in a “no blame” environment to improve care
(Schmalenberg et al., 2005b). A physician may help out a colleague when they are busy with a
critical patient or a charge nurse may cover a nurse’s patients so she can collaborate with a
physician regarding emergent needs.
Critical Pathways/Collaborative Practice Protocols
Structures supporting critical pathways/collaborative practice protocols include
development, maintenance, and assessment of the impact of the tool on patient outcomes
(Schmalenberg et al., 2005b). Pathways, guidelines, and protocols developed with nursephysician collaboration are excellent tools to foster nursing autonomy and nurse-physician
collaboration as they give nurses freedom to initiate interventions based on judgment without a
physician order (Schmalenberg et al., 2005b). In facilities that utilize collaborative practice
protocols, nurses report feeling that physicians and administration view them as “bright enough,
competent enough, and educated enough” to make decisions (Schmalenberg et al., 2005b, p.
509). Likewise collaborative practice protocols, guidelines and pathways kindle physician trust
and respect for nursing knowledge and judgment (Schmalenberg et al., 2005b).
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Established Mechanisms for Constructive Conflict Resolution
Two core values underpin this structure: poor behavior (nurse or physician) is “not
tolerated” and “everyone deserves to be treated with respect” (Schmalenberg et al., 2005b).
Mechanisms reported to support this structure include written policies, committees to review
issues, and established interpersonal channels for handling conflicts (Schmalenberg et al.,
2005b). Personal conflicts are handled at the unit level with the guidance of the nurse manager.
The patient should be the primary concern for nurses and physicians. Patient care issues are
handled depending on whether they are emergent or chronic. Emergent issues are handled
immediately followed by a chain-of-command review as far up as necessary which could mean
the nurse manager or medical director shows up in the middle of the night if necessary. Chronic
or repetitive issues are resolved via ethics or quality committee review or following “disruptive
behavior” policy. Solutions are provided for the individual with respect for anonymity and
professional integrity. High achieving units seldom ever have to go this route because of the
value assigned to respect and intolerance of poor behavior.
Committed Medical Director
This structure is mentioned by nearly all hospitals with high levels of
collegiality/collaboration in the nurse-physician relationship (Schmalenberg et al., 2005b). In
most hospitals, a salary is paid by the hospital to the individual to fulfill this role. This makes the
medical director more accountable to and invested in the institution (Schmalenberg et al.,
2005b). Additionally, it creates bonding and teamwork as problems are resolved via
collaboration of dedicated nursing and physician leadership.
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Nurse Leader Support
Of all the structures supporting nurse-physician relationships, the behavior of the nurse
leader is cited most frequently (Schmalenberg et al., 2005b). Schmalenberg et al (2005b) list
several beneficial behaviors:

Clarify the vision of collaboration, make expectations known, hold individuals
accountable, and be consistent with the consequences. Expect nurses to be competent and
to maintain competence – “knowledge is power and the basis for respect” (Schmalenberg
et al., 2005b, p. 511). Recognize collegiality when nurses and physicians identify and
create opportunities to discuss the plan of care.

Listen without judging, propose different approaches, and provide feedback.

Role model collaboration. Stress collaboration, not competition – "We’re all in it
together” type attitude.

Provide organizational endorsement for autonomous nursing practice by leading
collaborative development of guidelines, protocols and pathways.

Foster development of competence through education – competence is power. Recognize
individual marks of competence such as completion of degrees, national certification, or
awards.

Empowering nurses which instills self-confidence. “I’m just a nurse” is not acceptable
and a mistake is an opportunity to learn and improve.

Constructively manage conflict. The preferred method is 1:1 communication between the
nurse and the physician; however, the nurse leader can be involved if necessary if either
party is uncomfortable. Skillful nurse leaders get involved only as much and as long as
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necessary – they “coach” staff to resolve their issues thus developing self-confidence in
their ability to resolve issues directly.
Foster Communication via Use of Nurse-Centered-Communication Techniques
Research conducted by Wanzer, Wojtaszczyk, and Kelly (2009) revealed a strong
relationship between physicians’ use of nurse-centered-communication (NCC) behaviors (clarity,
humor, immediacy, listening, and empathy) and nurses’ satisfaction with physician
communication, nurse-physician relationship, job satisfaction, and perception of collaboration
with the target physician. Nurse-centered-communication is based on patient-centeredcommunication (PCC) (Wanzer et al., 2009). Physicians have been taught to employ PCC
techniques to improve relationships with patients and improve patient satisfaction; physicians
can use these same techniques (NCC) to improve work relationships and collaboration with
nurses which leads to better patient outcomes. Simply put, if physicians want to improve
relationships with nurses they should use NCC skills more frequently during interactions and
improving relationships can only improve patient outcomes.
Recommendation
An extensive summary of evidence-based structures to improve the nurse-physician
relationship has been provided. The use of quality improvement (QI) methodology to implement
change and measure improvement is suggested to incorporate structure into practice. Keeping
within the QI framework, the next step would be to convene a team of formal and informal
NICU leaders to discuss the listed structures in detail and determine which structures are
applicable in our NICU. The chosen structures would then be prioritized based on their perceived
impact and barriers to implementation. Individual Plan-Do-Study-Act (PDSA) cycles would be
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utilized to introduce the changes. A reliable measurement tool is needed to study or measure the
impact or outcome over time.
The Professional Practice Environment Assessment Scale (PPES) is ideal for this project.
The PPES is a reliable method of assessing and monitoring changes in the professional practice
environment related specifically to the nurse-physician relationship (Siedlecki & Hixson, 2011).
The PPES is a short sixteen question survey for both physicians and nurses as it is important to
get the physician perspective as well. There are four subscales which assist in identifying strong
and weak areas: positive physician characteristics, positive organizational characteristics,
positive nurse characteristics, and positive characteristics of patient care decision making
(Siedlecki & Hixson, 2011). The PPES could be administered via electronic survey methodology
which is fast, convenient, and provides feedback from a large number of stakeholders. Quarterly
surveys would suffice to measure improvement in nurse-physician relationships (outcome) over
time.
Summary
Collaboration becomes a unit norm when it is embraced as a core value and translated
into behavior. Nurse-physician relationships impact nurse satisfaction and nurse turnover as well
as patient outcomes therefore should be a priority for nurse and physician leadership. Building
collegial/collaborative nurse-physician relationships is a process that needs structure and
standards. Structures and standards can be identified using evidence-based practice methodology.
Schmalenberg et al (2005b) provide an excellent summary of evidence-based management
structures associated with high levels of nurse-physician collegiality/collaboration which can be
used as a base to evaluate existing nurse-physician relationships. Quality improvement
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methodology is an excellent platform to implement and assess the effectiveness of selected
structures over time with the goal of achieving excellent, collegial nurse-physician relationships.
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References
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Kramer, M., & Schmalenberg, C. (2003). Securing “good” nurse physician relationships.
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Schmalenberg, C., Kramer, M., King, C., Krugman, M., Lund, C., Poduska, D., & Rapp, D.
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Siedlecki, S. L., & Hixson, E. D. (2011). Development and psychometric exploration fo the
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http://dx.doi.org/10.1111/j.1547-5069.2011.01414.x
Wanzer, M. B., Wojtaszczyk, A. M., & Kelly, J. (2009). Nurses’ perceptions of physicians’
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