Ferris State UniversityNURS 350 Evidence-Based Nursing Practice EBNP Group Project

Lai HarperMargaret SilerGary WebsterJamie Ziemba

ldquoCommunication--the human connection--is the key to personal and career successrdquo Paul J Meyer

ldquoItrsquos important to make sure that wersquore talking with each other in a way that heals not in a way that woundsrdquo-Barack Obama

ldquoCommunication works for those who work at itrdquo John Powell

ldquoUnity is strength when there is teamwork and collaboration wonderful things can be achievedrdquo Mattie Stepanek

Introduction

Every day we have conversations between nurses and doctors What are the outcomes of these conversations both positive and negative for patients and nurses

What is patient safety What is acute care What is professional communication

What is patient safety bull Easily defined as anything that would directly affected the

patientbull Examples with negative consequences on patient safety

language barriers medication errors miscommunication between doctors and nurses

bull Based on the Joint Commission patient safety (deathinjury or medical errors) can be related to segmented communication or relationship between nurses and physicians (Saxton Hines and Enriquez 2009 p 180)

What is acute carebull Taking care of patients who are having a ldquonowrdquo type of medical conditionbull ldquoA pattern of health care in which a patient is treated for a brief but severe

episode of illness for the sequelae of an accident or other trauma or during recovery from surgery Acute care is usually given in a hospital by specialized personnel using complex and sophisticated technical equipment and materials and it may involve intensive or emergency care This pattern of care is often necessary for only a short time unlike chronic carerdquo (Mosbys Medical Dictionary 2009)

What is Professional Communication

Verbal communication is basic conversation of words that people say to one another Simple words or technical jargon Difficult if the nurse or doctor has English as

a second language if the terms in the technical jargon are not shared by either the doctor or nurse

Nonverbal communication is body language and written communication

body language and written communication can be taken positively or negatively

Communication between medical professionals is not just a local problem but is a problem found throughout the entire medical community

PICO Question

For adult patients in an acute care setting what does the literature reveal about the DIFFERENCE in communication styles (collaboration interdisciplinary versus segmented authoritarian) between physicians and nurses on indicators of nurse satisfaction rates and patient safety outcomes

Definitions

bull According to the American Nurses Association ldquocollaborationrdquo is ldquoa true partnership in which the power on both sides is valued by both with recognition and acceptance of separate and combined practice spheres of activity and responsibility mutual safeguarding of the legitimate interests of each party and a commonality of goals that is recognized by both partiesrdquo (Hendel Fish amp Berger 2007 p 251)

bull Ballou and Landreneau (2010) discuss that ldquoauthoritarian persons typify an outlook that is ethnocentric rigid and anti-democraticrdquo (p 71)

bull ldquoSegmentedrdquo ldquodivided into or composed of segments or sectionsrdquo ldquoAuthoritarianrdquo ldquoof relating to or favoring blind submission to authorityrdquo (Merriam-Webster Dictionary 2012)

A Survey of the Impacts of Disruptive Behaviors and Communication Defects on Patient Safety

Sample size N= 4530 From January 2004 to March 2007How often do you think disruptive behavior results in the following at your hospital

(Sometimes Frequent and Constant)

How often do you think that there is a link between disruptive behavior and the following

clinical outcomes at your hospital (Sometimes Frequent and Constant)

Adver

se E

vent

s

Error

s

Patient

Saf

ety

Qualit

y of

Car

e

Patient

Mor

talit

y

6771

51

71

27

Stres

s

Frustra

tion

Loss o

f con

cent

ratio

n

Reduc

ed te

am col

labo

ratio

n

Reduc

ed in

form

atio

n tran

sfer

Reduc

ed com

mun

icat

ion

Impa

ired

RNM

D

94 94

83

8987

91

99

A Survey of the Impacts of Disruptive Behaviors and Communication Defects on Patient Safety

Sample size N= 4530 From January 2004 to March 2007

Have your ever witnessed any disruptive behavior from a physician at your hospital

Have you ever witnessed any disruptive behavior from a nurse at your hospital

Aggre

gate

MD

(ph

ysician)

RN (

nurs

e)

Admin

stra

tive ex

ecut

ives

Other

77

51

88

78

66

Aggre

gate

MD

(ph

ysician)

RN (

nurs

e)

Admin

istra

tive ex

ecut

ives

Other

65

48

7377

64

Literature Review (Level One Evidence)Research Articles

Research Methods

Theoretical frameworksMeasurement Instruments

Samples Data AnalysesStudy Findings

Kramer Schmalenbeg amp Maguire (2010)

Meta-analysis of multiple published studies

Donabedianrsquos conceptual framework of structure process and outcome

Heberlein and Baumgartnerrsquosmethodology

12 publications from 7 professional and regulatory organizations

18 publications from studies using the Essential of Magnetism (including 1300 interviews with nurses physicians and mangers)

positive physician-nurse communication collaborative leadership and autonomy in Magnet hospitals (Kramer et al p 11)

Nursesrsquo autonomous role in identifying patientsrsquo worsening conditions (need to rescueNTR) for reducing the rates of mortality or adverse patient outcomes (Kramer et al p 11)

Schmalenberg amp Kramer (2009)

Review of six research studies

Essentials of Magnetism

Concepts of nurse-physician relationship(collegial collaborative student-teacher friendly stranger hostileadversarial

3602 staff nurses in 16 Magnet and 10 non-Magnet hospitals in the 2003 study

10514 staff nurses in 18 Magnet and 16 non-Magnet hospitals in the 2007 study

In 2003 physician-nurse relationship scores in Magnet hospitals were statistically significant and higher when compared to non-Magnet hospitals (F ratio 21279 P less than 0001)

In 2007 the higher scores in Magnet hospitals were also statistically significant (F ratio 14446 P less than 0001)(Schmalenberg pp 78-79)

Zwarenstein Goldman amp Reeves (2009)

Cochrane Systematic Review

Not specifically mentioned

Five studies about collaborative interventions

interprofessional roundsmeetings

externally facilitated interprofessional audit

no randomized controlled studies about the impacts of interdisciplinary collaboration (Zwarenstein et al p 8)

ldquoProblems with conceptualising and measuring collaborationrdquo No ldquogeneralizable inferences about interprofessional collaborationrdquo (Zwarenstein et al p 2)

Literature Review (Level Three Evidence)

Research Articles

Research Methods

Theoretical frameworksMeasurement Instruments

Samples Data AnalysesStudy Findings

Boone King Gresham Wahl amp Suh (2008)

Quasi-experimental (Pre- and Post- Test for the training in assertiveness and cooperation)

Kilmann and Thomasrsquo model of conflict resolution (accommodating avoidance competition compromise collaboration)

Collaborative Behavior Scale

9 nurses from the cardiovascular laboratory (experimental group) and 18 nurses from the telemetry unit (control group)

Non-probability sampling in an American hospital

No statistical significance for the Collaborative Behavior Scale beforeafter the training between the experimental group and the control group ldquop more than 005rdquo (Boone et al p 172)

the communication style of ldquoavoidancerdquo was associated with increased nursesrsquo emotional stress (Boone et al p 173)

Implication explore barriers before training programs involve physiciansrsquo participations

McCaffrey HayesCassell Miller-Reyes Donaldson amp Ferrell (2012)

Quasi-experimental (Pre- and Post-test for training in communication skills)

Jefferson Scale of Attitudes

68 nurses and 47 medical residents in a Florida hospital

Non-probability sampling

statistical significance (P=0001) of the T-test before and after the 6-month educational program for enhancing physician-nurse collegiality communication skills mutual decision-making processes (McCaffrey et al p 298)

Literature Review (Level Four Evidence)Research Articles

Research Studies

Theoretical Frameworks

Measurement Instruments

Samples Data AnalysesStudy Findings

Hendel Fish amp Berger (2007)

Cross-sectional Correlational study

Thomas-Kilman Model of Conflict Resolution

Conflict Mode Instrument (MODE)

75 physicians 54 charge nurses at 5 acute care hospitals in Israel

Non-probability sampling

charge nurses were more likely to use the ldquocollaboratingrdquo communication style when compared to physicians (P=0001) (Hendel et al p 249)

Karanikola et al (2012)

Descriptive Correlational study

Hamiltonrsquos Anxiety Scale

Stamprsquos Index of Work Satisfaction

2-stage random probability sampling

11 hospitals randomly selected in Greece then 229 nurses at intensive care units randomly selected

Satisfaction in physician communication was statistically significant and negatively associated with intensive care nursesrsquo anxiety level ldquocorrelation coefficient Kendall = -0160 P=0001rdquo and depressed mood ldquocorrelation coefficient = -0148 P=0005rdquo (p 41)

Limitations confounding variables of nursesrsquo personal psychiatric or psychological histories

Manojlovich amp DeCicco (2007)

Descriptive Cross-sectional Non-experimental

Concepts of workplace empowerment ICU Nurse-Physician QuestionnairePractice Environment Scale of the Nursing Work Index

462 nursesrsquo perceptions in 25 intensive care units from 8 Michigan hospitals

Non-probability sampling

statistical significance for the positive correlation of physician-nurse miscommunication to the perceived outcomes in medication errors (p 542)

Limitation not generalized findings not reflect cause-effect relationships

Literature Review (Level Four Evidence continued)

Research Articles

Research Studies

Theoretical Framework

Measurement Instruments

Samples Data AnalysesStudy Findings

Rosenstein amp ODaniel (2008)

Non-experimentalstudy quantitative and qualitative approach

Instrument ldquoNurse-Physician Impact of disruptive Behavior on Patient Carerdquo

Convenience samples 2846 nurses 944 physicians from 102 not-for-profit VHA member hospitals in the US from 2004 to 2007

physician-nurse disturbing behaviors are likely to reduce patient safety outcomes and nurse satisfaction Narrative data eg ldquoafraid to call Drrdquo ldquoget yelled atrdquo ldquopoor communication postoprdquo (Rosenstein amp OrsquoDaniel p 467)

67 respondents perceived that disruptive behaviors were associated with adverse patient outcomes (medical errors and patient mortality) (Rosenstein amp OrsquoDaniel p 464)

Limitation theoretical framework not specifically describedStrength large sample size

Rothsteinamp Hannum (2007)

Cross-sectional

Gender model (male physician dominance and nurse deference)

Professional model

self-reported close-ended questionnaire on nurse-physician relationship

125 advanced practice nursesAPN at a statewide professional conference

non-probability sampling

statistical significance for APNrsquo s positive attitudecommunication with female physicians (less than 50 years old) and male physicians (of all ages) male and female physicians are also likely to be positive and respectful about APNrsquos knowledge in patient care (2-tailed t test and one-way analysis of variance P value less than 005) (Rothstein amp Hannum p 238)

The gender model for the authoritative dominance of male physicians is not applicable to the female APNs who have at least a masterrsquos degree in nursing (p 235)

Limitation confounding variables not measured ldquotype and size of the work organization nurse and physician specialties and patient illness and social characteristicsrdquo (p 239)

Literature Review (Level Six Evidence)

Research

Article

Research Method

Theoretical Framework

Sample Study Findings

Gardezi Lingard Espin Whyte Orser amp Baker (2009)

Qualitative study

Ethnographic approach

Retrospective study

Critical Theory about silence in communication

observed physician-nurse communications over 700 surgeries at 3 acute care hospitals from 2005 to 2007 in Canada

Narrative and descriptive data about conflicts in physician-nurse communication styles at operating rooms due to nursesrsquo gap in knowledge about surgical procedures and surgeonsrsquo dominant authoritative power

Nursesrsquo passivesilent communication method had negative impacts on patient safety during surgeries (Gardezi et al p 1391)

Limitations evidence-based practice cannot be based on one qualitative study

Strengths explore the descriptive lived experiences about physician-nurse communication barriers over 2 years

Analysis of Evidence

The ability to critically analyze evidence presented in various research projects is necessary to evaluate the work for applicability and use in evidence based nursing practice ldquoTo use research evidence one must be able to evaluate this evidencerdquo (Nieswiadomy 2012 p 298)

bull STRENGTH OF EVIDENCEbull LEVEL 1 (HIGHEST)bull EXPERIMENTAL STUDY (RANDOMIZED CONTROLLED TRAIL OR RCT)bull bull Study participants (subjects) are randomly assigned to either a treatment (TX) or

controlbull (non-treatment) groupbull bull May bebull o Blind neither subject nor investigator knows which TX subject is receivingbull o Double-blind neither subject nor investigator knows which TX subject is receivingbull o Non-blind both subject and investigator know which TX subject is receiving usedbull when it is felt that the knowledge of treatment is unimportantbull META-ANALYSIS OF RCTSbull bull Quantitatively synthesizes and analyzes results of multiple primary studies addressing

abull similar research questionbull bull Statistically pools results from independent but combinable studiesbull bull Summary statistic (effect size) is expressed in terms of direction (positive negative

orbull zero) and magnitude (high medium small)

bull LEVEL 2bull QUASI-EXPERIMENTAL STUDYbull bull Always includes manipulation of an independent variablebull bull Lacks either random assignment or control groupbull bull Findings must be considered in light of threats to validity (particularly selection)

bull LEVEL 3bull NON-EXPERIMENTAL STUDYbull bull No manipulation of the independent variablebull bull Can be descriptive comparative or relationalbull bull Often uses secondary databull bull Findings must be considered in light of threats to validity (particularly selection lack

ofbull severity or co-morbidity adjustment)

bull QUALITATIVE STUDYbull 1048707 Explorative in nature such as interviews observations or focus groupsbull 1048707 Starting point for studies of questions for which little research currently existsbull 1048707 Sample sizes are usually small and study results are used to design stronger studies

thatbull are more objective and quantifiable

bull META-SYNTHESISbull 1048707 Research technique that critically analyzes and synthesizes findings from qualitativebull researchbull 1048707 Identifies key concepts and metaphors and determines their relationships to each

otherbull 1048707 Aim is not to produce a summary statistic but rather to interpret and

translate findings

JHNEBP Research Evidence Appraisal

The Johns Hopkins HospitalThe Johns Hopkins University

QUALITY RATING (SCIENTIFIC EVIDENCE)

A High quality consistent results sufficient sample size adequate control and

bull definitive conclusions consistent recommendations based on extensive literature

bull review that includes thoughtful reference to scientific evidence

B Good quality reasonably consistent results sufficient sample size some control

bull and fairly definitive conclusions reasonably consistent recommendations based

bull on fairly comprehensive literature review that includes some reference to

bull scientific evidence

C Low quality or major flaws little evidence with inconsistent results insufficient

bull sample size conclusions cannot be drawn

Article 1 ldquoConflict management training and nurse-physician collaborative behaviorsrdquo(Boone et al 2008)bull Quantitative quasi-experimental designbull The researchers are highly qualified and experiencedbull Convenience sample which closely approximates the real world experiencebull This study is ethically sound as a written explanation of the study was provided and

informed consent was obtainedbull The problem is clearly stated to examine a knowledge gap between a unit specific

intervention (conflict management training) and improved communication and collaboration between physicians and nurses

bull Theoretical framework Kilmann and Thomas conflict resolution theory (Boone et al 2008 p 168)

bull Findings reveal that the intervention was unsuccessful (The null hypothesis not rejected)

bull The importance of continued research for interventions that promote quality communication and collaboration is stressed

bull Creating a culture that values quality communication and collaboration forms the basis for developing a healthy work environment

bull Level of evidence varies by tool used but is evaluated as II or III Both levels are credible for utilization in evidence based care

bull Informed consent was obtained from all participants

Article 2 ldquoNine structures and leadership practices essential for a magnetic (healthy) work environmentrdquo (Kramer et al 2010)

bull This is a quantitative meta-analysis of thirty professional publications bull The problem is clearly stated to identify what structures and leadership

practices are necessary to support a healthy work environmentbull The researchers are experienced and well qualifiedbull The sample size was good Over 1300 interviews of expert nurses nurse

managers and physicians were compiled for comparison to findings from regulatory and professional organizations

bull The theoretical framework is based on the Donabedian model (httpwwwahrqgovqualmedteammedteamfig2htm) of patient safety

bull Healthy work environments lead to improved patient and nurse outcomesbull Creating a culture of interdisciplinary collaboration and teamwork through

shared power and administrative support were important themesbull This is a valid level I for evidence by all methods (course modules interview

with hospital research specialist and Johns Hopkins Nursing Research Evidence Appraisal) Level I is the highest level of evidence for utilization in evidence based practice

Structuresbest leadership practices essential for healthy work environments

Quality leadership at all levels in the organization

Availability of and support for education career performance and competence development

Administrative sanction for autonomous and collaborative practice

Evidence-based practice education and operational supports

Culture practice and opportunity to learn interdisciplinary collaboration

Empowered shared decision-making structures for control of the context of nursing practice

Generation and nurturance of a patient-centered culture

Staffing structures that take into account RN competence patient acuity and teamwork

Development and support of intradisciplinary teamwork

Article 3 ldquoThe effect of an educational programme on attitudes of nurses and medical residents towards the benefit of positive communication and collaborationrdquo(McCaffrey et al 2012)bull This is a quasi-experimental study based on a convenience sample of nurses and

medical residents bull The researchers are experienced and well qualifiedbull The research question is clearly statedbull Ethical research guidelines are carefully adhered tobull A pre and post-test design based on the Jefferson Scale of Attitudes towards

Physician-Nurse Collaboration and the Communication Collaboration and Critical Thinking for Quality Patient Outcomes tools Both tools are proven to be reliable and valid (the Cronbachrsquos alpha coefficient of 087-092)

bull A critical finding in this study is that ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Statistical findings reveal that the chosen intervention of an educational programme to improve physician-nurse communication and collaboration was beneficial

bull This study is evaluated as evidence level III due to lack of a control group by two methods (Ford 2012 C Bongiorno personal communication November 26 2012) Alternatively it is rated as level II on the Johns Hopkins scale (JHNEBP Research Evidence Appraisal nd)

Article 4 ldquoNurse-physician relationships in hospitals 20000 nurses tell their storyrdquo (Schmalenberg amp Kramer 2009)

bull This study is a quantitative synthesis of the findings of six research studies based on the Essentials of Magnetism

bull The researchers are experienced and highly qualifiedbull The purpose of the study is several fold 1) To discern what constitutes quality

communication and collaboration between physicians and nurses 2) Define types of nurse-physician relationships 3) Define organizational structures and leadership practices that help develop collaborative nurse-physician relationships and 4) Study differences in nurse-physician relationships between magnet and comparison hospitals

bull The sample size of 20616 staff nurses is excellentbull Thorough literature review is the foundation for this studybull It was consistently reported that nurses at magnet hospitals reported higher quality

relationships with physicians than the comparison hospitalsbull Structures that improve relationships and are supported by magnet institutions are

keep the patient first develop constructive conflict resolution techniques and have collaborative interdisciplinary patient rounds

bull Nurses can play an active role in bringing about these interventionsbull This is a double blinded peer review of six studies clearly making it evidence level I by

all methods

Percentage of staff nurses responding affirmatively to nurse-physician relationship types by magnet

and comparison hospitals and by period

Application of Evidence for oncology nursing practice (Lai Harper)

bull Utilize the Cochrane Database or the ldquoJHNEBP Research Evidence Appraisalrdquo as the research tools effectively communicate and collaborate with oncologists about the nursing perspective on evidence-based practice

bull Ongoing literature review for the most current credible and high-quality evidence-based practice for reducing oncology patientsrsquo physical psychological and emotional issues (such as pain nausea anxiety or depression)

bull Recommend the hospital nursing research committee to initiate a survey to explore possible physician-nurse communication barriers at an oncology unit

bull Recommend the implementation of the low-cost convenient computer-based training in physician-nurse communication skills

Application of Evidence at the Cardiovascular Department (Margaret Siler)

bull High quality communication and collaboration make a great difference in the cardiac catheterization laboratory (Boone King Gresham Wahl amp Suh 2008 p 168)

bull Experience and a broad knowledge base bring confidence to our daily work (Schmalenberg amp Kramer 2009 p 82)

bull All involved parties (patient nurse physician healthcare system) can reap the benefits of collaborative practice (Kramer et al 2012 p 7)

bull There are many educational opportunities available to improve interdisciplinary and interdepartmental communication Many are quite costly Some that may make the biggest difference are fairly inexpensive including Unit Action Council work and interdepartmental job shadowing (McCaffery et al 2012)

Application of Evidence into the Surgical Setting (Gary Webster)

Intra-operative settings place nurses and physicians in close collaborative work

settings The typical communication style is authoritarian Schmalenberg and

Kramer (2009) stated that physicians felt the nurse-physician relation to be more

collaborative than nurse did I can see that being true in my work environment

The Boone et al (2008) and McCaffrey (2011) articles combined are very

valuable Together the articles show a successful attempt to increase collaboration

and some pitfalls to avoid These can help direct any programs to support an

increase in collaboration

Application of Evidence (Jamie Ziemba)

bull Poor communication between nurses and physicians related to language and cultural barriers

bull Physiciansrsquo dysfunctional or authoritarian communication style (eg instruct nurses not to call at night unless it is a life-and-death emergency) is a major patient safety issue

bull As the patient advocate nurses have an important role of communicating with physicians to verify medication orders clinical procedures and improve patient outcomes

bull Hospital training programs in communication skills and cultural diversities are recommended for physicians and nurses with different culturalethnic backgrounds

Summary Statements

bull Meta-analytical review of evidence-based research articles support the clinical significance of effective communication styles

bull Authoritarian communication styles increase disruptive behaviors and negative hostile relationships at work environments

bull Healthy work environments have positive effects on nurses physicians patients and healthcare organizations

bull Inter-disciplinary collaboration is an essential aspect of healthy work environmentsbull Evidence-based studies have shown positive patient outcomes nursing job

satisfaction collaborative environments at Magnet hospitalsbull There is a need to address the barriers and incorporate educational programs to teach

effective communication and the need for collaboration Educational training should be re-enforced with weekly discussions ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Educate staff on the 5 types of nurse-physician relationships (collegial collaborative teacher-student friendly-stranger and hostileadversarial relationships)

bull Teach staff how to utilize positive relationships and change negative onesbull Training should avoid focusing on negative behaviorsbull Training should focus creating cooperative behaviors

ReferencesAgency for Healthcare Research and Quality (nd) Medical teamwork and patient safety The Donabedian model of patient safety Retrieved

from httpwwwahrqgovqualmedteammedteamfig2htm

American Nurses Association (1980) Nursing A social policy statement Washington DC American Nurses Association

Ballou K amp Landreneau K (2010) The authoritarian reign in American health care Policy Politics amp Nursing Practice 11(1) 71-79

doi1011771527154410372973

Boone B King M Gresham L Wahl P amp Suh E (2008) Conflict management training and nurse-physician collaborative behaviors

Journal For Nurses In Staff Development 24(4) 168-175 doi10109701NND00003206705641591

Burns N amp Grove S (2007) Understanding Nursing Research Building an Evidence Based Practice (4th Ed) St Louis Missouri Saunders

Elsevier Publishing

Ford L (2012) Week 8 amp 9 Critique of Research Retrieved from httpsfsulearnferriseduwebappsportalframesetjsp

tab_tab_group_id=_2_1ampurl=2Fwebapps2Fblackboard2Fexecute2Flauncher3Ftype3DCourseampid3D_2241_1ampurl3D

Gardezi F Lingard L Espin S Whyte S Orser B amp Baker G (2009) Silence power and communication in the operating room

Journal Of Advanced Nursing 65(7) 1390-1399 doi101111j1365-2648200904994x

Hendel T Fish M amp Berger O (2007) Nursephysician conflict management mode choices implications for improved collaborative

practice Nursing Administration Quarterly 31(3) 244-253

John Hopkins UniversityJohn Hopkins Hospital (nd) JHNEBP Research Evidence Appraisal Retrieved from

httpwwwnursingworldorgDocumentVaultNursingPracticeResearch-ToolkitJHNEBP-Research-Evidence-Appraisalpdf

Karanikola M Papathanassoglou E Kalafati M Stathopoulou H Mpouzika M amp Goutsikas C G (2012) Exploration of the

Association Between Professional Interactions and Emotional Distress of Intensive Care Unit Nursing Personnel Dimensions Of Critical

Care Nursing 31(1) 37-45 doi101097DCC0b013e31823a55b8

ReferencesKramer M Schmalenberg C amp Maguire P (2010) Nine structures and leadership practices essential for a magnetic (healthy)

work environment Nursing Administration Quarterly 34(1) 4-17 doi101097NAQ0b013e3181c95ef4

Manojlovich M amp DeCicco B (2007) Healthy work environments nurse-physician communication and patients outcome American Journal Of Critical Care 16(6) 536-543

McCaffrey R Hayes R Cassell A Miller-Reyes S Donaldson A amp Ferrell C (2012) The effect of an educational programme on attitudes of nurses and medical residents towards the benefits of positive communication and collaboration Journal Of Advanced Nursing 68(2) 293-301 doi101111j1365-2648201105736x

Nieswiadomy R M (2012) Foundations of Nursing Research (6th Ed) Upper Saddle River New Jersey Prentice Hall

Rosenstein A amp ODaniel M (2008) A survey of the impact of disruptive behaviors and communication defects on patient safety Joint Commission Journal On Quality amp Patient Safety 34(8) 464-471

Rothstein W amp Hannum S (2007) Profession and gender in relationships between advanced practice nurses and physicians Journal Of Professional Nursing 23(4) 235-240 doi101016jprofnurs200701008

Saxton R Hines T amp Enriquez M (2009) The negative impact of nurse-physician disruptive behavior on patient safety A review of the literature Journal of Patient Safety 5(3) 180-183

Stone P W (2002) Popping the PICO question in research and evidence-based practice Applied Nursing Research 16(2) 197-198

Schmalenberg C amp Kramer M (2009) Nurse-physician relationships in hospitals 20 000 nurses tell their story Critical Care Nurse 29(1) 74-83 doi104037ccn2009436

Zwarenstein M Goldman J amp Reeves S (2009) Interprofessional collaboration Effects of practice-based interventions on professional practice and healthcare outcomes Cochrane Database Of Systematic Reviews (3) 1-31 doi10100214651858CD000072

NURS 350 Evidence-Based Nursing Practice (Group paper plus Group Powerpoint presentation)

Total group grade 100Instructorrsquos comments Excellent paper I think your group

should consider submitting it for publication if you could flesh out the details on improving collaborative communication

• Ferris State University NURS 350 Evidence-Based Nursing Practic
• ldquoCommunication--the human connection--is the key to pers
• Slide 3
• What is patient safety
• What is acute care
• What is Professional Communication
• Communication between medical professionals is not just a local
• PICO Question
• Definitions
• A Survey of the Impacts of Disruptive Behaviors and Communicat
• A Survey of the Impacts of Disruptive Behaviors and Communicat (2)
• Literature Review (Level One Evidence)
• Literature Review (Level Three Evidence)
• Literature Review (Level Four Evidence)
• Literature Review (Level Four Evidence continued)
• Literature Review (Level Six Evidence)
• Analysis of Evidence
• Slide 18
• Slide 19
• Article 1 ldquoConflict management training and nurse-physician
• Article 2 ldquoNine structures and leadership practices essentia
• Slide 22
• Article 3 ldquoThe effect of an educational programme on attitud
• Article 4 ldquoNurse-physician relationships in hospitals 2000
• Percentage of staff nurses responding affirmatively to nurse-ph
• Application of Evidence for oncology nursing practice (Lai Har
• Application of Evidence at the Cardiovascular Department (Marg
• Application of Evidence into the Surgical Setting (Gary Webste
• Slide 29
• Summary Statements
• References
• References (2)
• NURS 350 Evidence-Based Nursing Practice (Group paper plus Gr

ldquoCommunication--the human connection--is the key to personal and career successrdquo Paul J Meyer

ldquoItrsquos important to make sure that wersquore talking with each other in a way that heals not in a way that woundsrdquo-Barack Obama

ldquoCommunication works for those who work at itrdquo John Powell

ldquoUnity is strength when there is teamwork and collaboration wonderful things can be achievedrdquo Mattie Stepanek

Introduction

Every day we have conversations between nurses and doctors What are the outcomes of these conversations both positive and negative for patients and nurses

What is patient safety What is acute care What is professional communication

What is patient safety bull Easily defined as anything that would directly affected the

patientbull Examples with negative consequences on patient safety

language barriers medication errors miscommunication between doctors and nurses

bull Based on the Joint Commission patient safety (deathinjury or medical errors) can be related to segmented communication or relationship between nurses and physicians (Saxton Hines and Enriquez 2009 p 180)

What is acute carebull Taking care of patients who are having a ldquonowrdquo type of medical conditionbull ldquoA pattern of health care in which a patient is treated for a brief but severe

episode of illness for the sequelae of an accident or other trauma or during recovery from surgery Acute care is usually given in a hospital by specialized personnel using complex and sophisticated technical equipment and materials and it may involve intensive or emergency care This pattern of care is often necessary for only a short time unlike chronic carerdquo (Mosbys Medical Dictionary 2009)

What is Professional Communication

Verbal communication is basic conversation of words that people say to one another Simple words or technical jargon Difficult if the nurse or doctor has English as

a second language if the terms in the technical jargon are not shared by either the doctor or nurse

Nonverbal communication is body language and written communication

body language and written communication can be taken positively or negatively

Communication between medical professionals is not just a local problem but is a problem found throughout the entire medical community

PICO Question

For adult patients in an acute care setting what does the literature reveal about the DIFFERENCE in communication styles (collaboration interdisciplinary versus segmented authoritarian) between physicians and nurses on indicators of nurse satisfaction rates and patient safety outcomes

Definitions

bull According to the American Nurses Association ldquocollaborationrdquo is ldquoa true partnership in which the power on both sides is valued by both with recognition and acceptance of separate and combined practice spheres of activity and responsibility mutual safeguarding of the legitimate interests of each party and a commonality of goals that is recognized by both partiesrdquo (Hendel Fish amp Berger 2007 p 251)

bull Ballou and Landreneau (2010) discuss that ldquoauthoritarian persons typify an outlook that is ethnocentric rigid and anti-democraticrdquo (p 71)

bull ldquoSegmentedrdquo ldquodivided into or composed of segments or sectionsrdquo ldquoAuthoritarianrdquo ldquoof relating to or favoring blind submission to authorityrdquo (Merriam-Webster Dictionary 2012)

A Survey of the Impacts of Disruptive Behaviors and Communication Defects on Patient Safety

Sample size N= 4530 From January 2004 to March 2007How often do you think disruptive behavior results in the following at your hospital

(Sometimes Frequent and Constant)

How often do you think that there is a link between disruptive behavior and the following

clinical outcomes at your hospital (Sometimes Frequent and Constant)

Adver

se E

vent

s

Error

s

Patient

Saf

ety

Qualit

y of

Car

e

Patient

Mor

talit

y

6771

51

71

27

Stres

s

Frustra

tion

Loss o

f con

cent

ratio

n

Reduc

ed te

am col

labo

ratio

n

Reduc

ed in

form

atio

n tran

sfer

Reduc

ed com

mun

icat

ion

Impa

ired

RNM

D

94 94

83

8987

91

99

A Survey of the Impacts of Disruptive Behaviors and Communication Defects on Patient Safety

Sample size N= 4530 From January 2004 to March 2007

Have your ever witnessed any disruptive behavior from a physician at your hospital

Have you ever witnessed any disruptive behavior from a nurse at your hospital

Aggre

gate

MD

(ph

ysician)

RN (

nurs

e)

Admin

stra

tive ex

ecut

ives

Other

77

51

88

78

66

Aggre

gate

MD

(ph

ysician)

RN (

nurs

e)

Admin

istra

tive ex

ecut

ives

Other

65

48

7377

64

Literature Review (Level One Evidence)Research Articles

Research Methods

Theoretical frameworksMeasurement Instruments

Samples Data AnalysesStudy Findings

Kramer Schmalenbeg amp Maguire (2010)

Meta-analysis of multiple published studies

Donabedianrsquos conceptual framework of structure process and outcome

Heberlein and Baumgartnerrsquosmethodology

12 publications from 7 professional and regulatory organizations

18 publications from studies using the Essential of Magnetism (including 1300 interviews with nurses physicians and mangers)

positive physician-nurse communication collaborative leadership and autonomy in Magnet hospitals (Kramer et al p 11)

Nursesrsquo autonomous role in identifying patientsrsquo worsening conditions (need to rescueNTR) for reducing the rates of mortality or adverse patient outcomes (Kramer et al p 11)

Schmalenberg amp Kramer (2009)

Review of six research studies

Essentials of Magnetism

Concepts of nurse-physician relationship(collegial collaborative student-teacher friendly stranger hostileadversarial

3602 staff nurses in 16 Magnet and 10 non-Magnet hospitals in the 2003 study

10514 staff nurses in 18 Magnet and 16 non-Magnet hospitals in the 2007 study

In 2003 physician-nurse relationship scores in Magnet hospitals were statistically significant and higher when compared to non-Magnet hospitals (F ratio 21279 P less than 0001)

In 2007 the higher scores in Magnet hospitals were also statistically significant (F ratio 14446 P less than 0001)(Schmalenberg pp 78-79)

Zwarenstein Goldman amp Reeves (2009)

Cochrane Systematic Review

Not specifically mentioned

Five studies about collaborative interventions

interprofessional roundsmeetings

externally facilitated interprofessional audit

no randomized controlled studies about the impacts of interdisciplinary collaboration (Zwarenstein et al p 8)

ldquoProblems with conceptualising and measuring collaborationrdquo No ldquogeneralizable inferences about interprofessional collaborationrdquo (Zwarenstein et al p 2)

Literature Review (Level Three Evidence)

Research Articles

Research Methods

Theoretical frameworksMeasurement Instruments

Samples Data AnalysesStudy Findings

Boone King Gresham Wahl amp Suh (2008)

Quasi-experimental (Pre- and Post- Test for the training in assertiveness and cooperation)

Kilmann and Thomasrsquo model of conflict resolution (accommodating avoidance competition compromise collaboration)

Collaborative Behavior Scale

9 nurses from the cardiovascular laboratory (experimental group) and 18 nurses from the telemetry unit (control group)

Non-probability sampling in an American hospital

No statistical significance for the Collaborative Behavior Scale beforeafter the training between the experimental group and the control group ldquop more than 005rdquo (Boone et al p 172)

the communication style of ldquoavoidancerdquo was associated with increased nursesrsquo emotional stress (Boone et al p 173)

Implication explore barriers before training programs involve physiciansrsquo participations

McCaffrey HayesCassell Miller-Reyes Donaldson amp Ferrell (2012)

Quasi-experimental (Pre- and Post-test for training in communication skills)

Jefferson Scale of Attitudes

68 nurses and 47 medical residents in a Florida hospital

Non-probability sampling

statistical significance (P=0001) of the T-test before and after the 6-month educational program for enhancing physician-nurse collegiality communication skills mutual decision-making processes (McCaffrey et al p 298)

Literature Review (Level Four Evidence)Research Articles

Research Studies

Theoretical Frameworks

Measurement Instruments

Samples Data AnalysesStudy Findings

Hendel Fish amp Berger (2007)

Cross-sectional Correlational study

Thomas-Kilman Model of Conflict Resolution

Conflict Mode Instrument (MODE)

75 physicians 54 charge nurses at 5 acute care hospitals in Israel

Non-probability sampling

charge nurses were more likely to use the ldquocollaboratingrdquo communication style when compared to physicians (P=0001) (Hendel et al p 249)

Karanikola et al (2012)

Descriptive Correlational study

Hamiltonrsquos Anxiety Scale

Stamprsquos Index of Work Satisfaction

2-stage random probability sampling

11 hospitals randomly selected in Greece then 229 nurses at intensive care units randomly selected

Satisfaction in physician communication was statistically significant and negatively associated with intensive care nursesrsquo anxiety level ldquocorrelation coefficient Kendall = -0160 P=0001rdquo and depressed mood ldquocorrelation coefficient = -0148 P=0005rdquo (p 41)

Limitations confounding variables of nursesrsquo personal psychiatric or psychological histories

Manojlovich amp DeCicco (2007)

Descriptive Cross-sectional Non-experimental

Concepts of workplace empowerment ICU Nurse-Physician QuestionnairePractice Environment Scale of the Nursing Work Index

462 nursesrsquo perceptions in 25 intensive care units from 8 Michigan hospitals

Non-probability sampling

statistical significance for the positive correlation of physician-nurse miscommunication to the perceived outcomes in medication errors (p 542)

Limitation not generalized findings not reflect cause-effect relationships

Literature Review (Level Four Evidence continued)

Research Articles

Research Studies

Theoretical Framework

Measurement Instruments

Samples Data AnalysesStudy Findings

Rosenstein amp ODaniel (2008)

Non-experimentalstudy quantitative and qualitative approach

Instrument ldquoNurse-Physician Impact of disruptive Behavior on Patient Carerdquo

Convenience samples 2846 nurses 944 physicians from 102 not-for-profit VHA member hospitals in the US from 2004 to 2007

physician-nurse disturbing behaviors are likely to reduce patient safety outcomes and nurse satisfaction Narrative data eg ldquoafraid to call Drrdquo ldquoget yelled atrdquo ldquopoor communication postoprdquo (Rosenstein amp OrsquoDaniel p 467)

67 respondents perceived that disruptive behaviors were associated with adverse patient outcomes (medical errors and patient mortality) (Rosenstein amp OrsquoDaniel p 464)

Limitation theoretical framework not specifically describedStrength large sample size

Rothsteinamp Hannum (2007)

Cross-sectional

Gender model (male physician dominance and nurse deference)

Professional model

self-reported close-ended questionnaire on nurse-physician relationship

125 advanced practice nursesAPN at a statewide professional conference

non-probability sampling

statistical significance for APNrsquo s positive attitudecommunication with female physicians (less than 50 years old) and male physicians (of all ages) male and female physicians are also likely to be positive and respectful about APNrsquos knowledge in patient care (2-tailed t test and one-way analysis of variance P value less than 005) (Rothstein amp Hannum p 238)

The gender model for the authoritative dominance of male physicians is not applicable to the female APNs who have at least a masterrsquos degree in nursing (p 235)

Limitation confounding variables not measured ldquotype and size of the work organization nurse and physician specialties and patient illness and social characteristicsrdquo (p 239)

Literature Review (Level Six Evidence)

Research

Article

Research Method

Theoretical Framework

Sample Study Findings

Gardezi Lingard Espin Whyte Orser amp Baker (2009)

Qualitative study

Ethnographic approach

Retrospective study

Critical Theory about silence in communication

observed physician-nurse communications over 700 surgeries at 3 acute care hospitals from 2005 to 2007 in Canada

Narrative and descriptive data about conflicts in physician-nurse communication styles at operating rooms due to nursesrsquo gap in knowledge about surgical procedures and surgeonsrsquo dominant authoritative power

Nursesrsquo passivesilent communication method had negative impacts on patient safety during surgeries (Gardezi et al p 1391)

Limitations evidence-based practice cannot be based on one qualitative study

Strengths explore the descriptive lived experiences about physician-nurse communication barriers over 2 years

Analysis of Evidence

The ability to critically analyze evidence presented in various research projects is necessary to evaluate the work for applicability and use in evidence based nursing practice ldquoTo use research evidence one must be able to evaluate this evidencerdquo (Nieswiadomy 2012 p 298)

bull STRENGTH OF EVIDENCEbull LEVEL 1 (HIGHEST)bull EXPERIMENTAL STUDY (RANDOMIZED CONTROLLED TRAIL OR RCT)bull bull Study participants (subjects) are randomly assigned to either a treatment (TX) or

controlbull (non-treatment) groupbull bull May bebull o Blind neither subject nor investigator knows which TX subject is receivingbull o Double-blind neither subject nor investigator knows which TX subject is receivingbull o Non-blind both subject and investigator know which TX subject is receiving usedbull when it is felt that the knowledge of treatment is unimportantbull META-ANALYSIS OF RCTSbull bull Quantitatively synthesizes and analyzes results of multiple primary studies addressing

abull similar research questionbull bull Statistically pools results from independent but combinable studiesbull bull Summary statistic (effect size) is expressed in terms of direction (positive negative

orbull zero) and magnitude (high medium small)

bull LEVEL 2bull QUASI-EXPERIMENTAL STUDYbull bull Always includes manipulation of an independent variablebull bull Lacks either random assignment or control groupbull bull Findings must be considered in light of threats to validity (particularly selection)

bull LEVEL 3bull NON-EXPERIMENTAL STUDYbull bull No manipulation of the independent variablebull bull Can be descriptive comparative or relationalbull bull Often uses secondary databull bull Findings must be considered in light of threats to validity (particularly selection lack

ofbull severity or co-morbidity adjustment)

bull QUALITATIVE STUDYbull 1048707 Explorative in nature such as interviews observations or focus groupsbull 1048707 Starting point for studies of questions for which little research currently existsbull 1048707 Sample sizes are usually small and study results are used to design stronger studies

thatbull are more objective and quantifiable

bull META-SYNTHESISbull 1048707 Research technique that critically analyzes and synthesizes findings from qualitativebull researchbull 1048707 Identifies key concepts and metaphors and determines their relationships to each

otherbull 1048707 Aim is not to produce a summary statistic but rather to interpret and

translate findings

JHNEBP Research Evidence Appraisal

The Johns Hopkins HospitalThe Johns Hopkins University

QUALITY RATING (SCIENTIFIC EVIDENCE)

A High quality consistent results sufficient sample size adequate control and

bull definitive conclusions consistent recommendations based on extensive literature

bull review that includes thoughtful reference to scientific evidence

B Good quality reasonably consistent results sufficient sample size some control

bull and fairly definitive conclusions reasonably consistent recommendations based

bull on fairly comprehensive literature review that includes some reference to

bull scientific evidence

C Low quality or major flaws little evidence with inconsistent results insufficient

bull sample size conclusions cannot be drawn

Article 1 ldquoConflict management training and nurse-physician collaborative behaviorsrdquo(Boone et al 2008)bull Quantitative quasi-experimental designbull The researchers are highly qualified and experiencedbull Convenience sample which closely approximates the real world experiencebull This study is ethically sound as a written explanation of the study was provided and

informed consent was obtainedbull The problem is clearly stated to examine a knowledge gap between a unit specific

intervention (conflict management training) and improved communication and collaboration between physicians and nurses

bull Theoretical framework Kilmann and Thomas conflict resolution theory (Boone et al 2008 p 168)

bull Findings reveal that the intervention was unsuccessful (The null hypothesis not rejected)

bull The importance of continued research for interventions that promote quality communication and collaboration is stressed

bull Creating a culture that values quality communication and collaboration forms the basis for developing a healthy work environment

bull Level of evidence varies by tool used but is evaluated as II or III Both levels are credible for utilization in evidence based care

bull Informed consent was obtained from all participants

Article 2 ldquoNine structures and leadership practices essential for a magnetic (healthy) work environmentrdquo (Kramer et al 2010)

bull This is a quantitative meta-analysis of thirty professional publications bull The problem is clearly stated to identify what structures and leadership

practices are necessary to support a healthy work environmentbull The researchers are experienced and well qualifiedbull The sample size was good Over 1300 interviews of expert nurses nurse

managers and physicians were compiled for comparison to findings from regulatory and professional organizations

bull The theoretical framework is based on the Donabedian model (httpwwwahrqgovqualmedteammedteamfig2htm) of patient safety

bull Healthy work environments lead to improved patient and nurse outcomesbull Creating a culture of interdisciplinary collaboration and teamwork through

shared power and administrative support were important themesbull This is a valid level I for evidence by all methods (course modules interview

with hospital research specialist and Johns Hopkins Nursing Research Evidence Appraisal) Level I is the highest level of evidence for utilization in evidence based practice

Structuresbest leadership practices essential for healthy work environments

Quality leadership at all levels in the organization

Availability of and support for education career performance and competence development

Administrative sanction for autonomous and collaborative practice

Evidence-based practice education and operational supports

Culture practice and opportunity to learn interdisciplinary collaboration

Empowered shared decision-making structures for control of the context of nursing practice

Generation and nurturance of a patient-centered culture

Staffing structures that take into account RN competence patient acuity and teamwork

Development and support of intradisciplinary teamwork

Article 3 ldquoThe effect of an educational programme on attitudes of nurses and medical residents towards the benefit of positive communication and collaborationrdquo(McCaffrey et al 2012)bull This is a quasi-experimental study based on a convenience sample of nurses and

medical residents bull The researchers are experienced and well qualifiedbull The research question is clearly statedbull Ethical research guidelines are carefully adhered tobull A pre and post-test design based on the Jefferson Scale of Attitudes towards

Physician-Nurse Collaboration and the Communication Collaboration and Critical Thinking for Quality Patient Outcomes tools Both tools are proven to be reliable and valid (the Cronbachrsquos alpha coefficient of 087-092)

bull A critical finding in this study is that ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Statistical findings reveal that the chosen intervention of an educational programme to improve physician-nurse communication and collaboration was beneficial

bull This study is evaluated as evidence level III due to lack of a control group by two methods (Ford 2012 C Bongiorno personal communication November 26 2012) Alternatively it is rated as level II on the Johns Hopkins scale (JHNEBP Research Evidence Appraisal nd)

Article 4 ldquoNurse-physician relationships in hospitals 20000 nurses tell their storyrdquo (Schmalenberg amp Kramer 2009)

bull This study is a quantitative synthesis of the findings of six research studies based on the Essentials of Magnetism

bull The researchers are experienced and highly qualifiedbull The purpose of the study is several fold 1) To discern what constitutes quality

communication and collaboration between physicians and nurses 2) Define types of nurse-physician relationships 3) Define organizational structures and leadership practices that help develop collaborative nurse-physician relationships and 4) Study differences in nurse-physician relationships between magnet and comparison hospitals

bull The sample size of 20616 staff nurses is excellentbull Thorough literature review is the foundation for this studybull It was consistently reported that nurses at magnet hospitals reported higher quality

relationships with physicians than the comparison hospitalsbull Structures that improve relationships and are supported by magnet institutions are

keep the patient first develop constructive conflict resolution techniques and have collaborative interdisciplinary patient rounds

bull Nurses can play an active role in bringing about these interventionsbull This is a double blinded peer review of six studies clearly making it evidence level I by

all methods

Percentage of staff nurses responding affirmatively to nurse-physician relationship types by magnet

and comparison hospitals and by period

Application of Evidence for oncology nursing practice (Lai Harper)

bull Utilize the Cochrane Database or the ldquoJHNEBP Research Evidence Appraisalrdquo as the research tools effectively communicate and collaborate with oncologists about the nursing perspective on evidence-based practice

bull Ongoing literature review for the most current credible and high-quality evidence-based practice for reducing oncology patientsrsquo physical psychological and emotional issues (such as pain nausea anxiety or depression)

bull Recommend the hospital nursing research committee to initiate a survey to explore possible physician-nurse communication barriers at an oncology unit

bull Recommend the implementation of the low-cost convenient computer-based training in physician-nurse communication skills

Application of Evidence at the Cardiovascular Department (Margaret Siler)

bull High quality communication and collaboration make a great difference in the cardiac catheterization laboratory (Boone King Gresham Wahl amp Suh 2008 p 168)

bull Experience and a broad knowledge base bring confidence to our daily work (Schmalenberg amp Kramer 2009 p 82)

bull All involved parties (patient nurse physician healthcare system) can reap the benefits of collaborative practice (Kramer et al 2012 p 7)

bull There are many educational opportunities available to improve interdisciplinary and interdepartmental communication Many are quite costly Some that may make the biggest difference are fairly inexpensive including Unit Action Council work and interdepartmental job shadowing (McCaffery et al 2012)

Application of Evidence into the Surgical Setting (Gary Webster)

Intra-operative settings place nurses and physicians in close collaborative work

settings The typical communication style is authoritarian Schmalenberg and

Kramer (2009) stated that physicians felt the nurse-physician relation to be more

collaborative than nurse did I can see that being true in my work environment

The Boone et al (2008) and McCaffrey (2011) articles combined are very

valuable Together the articles show a successful attempt to increase collaboration

and some pitfalls to avoid These can help direct any programs to support an

increase in collaboration

Application of Evidence (Jamie Ziemba)

bull Poor communication between nurses and physicians related to language and cultural barriers

bull Physiciansrsquo dysfunctional or authoritarian communication style (eg instruct nurses not to call at night unless it is a life-and-death emergency) is a major patient safety issue

bull As the patient advocate nurses have an important role of communicating with physicians to verify medication orders clinical procedures and improve patient outcomes

bull Hospital training programs in communication skills and cultural diversities are recommended for physicians and nurses with different culturalethnic backgrounds

Summary Statements

bull Meta-analytical review of evidence-based research articles support the clinical significance of effective communication styles

bull Authoritarian communication styles increase disruptive behaviors and negative hostile relationships at work environments

bull Healthy work environments have positive effects on nurses physicians patients and healthcare organizations

bull Inter-disciplinary collaboration is an essential aspect of healthy work environmentsbull Evidence-based studies have shown positive patient outcomes nursing job

satisfaction collaborative environments at Magnet hospitalsbull There is a need to address the barriers and incorporate educational programs to teach

effective communication and the need for collaboration Educational training should be re-enforced with weekly discussions ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Educate staff on the 5 types of nurse-physician relationships (collegial collaborative teacher-student friendly-stranger and hostileadversarial relationships)

bull Teach staff how to utilize positive relationships and change negative onesbull Training should avoid focusing on negative behaviorsbull Training should focus creating cooperative behaviors

ReferencesAgency for Healthcare Research and Quality (nd) Medical teamwork and patient safety The Donabedian model of patient safety Retrieved

from httpwwwahrqgovqualmedteammedteamfig2htm

American Nurses Association (1980) Nursing A social policy statement Washington DC American Nurses Association

Ballou K amp Landreneau K (2010) The authoritarian reign in American health care Policy Politics amp Nursing Practice 11(1) 71-79

doi1011771527154410372973

Boone B King M Gresham L Wahl P amp Suh E (2008) Conflict management training and nurse-physician collaborative behaviors

Journal For Nurses In Staff Development 24(4) 168-175 doi10109701NND00003206705641591

Burns N amp Grove S (2007) Understanding Nursing Research Building an Evidence Based Practice (4th Ed) St Louis Missouri Saunders

Elsevier Publishing

Ford L (2012) Week 8 amp 9 Critique of Research Retrieved from httpsfsulearnferriseduwebappsportalframesetjsp

tab_tab_group_id=_2_1ampurl=2Fwebapps2Fblackboard2Fexecute2Flauncher3Ftype3DCourseampid3D_2241_1ampurl3D

Gardezi F Lingard L Espin S Whyte S Orser B amp Baker G (2009) Silence power and communication in the operating room

Journal Of Advanced Nursing 65(7) 1390-1399 doi101111j1365-2648200904994x

Hendel T Fish M amp Berger O (2007) Nursephysician conflict management mode choices implications for improved collaborative

practice Nursing Administration Quarterly 31(3) 244-253

John Hopkins UniversityJohn Hopkins Hospital (nd) JHNEBP Research Evidence Appraisal Retrieved from

httpwwwnursingworldorgDocumentVaultNursingPracticeResearch-ToolkitJHNEBP-Research-Evidence-Appraisalpdf

Karanikola M Papathanassoglou E Kalafati M Stathopoulou H Mpouzika M amp Goutsikas C G (2012) Exploration of the

Association Between Professional Interactions and Emotional Distress of Intensive Care Unit Nursing Personnel Dimensions Of Critical

Care Nursing 31(1) 37-45 doi101097DCC0b013e31823a55b8

ReferencesKramer M Schmalenberg C amp Maguire P (2010) Nine structures and leadership practices essential for a magnetic (healthy)

work environment Nursing Administration Quarterly 34(1) 4-17 doi101097NAQ0b013e3181c95ef4

Manojlovich M amp DeCicco B (2007) Healthy work environments nurse-physician communication and patients outcome American Journal Of Critical Care 16(6) 536-543

McCaffrey R Hayes R Cassell A Miller-Reyes S Donaldson A amp Ferrell C (2012) The effect of an educational programme on attitudes of nurses and medical residents towards the benefits of positive communication and collaboration Journal Of Advanced Nursing 68(2) 293-301 doi101111j1365-2648201105736x

Nieswiadomy R M (2012) Foundations of Nursing Research (6th Ed) Upper Saddle River New Jersey Prentice Hall

Rosenstein A amp ODaniel M (2008) A survey of the impact of disruptive behaviors and communication defects on patient safety Joint Commission Journal On Quality amp Patient Safety 34(8) 464-471

Rothstein W amp Hannum S (2007) Profession and gender in relationships between advanced practice nurses and physicians Journal Of Professional Nursing 23(4) 235-240 doi101016jprofnurs200701008

Saxton R Hines T amp Enriquez M (2009) The negative impact of nurse-physician disruptive behavior on patient safety A review of the literature Journal of Patient Safety 5(3) 180-183

Stone P W (2002) Popping the PICO question in research and evidence-based practice Applied Nursing Research 16(2) 197-198

Schmalenberg C amp Kramer M (2009) Nurse-physician relationships in hospitals 20 000 nurses tell their story Critical Care Nurse 29(1) 74-83 doi104037ccn2009436

Zwarenstein M Goldman J amp Reeves S (2009) Interprofessional collaboration Effects of practice-based interventions on professional practice and healthcare outcomes Cochrane Database Of Systematic Reviews (3) 1-31 doi10100214651858CD000072

NURS 350 Evidence-Based Nursing Practice (Group paper plus Group Powerpoint presentation)

Total group grade 100Instructorrsquos comments Excellent paper I think your group

should consider submitting it for publication if you could flesh out the details on improving collaborative communication

• Ferris State University NURS 350 Evidence-Based Nursing Practic
• ldquoCommunication--the human connection--is the key to pers
• Slide 3
• What is patient safety
• What is acute care
• What is Professional Communication
• Communication between medical professionals is not just a local
• PICO Question
• Definitions
• A Survey of the Impacts of Disruptive Behaviors and Communicat
• A Survey of the Impacts of Disruptive Behaviors and Communicat (2)
• Literature Review (Level One Evidence)
• Literature Review (Level Three Evidence)
• Literature Review (Level Four Evidence)
• Literature Review (Level Four Evidence continued)
• Literature Review (Level Six Evidence)
• Analysis of Evidence
• Slide 18
• Slide 19
• Article 1 ldquoConflict management training and nurse-physician
• Article 2 ldquoNine structures and leadership practices essentia
• Slide 22
• Article 3 ldquoThe effect of an educational programme on attitud
• Article 4 ldquoNurse-physician relationships in hospitals 2000
• Percentage of staff nurses responding affirmatively to nurse-ph
• Application of Evidence for oncology nursing practice (Lai Har
• Application of Evidence at the Cardiovascular Department (Marg
• Application of Evidence into the Surgical Setting (Gary Webste
• Slide 29
• Summary Statements
• References
• References (2)
• NURS 350 Evidence-Based Nursing Practice (Group paper plus Gr

Introduction

Every day we have conversations between nurses and doctors What are the outcomes of these conversations both positive and negative for patients and nurses

What is patient safety What is acute care What is professional communication

What is patient safety bull Easily defined as anything that would directly affected the

patientbull Examples with negative consequences on patient safety

language barriers medication errors miscommunication between doctors and nurses

bull Based on the Joint Commission patient safety (deathinjury or medical errors) can be related to segmented communication or relationship between nurses and physicians (Saxton Hines and Enriquez 2009 p 180)

What is acute carebull Taking care of patients who are having a ldquonowrdquo type of medical conditionbull ldquoA pattern of health care in which a patient is treated for a brief but severe

episode of illness for the sequelae of an accident or other trauma or during recovery from surgery Acute care is usually given in a hospital by specialized personnel using complex and sophisticated technical equipment and materials and it may involve intensive or emergency care This pattern of care is often necessary for only a short time unlike chronic carerdquo (Mosbys Medical Dictionary 2009)

What is Professional Communication

Verbal communication is basic conversation of words that people say to one another Simple words or technical jargon Difficult if the nurse or doctor has English as

a second language if the terms in the technical jargon are not shared by either the doctor or nurse

Nonverbal communication is body language and written communication

body language and written communication can be taken positively or negatively

Communication between medical professionals is not just a local problem but is a problem found throughout the entire medical community

PICO Question

For adult patients in an acute care setting what does the literature reveal about the DIFFERENCE in communication styles (collaboration interdisciplinary versus segmented authoritarian) between physicians and nurses on indicators of nurse satisfaction rates and patient safety outcomes

Definitions

bull According to the American Nurses Association ldquocollaborationrdquo is ldquoa true partnership in which the power on both sides is valued by both with recognition and acceptance of separate and combined practice spheres of activity and responsibility mutual safeguarding of the legitimate interests of each party and a commonality of goals that is recognized by both partiesrdquo (Hendel Fish amp Berger 2007 p 251)

bull Ballou and Landreneau (2010) discuss that ldquoauthoritarian persons typify an outlook that is ethnocentric rigid and anti-democraticrdquo (p 71)

bull ldquoSegmentedrdquo ldquodivided into or composed of segments or sectionsrdquo ldquoAuthoritarianrdquo ldquoof relating to or favoring blind submission to authorityrdquo (Merriam-Webster Dictionary 2012)

A Survey of the Impacts of Disruptive Behaviors and Communication Defects on Patient Safety

Sample size N= 4530 From January 2004 to March 2007How often do you think disruptive behavior results in the following at your hospital

(Sometimes Frequent and Constant)

How often do you think that there is a link between disruptive behavior and the following

clinical outcomes at your hospital (Sometimes Frequent and Constant)

Adver

se E

vent

s

Error

s

Patient

Saf

ety

Qualit

y of

Car

e

Patient

Mor

talit

y

6771

51

71

27

Stres

s

Frustra

tion

Loss o

f con

cent

ratio

n

Reduc

ed te

am col

labo

ratio

n

Reduc

ed in

form

atio

n tran

sfer

Reduc

ed com

mun

icat

ion

Impa

ired

RNM

D

94 94

83

8987

91

99

A Survey of the Impacts of Disruptive Behaviors and Communication Defects on Patient Safety

Sample size N= 4530 From January 2004 to March 2007

Have your ever witnessed any disruptive behavior from a physician at your hospital

Have you ever witnessed any disruptive behavior from a nurse at your hospital

Aggre

gate

MD

(ph

ysician)

RN (

nurs

e)

Admin

stra

tive ex

ecut

ives

Other

77

51

88

78

66

Aggre

gate

MD

(ph

ysician)

RN (

nurs

e)

Admin

istra

tive ex

ecut

ives

Other

65

48

7377

64

Literature Review (Level One Evidence)Research Articles

Research Methods

Theoretical frameworksMeasurement Instruments

Samples Data AnalysesStudy Findings

Kramer Schmalenbeg amp Maguire (2010)

Meta-analysis of multiple published studies

Donabedianrsquos conceptual framework of structure process and outcome

Heberlein and Baumgartnerrsquosmethodology

12 publications from 7 professional and regulatory organizations

18 publications from studies using the Essential of Magnetism (including 1300 interviews with nurses physicians and mangers)

positive physician-nurse communication collaborative leadership and autonomy in Magnet hospitals (Kramer et al p 11)

Nursesrsquo autonomous role in identifying patientsrsquo worsening conditions (need to rescueNTR) for reducing the rates of mortality or adverse patient outcomes (Kramer et al p 11)

Schmalenberg amp Kramer (2009)

Review of six research studies

Essentials of Magnetism

Concepts of nurse-physician relationship(collegial collaborative student-teacher friendly stranger hostileadversarial

3602 staff nurses in 16 Magnet and 10 non-Magnet hospitals in the 2003 study

10514 staff nurses in 18 Magnet and 16 non-Magnet hospitals in the 2007 study

In 2003 physician-nurse relationship scores in Magnet hospitals were statistically significant and higher when compared to non-Magnet hospitals (F ratio 21279 P less than 0001)

In 2007 the higher scores in Magnet hospitals were also statistically significant (F ratio 14446 P less than 0001)(Schmalenberg pp 78-79)

Zwarenstein Goldman amp Reeves (2009)

Cochrane Systematic Review

Not specifically mentioned

Five studies about collaborative interventions

interprofessional roundsmeetings

externally facilitated interprofessional audit

no randomized controlled studies about the impacts of interdisciplinary collaboration (Zwarenstein et al p 8)

ldquoProblems with conceptualising and measuring collaborationrdquo No ldquogeneralizable inferences about interprofessional collaborationrdquo (Zwarenstein et al p 2)

Literature Review (Level Three Evidence)

Research Articles

Research Methods

Theoretical frameworksMeasurement Instruments

Samples Data AnalysesStudy Findings

Boone King Gresham Wahl amp Suh (2008)

Quasi-experimental (Pre- and Post- Test for the training in assertiveness and cooperation)

Kilmann and Thomasrsquo model of conflict resolution (accommodating avoidance competition compromise collaboration)

Collaborative Behavior Scale

9 nurses from the cardiovascular laboratory (experimental group) and 18 nurses from the telemetry unit (control group)

Non-probability sampling in an American hospital

No statistical significance for the Collaborative Behavior Scale beforeafter the training between the experimental group and the control group ldquop more than 005rdquo (Boone et al p 172)

the communication style of ldquoavoidancerdquo was associated with increased nursesrsquo emotional stress (Boone et al p 173)

Implication explore barriers before training programs involve physiciansrsquo participations

McCaffrey HayesCassell Miller-Reyes Donaldson amp Ferrell (2012)

Quasi-experimental (Pre- and Post-test for training in communication skills)

Jefferson Scale of Attitudes

68 nurses and 47 medical residents in a Florida hospital

Non-probability sampling

statistical significance (P=0001) of the T-test before and after the 6-month educational program for enhancing physician-nurse collegiality communication skills mutual decision-making processes (McCaffrey et al p 298)

Literature Review (Level Four Evidence)Research Articles

Research Studies

Theoretical Frameworks

Measurement Instruments

Samples Data AnalysesStudy Findings

Hendel Fish amp Berger (2007)

Cross-sectional Correlational study

Thomas-Kilman Model of Conflict Resolution

Conflict Mode Instrument (MODE)

75 physicians 54 charge nurses at 5 acute care hospitals in Israel

Non-probability sampling

charge nurses were more likely to use the ldquocollaboratingrdquo communication style when compared to physicians (P=0001) (Hendel et al p 249)

Karanikola et al (2012)

Descriptive Correlational study

Hamiltonrsquos Anxiety Scale

Stamprsquos Index of Work Satisfaction

2-stage random probability sampling

11 hospitals randomly selected in Greece then 229 nurses at intensive care units randomly selected

Satisfaction in physician communication was statistically significant and negatively associated with intensive care nursesrsquo anxiety level ldquocorrelation coefficient Kendall = -0160 P=0001rdquo and depressed mood ldquocorrelation coefficient = -0148 P=0005rdquo (p 41)

Limitations confounding variables of nursesrsquo personal psychiatric or psychological histories

Manojlovich amp DeCicco (2007)

Descriptive Cross-sectional Non-experimental

Concepts of workplace empowerment ICU Nurse-Physician QuestionnairePractice Environment Scale of the Nursing Work Index

462 nursesrsquo perceptions in 25 intensive care units from 8 Michigan hospitals

Non-probability sampling

statistical significance for the positive correlation of physician-nurse miscommunication to the perceived outcomes in medication errors (p 542)

Limitation not generalized findings not reflect cause-effect relationships

Literature Review (Level Four Evidence continued)

Research Articles

Research Studies

Theoretical Framework

Measurement Instruments

Samples Data AnalysesStudy Findings

Rosenstein amp ODaniel (2008)

Non-experimentalstudy quantitative and qualitative approach

Instrument ldquoNurse-Physician Impact of disruptive Behavior on Patient Carerdquo

Convenience samples 2846 nurses 944 physicians from 102 not-for-profit VHA member hospitals in the US from 2004 to 2007

physician-nurse disturbing behaviors are likely to reduce patient safety outcomes and nurse satisfaction Narrative data eg ldquoafraid to call Drrdquo ldquoget yelled atrdquo ldquopoor communication postoprdquo (Rosenstein amp OrsquoDaniel p 467)

67 respondents perceived that disruptive behaviors were associated with adverse patient outcomes (medical errors and patient mortality) (Rosenstein amp OrsquoDaniel p 464)

Limitation theoretical framework not specifically describedStrength large sample size

Rothsteinamp Hannum (2007)

Cross-sectional

Gender model (male physician dominance and nurse deference)

Professional model

self-reported close-ended questionnaire on nurse-physician relationship

125 advanced practice nursesAPN at a statewide professional conference

non-probability sampling

statistical significance for APNrsquo s positive attitudecommunication with female physicians (less than 50 years old) and male physicians (of all ages) male and female physicians are also likely to be positive and respectful about APNrsquos knowledge in patient care (2-tailed t test and one-way analysis of variance P value less than 005) (Rothstein amp Hannum p 238)

The gender model for the authoritative dominance of male physicians is not applicable to the female APNs who have at least a masterrsquos degree in nursing (p 235)

Limitation confounding variables not measured ldquotype and size of the work organization nurse and physician specialties and patient illness and social characteristicsrdquo (p 239)

Literature Review (Level Six Evidence)

Research

Article

Research Method

Theoretical Framework

Sample Study Findings

Gardezi Lingard Espin Whyte Orser amp Baker (2009)

Qualitative study

Ethnographic approach

Retrospective study

Critical Theory about silence in communication

observed physician-nurse communications over 700 surgeries at 3 acute care hospitals from 2005 to 2007 in Canada

Narrative and descriptive data about conflicts in physician-nurse communication styles at operating rooms due to nursesrsquo gap in knowledge about surgical procedures and surgeonsrsquo dominant authoritative power

Nursesrsquo passivesilent communication method had negative impacts on patient safety during surgeries (Gardezi et al p 1391)

Limitations evidence-based practice cannot be based on one qualitative study

Strengths explore the descriptive lived experiences about physician-nurse communication barriers over 2 years

Analysis of Evidence

The ability to critically analyze evidence presented in various research projects is necessary to evaluate the work for applicability and use in evidence based nursing practice ldquoTo use research evidence one must be able to evaluate this evidencerdquo (Nieswiadomy 2012 p 298)

bull STRENGTH OF EVIDENCEbull LEVEL 1 (HIGHEST)bull EXPERIMENTAL STUDY (RANDOMIZED CONTROLLED TRAIL OR RCT)bull bull Study participants (subjects) are randomly assigned to either a treatment (TX) or

controlbull (non-treatment) groupbull bull May bebull o Blind neither subject nor investigator knows which TX subject is receivingbull o Double-blind neither subject nor investigator knows which TX subject is receivingbull o Non-blind both subject and investigator know which TX subject is receiving usedbull when it is felt that the knowledge of treatment is unimportantbull META-ANALYSIS OF RCTSbull bull Quantitatively synthesizes and analyzes results of multiple primary studies addressing

abull similar research questionbull bull Statistically pools results from independent but combinable studiesbull bull Summary statistic (effect size) is expressed in terms of direction (positive negative

orbull zero) and magnitude (high medium small)

bull LEVEL 2bull QUASI-EXPERIMENTAL STUDYbull bull Always includes manipulation of an independent variablebull bull Lacks either random assignment or control groupbull bull Findings must be considered in light of threats to validity (particularly selection)

bull LEVEL 3bull NON-EXPERIMENTAL STUDYbull bull No manipulation of the independent variablebull bull Can be descriptive comparative or relationalbull bull Often uses secondary databull bull Findings must be considered in light of threats to validity (particularly selection lack

ofbull severity or co-morbidity adjustment)

bull QUALITATIVE STUDYbull 1048707 Explorative in nature such as interviews observations or focus groupsbull 1048707 Starting point for studies of questions for which little research currently existsbull 1048707 Sample sizes are usually small and study results are used to design stronger studies

thatbull are more objective and quantifiable

bull META-SYNTHESISbull 1048707 Research technique that critically analyzes and synthesizes findings from qualitativebull researchbull 1048707 Identifies key concepts and metaphors and determines their relationships to each

otherbull 1048707 Aim is not to produce a summary statistic but rather to interpret and

translate findings

JHNEBP Research Evidence Appraisal

The Johns Hopkins HospitalThe Johns Hopkins University

QUALITY RATING (SCIENTIFIC EVIDENCE)

A High quality consistent results sufficient sample size adequate control and

bull definitive conclusions consistent recommendations based on extensive literature

bull review that includes thoughtful reference to scientific evidence

B Good quality reasonably consistent results sufficient sample size some control

bull and fairly definitive conclusions reasonably consistent recommendations based

bull on fairly comprehensive literature review that includes some reference to

bull scientific evidence

C Low quality or major flaws little evidence with inconsistent results insufficient

bull sample size conclusions cannot be drawn

Article 1 ldquoConflict management training and nurse-physician collaborative behaviorsrdquo(Boone et al 2008)bull Quantitative quasi-experimental designbull The researchers are highly qualified and experiencedbull Convenience sample which closely approximates the real world experiencebull This study is ethically sound as a written explanation of the study was provided and

informed consent was obtainedbull The problem is clearly stated to examine a knowledge gap between a unit specific

intervention (conflict management training) and improved communication and collaboration between physicians and nurses

bull Theoretical framework Kilmann and Thomas conflict resolution theory (Boone et al 2008 p 168)

bull Findings reveal that the intervention was unsuccessful (The null hypothesis not rejected)

bull The importance of continued research for interventions that promote quality communication and collaboration is stressed

bull Creating a culture that values quality communication and collaboration forms the basis for developing a healthy work environment

bull Level of evidence varies by tool used but is evaluated as II or III Both levels are credible for utilization in evidence based care

bull Informed consent was obtained from all participants

Article 2 ldquoNine structures and leadership practices essential for a magnetic (healthy) work environmentrdquo (Kramer et al 2010)

bull This is a quantitative meta-analysis of thirty professional publications bull The problem is clearly stated to identify what structures and leadership

practices are necessary to support a healthy work environmentbull The researchers are experienced and well qualifiedbull The sample size was good Over 1300 interviews of expert nurses nurse

managers and physicians were compiled for comparison to findings from regulatory and professional organizations

bull The theoretical framework is based on the Donabedian model (httpwwwahrqgovqualmedteammedteamfig2htm) of patient safety

bull Healthy work environments lead to improved patient and nurse outcomesbull Creating a culture of interdisciplinary collaboration and teamwork through

shared power and administrative support were important themesbull This is a valid level I for evidence by all methods (course modules interview

with hospital research specialist and Johns Hopkins Nursing Research Evidence Appraisal) Level I is the highest level of evidence for utilization in evidence based practice

Structuresbest leadership practices essential for healthy work environments

Quality leadership at all levels in the organization

Availability of and support for education career performance and competence development

Administrative sanction for autonomous and collaborative practice

Evidence-based practice education and operational supports

Culture practice and opportunity to learn interdisciplinary collaboration

Empowered shared decision-making structures for control of the context of nursing practice

Generation and nurturance of a patient-centered culture

Staffing structures that take into account RN competence patient acuity and teamwork

Development and support of intradisciplinary teamwork

Article 3 ldquoThe effect of an educational programme on attitudes of nurses and medical residents towards the benefit of positive communication and collaborationrdquo(McCaffrey et al 2012)bull This is a quasi-experimental study based on a convenience sample of nurses and

medical residents bull The researchers are experienced and well qualifiedbull The research question is clearly statedbull Ethical research guidelines are carefully adhered tobull A pre and post-test design based on the Jefferson Scale of Attitudes towards

Physician-Nurse Collaboration and the Communication Collaboration and Critical Thinking for Quality Patient Outcomes tools Both tools are proven to be reliable and valid (the Cronbachrsquos alpha coefficient of 087-092)

bull A critical finding in this study is that ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Statistical findings reveal that the chosen intervention of an educational programme to improve physician-nurse communication and collaboration was beneficial

bull This study is evaluated as evidence level III due to lack of a control group by two methods (Ford 2012 C Bongiorno personal communication November 26 2012) Alternatively it is rated as level II on the Johns Hopkins scale (JHNEBP Research Evidence Appraisal nd)

Article 4 ldquoNurse-physician relationships in hospitals 20000 nurses tell their storyrdquo (Schmalenberg amp Kramer 2009)

bull This study is a quantitative synthesis of the findings of six research studies based on the Essentials of Magnetism

bull The researchers are experienced and highly qualifiedbull The purpose of the study is several fold 1) To discern what constitutes quality

communication and collaboration between physicians and nurses 2) Define types of nurse-physician relationships 3) Define organizational structures and leadership practices that help develop collaborative nurse-physician relationships and 4) Study differences in nurse-physician relationships between magnet and comparison hospitals

bull The sample size of 20616 staff nurses is excellentbull Thorough literature review is the foundation for this studybull It was consistently reported that nurses at magnet hospitals reported higher quality

relationships with physicians than the comparison hospitalsbull Structures that improve relationships and are supported by magnet institutions are

keep the patient first develop constructive conflict resolution techniques and have collaborative interdisciplinary patient rounds

bull Nurses can play an active role in bringing about these interventionsbull This is a double blinded peer review of six studies clearly making it evidence level I by

all methods

Percentage of staff nurses responding affirmatively to nurse-physician relationship types by magnet

and comparison hospitals and by period

Application of Evidence for oncology nursing practice (Lai Harper)

bull Utilize the Cochrane Database or the ldquoJHNEBP Research Evidence Appraisalrdquo as the research tools effectively communicate and collaborate with oncologists about the nursing perspective on evidence-based practice

bull Ongoing literature review for the most current credible and high-quality evidence-based practice for reducing oncology patientsrsquo physical psychological and emotional issues (such as pain nausea anxiety or depression)

bull Recommend the hospital nursing research committee to initiate a survey to explore possible physician-nurse communication barriers at an oncology unit

bull Recommend the implementation of the low-cost convenient computer-based training in physician-nurse communication skills

Application of Evidence at the Cardiovascular Department (Margaret Siler)

bull High quality communication and collaboration make a great difference in the cardiac catheterization laboratory (Boone King Gresham Wahl amp Suh 2008 p 168)

bull Experience and a broad knowledge base bring confidence to our daily work (Schmalenberg amp Kramer 2009 p 82)

bull All involved parties (patient nurse physician healthcare system) can reap the benefits of collaborative practice (Kramer et al 2012 p 7)

bull There are many educational opportunities available to improve interdisciplinary and interdepartmental communication Many are quite costly Some that may make the biggest difference are fairly inexpensive including Unit Action Council work and interdepartmental job shadowing (McCaffery et al 2012)

Application of Evidence into the Surgical Setting (Gary Webster)

Intra-operative settings place nurses and physicians in close collaborative work

settings The typical communication style is authoritarian Schmalenberg and

Kramer (2009) stated that physicians felt the nurse-physician relation to be more

collaborative than nurse did I can see that being true in my work environment

The Boone et al (2008) and McCaffrey (2011) articles combined are very

valuable Together the articles show a successful attempt to increase collaboration

and some pitfalls to avoid These can help direct any programs to support an

increase in collaboration

Application of Evidence (Jamie Ziemba)

bull Poor communication between nurses and physicians related to language and cultural barriers

bull Physiciansrsquo dysfunctional or authoritarian communication style (eg instruct nurses not to call at night unless it is a life-and-death emergency) is a major patient safety issue

bull As the patient advocate nurses have an important role of communicating with physicians to verify medication orders clinical procedures and improve patient outcomes

bull Hospital training programs in communication skills and cultural diversities are recommended for physicians and nurses with different culturalethnic backgrounds

Summary Statements

bull Meta-analytical review of evidence-based research articles support the clinical significance of effective communication styles

bull Authoritarian communication styles increase disruptive behaviors and negative hostile relationships at work environments

bull Healthy work environments have positive effects on nurses physicians patients and healthcare organizations

bull Inter-disciplinary collaboration is an essential aspect of healthy work environmentsbull Evidence-based studies have shown positive patient outcomes nursing job

satisfaction collaborative environments at Magnet hospitalsbull There is a need to address the barriers and incorporate educational programs to teach

effective communication and the need for collaboration Educational training should be re-enforced with weekly discussions ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Educate staff on the 5 types of nurse-physician relationships (collegial collaborative teacher-student friendly-stranger and hostileadversarial relationships)

bull Teach staff how to utilize positive relationships and change negative onesbull Training should avoid focusing on negative behaviorsbull Training should focus creating cooperative behaviors

ReferencesAgency for Healthcare Research and Quality (nd) Medical teamwork and patient safety The Donabedian model of patient safety Retrieved

from httpwwwahrqgovqualmedteammedteamfig2htm

American Nurses Association (1980) Nursing A social policy statement Washington DC American Nurses Association

Ballou K amp Landreneau K (2010) The authoritarian reign in American health care Policy Politics amp Nursing Practice 11(1) 71-79

doi1011771527154410372973

Boone B King M Gresham L Wahl P amp Suh E (2008) Conflict management training and nurse-physician collaborative behaviors

Journal For Nurses In Staff Development 24(4) 168-175 doi10109701NND00003206705641591

Burns N amp Grove S (2007) Understanding Nursing Research Building an Evidence Based Practice (4th Ed) St Louis Missouri Saunders

Elsevier Publishing

Ford L (2012) Week 8 amp 9 Critique of Research Retrieved from httpsfsulearnferriseduwebappsportalframesetjsp

tab_tab_group_id=_2_1ampurl=2Fwebapps2Fblackboard2Fexecute2Flauncher3Ftype3DCourseampid3D_2241_1ampurl3D

Gardezi F Lingard L Espin S Whyte S Orser B amp Baker G (2009) Silence power and communication in the operating room

Journal Of Advanced Nursing 65(7) 1390-1399 doi101111j1365-2648200904994x

Hendel T Fish M amp Berger O (2007) Nursephysician conflict management mode choices implications for improved collaborative

practice Nursing Administration Quarterly 31(3) 244-253

John Hopkins UniversityJohn Hopkins Hospital (nd) JHNEBP Research Evidence Appraisal Retrieved from

httpwwwnursingworldorgDocumentVaultNursingPracticeResearch-ToolkitJHNEBP-Research-Evidence-Appraisalpdf

Karanikola M Papathanassoglou E Kalafati M Stathopoulou H Mpouzika M amp Goutsikas C G (2012) Exploration of the

Association Between Professional Interactions and Emotional Distress of Intensive Care Unit Nursing Personnel Dimensions Of Critical

Care Nursing 31(1) 37-45 doi101097DCC0b013e31823a55b8

ReferencesKramer M Schmalenberg C amp Maguire P (2010) Nine structures and leadership practices essential for a magnetic (healthy)

work environment Nursing Administration Quarterly 34(1) 4-17 doi101097NAQ0b013e3181c95ef4

Manojlovich M amp DeCicco B (2007) Healthy work environments nurse-physician communication and patients outcome American Journal Of Critical Care 16(6) 536-543

McCaffrey R Hayes R Cassell A Miller-Reyes S Donaldson A amp Ferrell C (2012) The effect of an educational programme on attitudes of nurses and medical residents towards the benefits of positive communication and collaboration Journal Of Advanced Nursing 68(2) 293-301 doi101111j1365-2648201105736x

Nieswiadomy R M (2012) Foundations of Nursing Research (6th Ed) Upper Saddle River New Jersey Prentice Hall

Rosenstein A amp ODaniel M (2008) A survey of the impact of disruptive behaviors and communication defects on patient safety Joint Commission Journal On Quality amp Patient Safety 34(8) 464-471

Rothstein W amp Hannum S (2007) Profession and gender in relationships between advanced practice nurses and physicians Journal Of Professional Nursing 23(4) 235-240 doi101016jprofnurs200701008

Saxton R Hines T amp Enriquez M (2009) The negative impact of nurse-physician disruptive behavior on patient safety A review of the literature Journal of Patient Safety 5(3) 180-183

Stone P W (2002) Popping the PICO question in research and evidence-based practice Applied Nursing Research 16(2) 197-198

Schmalenberg C amp Kramer M (2009) Nurse-physician relationships in hospitals 20 000 nurses tell their story Critical Care Nurse 29(1) 74-83 doi104037ccn2009436

Zwarenstein M Goldman J amp Reeves S (2009) Interprofessional collaboration Effects of practice-based interventions on professional practice and healthcare outcomes Cochrane Database Of Systematic Reviews (3) 1-31 doi10100214651858CD000072

NURS 350 Evidence-Based Nursing Practice (Group paper plus Group Powerpoint presentation)

Total group grade 100Instructorrsquos comments Excellent paper I think your group

should consider submitting it for publication if you could flesh out the details on improving collaborative communication

• Ferris State University NURS 350 Evidence-Based Nursing Practic
• ldquoCommunication--the human connection--is the key to pers
• Slide 3
• What is patient safety
• What is acute care
• What is Professional Communication
• Communication between medical professionals is not just a local
• PICO Question
• Definitions
• A Survey of the Impacts of Disruptive Behaviors and Communicat
• A Survey of the Impacts of Disruptive Behaviors and Communicat (2)
• Literature Review (Level One Evidence)
• Literature Review (Level Three Evidence)
• Literature Review (Level Four Evidence)
• Literature Review (Level Four Evidence continued)
• Literature Review (Level Six Evidence)
• Analysis of Evidence
• Slide 18
• Slide 19
• Article 1 ldquoConflict management training and nurse-physician
• Article 2 ldquoNine structures and leadership practices essentia
• Slide 22
• Article 3 ldquoThe effect of an educational programme on attitud
• Article 4 ldquoNurse-physician relationships in hospitals 2000
• Percentage of staff nurses responding affirmatively to nurse-ph
• Application of Evidence for oncology nursing practice (Lai Har
• Application of Evidence at the Cardiovascular Department (Marg
• Application of Evidence into the Surgical Setting (Gary Webste
• Slide 29
• Summary Statements
• References
• References (2)
• NURS 350 Evidence-Based Nursing Practice (Group paper plus Gr

What is patient safety bull Easily defined as anything that would directly affected the

patientbull Examples with negative consequences on patient safety

language barriers medication errors miscommunication between doctors and nurses

bull Based on the Joint Commission patient safety (deathinjury or medical errors) can be related to segmented communication or relationship between nurses and physicians (Saxton Hines and Enriquez 2009 p 180)

What is acute carebull Taking care of patients who are having a ldquonowrdquo type of medical conditionbull ldquoA pattern of health care in which a patient is treated for a brief but severe

episode of illness for the sequelae of an accident or other trauma or during recovery from surgery Acute care is usually given in a hospital by specialized personnel using complex and sophisticated technical equipment and materials and it may involve intensive or emergency care This pattern of care is often necessary for only a short time unlike chronic carerdquo (Mosbys Medical Dictionary 2009)

What is Professional Communication

Verbal communication is basic conversation of words that people say to one another Simple words or technical jargon Difficult if the nurse or doctor has English as

a second language if the terms in the technical jargon are not shared by either the doctor or nurse

Nonverbal communication is body language and written communication

body language and written communication can be taken positively or negatively

Communication between medical professionals is not just a local problem but is a problem found throughout the entire medical community

PICO Question

For adult patients in an acute care setting what does the literature reveal about the DIFFERENCE in communication styles (collaboration interdisciplinary versus segmented authoritarian) between physicians and nurses on indicators of nurse satisfaction rates and patient safety outcomes

Definitions

bull According to the American Nurses Association ldquocollaborationrdquo is ldquoa true partnership in which the power on both sides is valued by both with recognition and acceptance of separate and combined practice spheres of activity and responsibility mutual safeguarding of the legitimate interests of each party and a commonality of goals that is recognized by both partiesrdquo (Hendel Fish amp Berger 2007 p 251)

bull Ballou and Landreneau (2010) discuss that ldquoauthoritarian persons typify an outlook that is ethnocentric rigid and anti-democraticrdquo (p 71)

bull ldquoSegmentedrdquo ldquodivided into or composed of segments or sectionsrdquo ldquoAuthoritarianrdquo ldquoof relating to or favoring blind submission to authorityrdquo (Merriam-Webster Dictionary 2012)

A Survey of the Impacts of Disruptive Behaviors and Communication Defects on Patient Safety

Sample size N= 4530 From January 2004 to March 2007How often do you think disruptive behavior results in the following at your hospital

(Sometimes Frequent and Constant)

How often do you think that there is a link between disruptive behavior and the following

clinical outcomes at your hospital (Sometimes Frequent and Constant)

Adver

se E

vent

s

Error

s

Patient

Saf

ety

Qualit

y of

Car

e

Patient

Mor

talit

y

6771

51

71

27

Stres

s

Frustra

tion

Loss o

f con

cent

ratio

n

Reduc

ed te

am col

labo

ratio

n

Reduc

ed in

form

atio

n tran

sfer

Reduc

ed com

mun

icat

ion

Impa

ired

RNM

D

94 94

83

8987

91

99

A Survey of the Impacts of Disruptive Behaviors and Communication Defects on Patient Safety

Sample size N= 4530 From January 2004 to March 2007

Have your ever witnessed any disruptive behavior from a physician at your hospital

Have you ever witnessed any disruptive behavior from a nurse at your hospital

Aggre

gate

MD

(ph

ysician)

RN (

nurs

e)

Admin

stra

tive ex

ecut

ives

Other

77

51

88

78

66

Aggre

gate

MD

(ph

ysician)

RN (

nurs

e)

Admin

istra

tive ex

ecut

ives

Other

65

48

7377

64

Literature Review (Level One Evidence)Research Articles

Research Methods

Theoretical frameworksMeasurement Instruments

Samples Data AnalysesStudy Findings

Kramer Schmalenbeg amp Maguire (2010)

Meta-analysis of multiple published studies

Donabedianrsquos conceptual framework of structure process and outcome

Heberlein and Baumgartnerrsquosmethodology

12 publications from 7 professional and regulatory organizations

18 publications from studies using the Essential of Magnetism (including 1300 interviews with nurses physicians and mangers)

positive physician-nurse communication collaborative leadership and autonomy in Magnet hospitals (Kramer et al p 11)

Nursesrsquo autonomous role in identifying patientsrsquo worsening conditions (need to rescueNTR) for reducing the rates of mortality or adverse patient outcomes (Kramer et al p 11)

Schmalenberg amp Kramer (2009)

Review of six research studies

Essentials of Magnetism

Concepts of nurse-physician relationship(collegial collaborative student-teacher friendly stranger hostileadversarial

3602 staff nurses in 16 Magnet and 10 non-Magnet hospitals in the 2003 study

10514 staff nurses in 18 Magnet and 16 non-Magnet hospitals in the 2007 study

In 2003 physician-nurse relationship scores in Magnet hospitals were statistically significant and higher when compared to non-Magnet hospitals (F ratio 21279 P less than 0001)

In 2007 the higher scores in Magnet hospitals were also statistically significant (F ratio 14446 P less than 0001)(Schmalenberg pp 78-79)

Zwarenstein Goldman amp Reeves (2009)

Cochrane Systematic Review

Not specifically mentioned

Five studies about collaborative interventions

interprofessional roundsmeetings

externally facilitated interprofessional audit

no randomized controlled studies about the impacts of interdisciplinary collaboration (Zwarenstein et al p 8)

ldquoProblems with conceptualising and measuring collaborationrdquo No ldquogeneralizable inferences about interprofessional collaborationrdquo (Zwarenstein et al p 2)

Literature Review (Level Three Evidence)

Research Articles

Research Methods

Theoretical frameworksMeasurement Instruments

Samples Data AnalysesStudy Findings

Boone King Gresham Wahl amp Suh (2008)

Quasi-experimental (Pre- and Post- Test for the training in assertiveness and cooperation)

Kilmann and Thomasrsquo model of conflict resolution (accommodating avoidance competition compromise collaboration)

Collaborative Behavior Scale

9 nurses from the cardiovascular laboratory (experimental group) and 18 nurses from the telemetry unit (control group)

Non-probability sampling in an American hospital

No statistical significance for the Collaborative Behavior Scale beforeafter the training between the experimental group and the control group ldquop more than 005rdquo (Boone et al p 172)

the communication style of ldquoavoidancerdquo was associated with increased nursesrsquo emotional stress (Boone et al p 173)

Implication explore barriers before training programs involve physiciansrsquo participations

McCaffrey HayesCassell Miller-Reyes Donaldson amp Ferrell (2012)

Quasi-experimental (Pre- and Post-test for training in communication skills)

Jefferson Scale of Attitudes

68 nurses and 47 medical residents in a Florida hospital

Non-probability sampling

statistical significance (P=0001) of the T-test before and after the 6-month educational program for enhancing physician-nurse collegiality communication skills mutual decision-making processes (McCaffrey et al p 298)

Literature Review (Level Four Evidence)Research Articles

Research Studies

Theoretical Frameworks

Measurement Instruments

Samples Data AnalysesStudy Findings

Hendel Fish amp Berger (2007)

Cross-sectional Correlational study

Thomas-Kilman Model of Conflict Resolution

Conflict Mode Instrument (MODE)

75 physicians 54 charge nurses at 5 acute care hospitals in Israel

Non-probability sampling

charge nurses were more likely to use the ldquocollaboratingrdquo communication style when compared to physicians (P=0001) (Hendel et al p 249)

Karanikola et al (2012)

Descriptive Correlational study

Hamiltonrsquos Anxiety Scale

Stamprsquos Index of Work Satisfaction

2-stage random probability sampling

11 hospitals randomly selected in Greece then 229 nurses at intensive care units randomly selected

Satisfaction in physician communication was statistically significant and negatively associated with intensive care nursesrsquo anxiety level ldquocorrelation coefficient Kendall = -0160 P=0001rdquo and depressed mood ldquocorrelation coefficient = -0148 P=0005rdquo (p 41)

Limitations confounding variables of nursesrsquo personal psychiatric or psychological histories

Manojlovich amp DeCicco (2007)

Descriptive Cross-sectional Non-experimental

Concepts of workplace empowerment ICU Nurse-Physician QuestionnairePractice Environment Scale of the Nursing Work Index

462 nursesrsquo perceptions in 25 intensive care units from 8 Michigan hospitals

Non-probability sampling

statistical significance for the positive correlation of physician-nurse miscommunication to the perceived outcomes in medication errors (p 542)

Limitation not generalized findings not reflect cause-effect relationships

Literature Review (Level Four Evidence continued)

Research Articles

Research Studies

Theoretical Framework

Measurement Instruments

Samples Data AnalysesStudy Findings

Rosenstein amp ODaniel (2008)

Non-experimentalstudy quantitative and qualitative approach

Instrument ldquoNurse-Physician Impact of disruptive Behavior on Patient Carerdquo

Convenience samples 2846 nurses 944 physicians from 102 not-for-profit VHA member hospitals in the US from 2004 to 2007

physician-nurse disturbing behaviors are likely to reduce patient safety outcomes and nurse satisfaction Narrative data eg ldquoafraid to call Drrdquo ldquoget yelled atrdquo ldquopoor communication postoprdquo (Rosenstein amp OrsquoDaniel p 467)

67 respondents perceived that disruptive behaviors were associated with adverse patient outcomes (medical errors and patient mortality) (Rosenstein amp OrsquoDaniel p 464)

Limitation theoretical framework not specifically describedStrength large sample size

Rothsteinamp Hannum (2007)

Cross-sectional

Gender model (male physician dominance and nurse deference)

Professional model

self-reported close-ended questionnaire on nurse-physician relationship

125 advanced practice nursesAPN at a statewide professional conference

non-probability sampling

statistical significance for APNrsquo s positive attitudecommunication with female physicians (less than 50 years old) and male physicians (of all ages) male and female physicians are also likely to be positive and respectful about APNrsquos knowledge in patient care (2-tailed t test and one-way analysis of variance P value less than 005) (Rothstein amp Hannum p 238)

The gender model for the authoritative dominance of male physicians is not applicable to the female APNs who have at least a masterrsquos degree in nursing (p 235)

Limitation confounding variables not measured ldquotype and size of the work organization nurse and physician specialties and patient illness and social characteristicsrdquo (p 239)

Literature Review (Level Six Evidence)

Research

Article

Research Method

Theoretical Framework

Sample Study Findings

Gardezi Lingard Espin Whyte Orser amp Baker (2009)

Qualitative study

Ethnographic approach

Retrospective study

Critical Theory about silence in communication

observed physician-nurse communications over 700 surgeries at 3 acute care hospitals from 2005 to 2007 in Canada

Narrative and descriptive data about conflicts in physician-nurse communication styles at operating rooms due to nursesrsquo gap in knowledge about surgical procedures and surgeonsrsquo dominant authoritative power

Nursesrsquo passivesilent communication method had negative impacts on patient safety during surgeries (Gardezi et al p 1391)

Limitations evidence-based practice cannot be based on one qualitative study

Strengths explore the descriptive lived experiences about physician-nurse communication barriers over 2 years

Analysis of Evidence

The ability to critically analyze evidence presented in various research projects is necessary to evaluate the work for applicability and use in evidence based nursing practice ldquoTo use research evidence one must be able to evaluate this evidencerdquo (Nieswiadomy 2012 p 298)

bull STRENGTH OF EVIDENCEbull LEVEL 1 (HIGHEST)bull EXPERIMENTAL STUDY (RANDOMIZED CONTROLLED TRAIL OR RCT)bull bull Study participants (subjects) are randomly assigned to either a treatment (TX) or

controlbull (non-treatment) groupbull bull May bebull o Blind neither subject nor investigator knows which TX subject is receivingbull o Double-blind neither subject nor investigator knows which TX subject is receivingbull o Non-blind both subject and investigator know which TX subject is receiving usedbull when it is felt that the knowledge of treatment is unimportantbull META-ANALYSIS OF RCTSbull bull Quantitatively synthesizes and analyzes results of multiple primary studies addressing

abull similar research questionbull bull Statistically pools results from independent but combinable studiesbull bull Summary statistic (effect size) is expressed in terms of direction (positive negative

orbull zero) and magnitude (high medium small)

bull LEVEL 2bull QUASI-EXPERIMENTAL STUDYbull bull Always includes manipulation of an independent variablebull bull Lacks either random assignment or control groupbull bull Findings must be considered in light of threats to validity (particularly selection)

bull LEVEL 3bull NON-EXPERIMENTAL STUDYbull bull No manipulation of the independent variablebull bull Can be descriptive comparative or relationalbull bull Often uses secondary databull bull Findings must be considered in light of threats to validity (particularly selection lack

ofbull severity or co-morbidity adjustment)

bull QUALITATIVE STUDYbull 1048707 Explorative in nature such as interviews observations or focus groupsbull 1048707 Starting point for studies of questions for which little research currently existsbull 1048707 Sample sizes are usually small and study results are used to design stronger studies

thatbull are more objective and quantifiable

bull META-SYNTHESISbull 1048707 Research technique that critically analyzes and synthesizes findings from qualitativebull researchbull 1048707 Identifies key concepts and metaphors and determines their relationships to each

otherbull 1048707 Aim is not to produce a summary statistic but rather to interpret and

translate findings

JHNEBP Research Evidence Appraisal

The Johns Hopkins HospitalThe Johns Hopkins University

QUALITY RATING (SCIENTIFIC EVIDENCE)

A High quality consistent results sufficient sample size adequate control and

bull definitive conclusions consistent recommendations based on extensive literature

bull review that includes thoughtful reference to scientific evidence

B Good quality reasonably consistent results sufficient sample size some control

bull and fairly definitive conclusions reasonably consistent recommendations based

bull on fairly comprehensive literature review that includes some reference to

bull scientific evidence

C Low quality or major flaws little evidence with inconsistent results insufficient

bull sample size conclusions cannot be drawn

Article 1 ldquoConflict management training and nurse-physician collaborative behaviorsrdquo(Boone et al 2008)bull Quantitative quasi-experimental designbull The researchers are highly qualified and experiencedbull Convenience sample which closely approximates the real world experiencebull This study is ethically sound as a written explanation of the study was provided and

informed consent was obtainedbull The problem is clearly stated to examine a knowledge gap between a unit specific

intervention (conflict management training) and improved communication and collaboration between physicians and nurses

bull Theoretical framework Kilmann and Thomas conflict resolution theory (Boone et al 2008 p 168)

bull Findings reveal that the intervention was unsuccessful (The null hypothesis not rejected)

bull The importance of continued research for interventions that promote quality communication and collaboration is stressed

bull Creating a culture that values quality communication and collaboration forms the basis for developing a healthy work environment

bull Level of evidence varies by tool used but is evaluated as II or III Both levels are credible for utilization in evidence based care

bull Informed consent was obtained from all participants

Article 2 ldquoNine structures and leadership practices essential for a magnetic (healthy) work environmentrdquo (Kramer et al 2010)

bull This is a quantitative meta-analysis of thirty professional publications bull The problem is clearly stated to identify what structures and leadership

practices are necessary to support a healthy work environmentbull The researchers are experienced and well qualifiedbull The sample size was good Over 1300 interviews of expert nurses nurse

managers and physicians were compiled for comparison to findings from regulatory and professional organizations

bull The theoretical framework is based on the Donabedian model (httpwwwahrqgovqualmedteammedteamfig2htm) of patient safety

bull Healthy work environments lead to improved patient and nurse outcomesbull Creating a culture of interdisciplinary collaboration and teamwork through

shared power and administrative support were important themesbull This is a valid level I for evidence by all methods (course modules interview

with hospital research specialist and Johns Hopkins Nursing Research Evidence Appraisal) Level I is the highest level of evidence for utilization in evidence based practice

Structuresbest leadership practices essential for healthy work environments

Quality leadership at all levels in the organization

Availability of and support for education career performance and competence development

Administrative sanction for autonomous and collaborative practice

Evidence-based practice education and operational supports

Culture practice and opportunity to learn interdisciplinary collaboration

Empowered shared decision-making structures for control of the context of nursing practice

Generation and nurturance of a patient-centered culture

Staffing structures that take into account RN competence patient acuity and teamwork

Development and support of intradisciplinary teamwork

Article 3 ldquoThe effect of an educational programme on attitudes of nurses and medical residents towards the benefit of positive communication and collaborationrdquo(McCaffrey et al 2012)bull This is a quasi-experimental study based on a convenience sample of nurses and

medical residents bull The researchers are experienced and well qualifiedbull The research question is clearly statedbull Ethical research guidelines are carefully adhered tobull A pre and post-test design based on the Jefferson Scale of Attitudes towards

Physician-Nurse Collaboration and the Communication Collaboration and Critical Thinking for Quality Patient Outcomes tools Both tools are proven to be reliable and valid (the Cronbachrsquos alpha coefficient of 087-092)

bull A critical finding in this study is that ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Statistical findings reveal that the chosen intervention of an educational programme to improve physician-nurse communication and collaboration was beneficial

bull This study is evaluated as evidence level III due to lack of a control group by two methods (Ford 2012 C Bongiorno personal communication November 26 2012) Alternatively it is rated as level II on the Johns Hopkins scale (JHNEBP Research Evidence Appraisal nd)

Article 4 ldquoNurse-physician relationships in hospitals 20000 nurses tell their storyrdquo (Schmalenberg amp Kramer 2009)

bull This study is a quantitative synthesis of the findings of six research studies based on the Essentials of Magnetism

bull The researchers are experienced and highly qualifiedbull The purpose of the study is several fold 1) To discern what constitutes quality

communication and collaboration between physicians and nurses 2) Define types of nurse-physician relationships 3) Define organizational structures and leadership practices that help develop collaborative nurse-physician relationships and 4) Study differences in nurse-physician relationships between magnet and comparison hospitals

bull The sample size of 20616 staff nurses is excellentbull Thorough literature review is the foundation for this studybull It was consistently reported that nurses at magnet hospitals reported higher quality

relationships with physicians than the comparison hospitalsbull Structures that improve relationships and are supported by magnet institutions are

keep the patient first develop constructive conflict resolution techniques and have collaborative interdisciplinary patient rounds

bull Nurses can play an active role in bringing about these interventionsbull This is a double blinded peer review of six studies clearly making it evidence level I by

all methods

Percentage of staff nurses responding affirmatively to nurse-physician relationship types by magnet

and comparison hospitals and by period

Application of Evidence for oncology nursing practice (Lai Harper)

bull Utilize the Cochrane Database or the ldquoJHNEBP Research Evidence Appraisalrdquo as the research tools effectively communicate and collaborate with oncologists about the nursing perspective on evidence-based practice

bull Ongoing literature review for the most current credible and high-quality evidence-based practice for reducing oncology patientsrsquo physical psychological and emotional issues (such as pain nausea anxiety or depression)

bull Recommend the hospital nursing research committee to initiate a survey to explore possible physician-nurse communication barriers at an oncology unit

bull Recommend the implementation of the low-cost convenient computer-based training in physician-nurse communication skills

Application of Evidence at the Cardiovascular Department (Margaret Siler)

bull High quality communication and collaboration make a great difference in the cardiac catheterization laboratory (Boone King Gresham Wahl amp Suh 2008 p 168)

bull Experience and a broad knowledge base bring confidence to our daily work (Schmalenberg amp Kramer 2009 p 82)

bull All involved parties (patient nurse physician healthcare system) can reap the benefits of collaborative practice (Kramer et al 2012 p 7)

bull There are many educational opportunities available to improve interdisciplinary and interdepartmental communication Many are quite costly Some that may make the biggest difference are fairly inexpensive including Unit Action Council work and interdepartmental job shadowing (McCaffery et al 2012)

Application of Evidence into the Surgical Setting (Gary Webster)

Intra-operative settings place nurses and physicians in close collaborative work

settings The typical communication style is authoritarian Schmalenberg and

Kramer (2009) stated that physicians felt the nurse-physician relation to be more

collaborative than nurse did I can see that being true in my work environment

The Boone et al (2008) and McCaffrey (2011) articles combined are very

valuable Together the articles show a successful attempt to increase collaboration

and some pitfalls to avoid These can help direct any programs to support an

increase in collaboration

Application of Evidence (Jamie Ziemba)

bull Poor communication between nurses and physicians related to language and cultural barriers

bull Physiciansrsquo dysfunctional or authoritarian communication style (eg instruct nurses not to call at night unless it is a life-and-death emergency) is a major patient safety issue

bull As the patient advocate nurses have an important role of communicating with physicians to verify medication orders clinical procedures and improve patient outcomes

bull Hospital training programs in communication skills and cultural diversities are recommended for physicians and nurses with different culturalethnic backgrounds

Summary Statements

bull Meta-analytical review of evidence-based research articles support the clinical significance of effective communication styles

bull Authoritarian communication styles increase disruptive behaviors and negative hostile relationships at work environments

bull Healthy work environments have positive effects on nurses physicians patients and healthcare organizations

bull Inter-disciplinary collaboration is an essential aspect of healthy work environmentsbull Evidence-based studies have shown positive patient outcomes nursing job

satisfaction collaborative environments at Magnet hospitalsbull There is a need to address the barriers and incorporate educational programs to teach

effective communication and the need for collaboration Educational training should be re-enforced with weekly discussions ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Educate staff on the 5 types of nurse-physician relationships (collegial collaborative teacher-student friendly-stranger and hostileadversarial relationships)

bull Teach staff how to utilize positive relationships and change negative onesbull Training should avoid focusing on negative behaviorsbull Training should focus creating cooperative behaviors

ReferencesAgency for Healthcare Research and Quality (nd) Medical teamwork and patient safety The Donabedian model of patient safety Retrieved

from httpwwwahrqgovqualmedteammedteamfig2htm

American Nurses Association (1980) Nursing A social policy statement Washington DC American Nurses Association

Ballou K amp Landreneau K (2010) The authoritarian reign in American health care Policy Politics amp Nursing Practice 11(1) 71-79

doi1011771527154410372973

Boone B King M Gresham L Wahl P amp Suh E (2008) Conflict management training and nurse-physician collaborative behaviors

Journal For Nurses In Staff Development 24(4) 168-175 doi10109701NND00003206705641591

Burns N amp Grove S (2007) Understanding Nursing Research Building an Evidence Based Practice (4th Ed) St Louis Missouri Saunders

Elsevier Publishing

Ford L (2012) Week 8 amp 9 Critique of Research Retrieved from httpsfsulearnferriseduwebappsportalframesetjsp

tab_tab_group_id=_2_1ampurl=2Fwebapps2Fblackboard2Fexecute2Flauncher3Ftype3DCourseampid3D_2241_1ampurl3D

Gardezi F Lingard L Espin S Whyte S Orser B amp Baker G (2009) Silence power and communication in the operating room

Journal Of Advanced Nursing 65(7) 1390-1399 doi101111j1365-2648200904994x

Hendel T Fish M amp Berger O (2007) Nursephysician conflict management mode choices implications for improved collaborative

practice Nursing Administration Quarterly 31(3) 244-253

John Hopkins UniversityJohn Hopkins Hospital (nd) JHNEBP Research Evidence Appraisal Retrieved from

httpwwwnursingworldorgDocumentVaultNursingPracticeResearch-ToolkitJHNEBP-Research-Evidence-Appraisalpdf

Karanikola M Papathanassoglou E Kalafati M Stathopoulou H Mpouzika M amp Goutsikas C G (2012) Exploration of the

Association Between Professional Interactions and Emotional Distress of Intensive Care Unit Nursing Personnel Dimensions Of Critical

Care Nursing 31(1) 37-45 doi101097DCC0b013e31823a55b8

ReferencesKramer M Schmalenberg C amp Maguire P (2010) Nine structures and leadership practices essential for a magnetic (healthy)

work environment Nursing Administration Quarterly 34(1) 4-17 doi101097NAQ0b013e3181c95ef4

Manojlovich M amp DeCicco B (2007) Healthy work environments nurse-physician communication and patients outcome American Journal Of Critical Care 16(6) 536-543

McCaffrey R Hayes R Cassell A Miller-Reyes S Donaldson A amp Ferrell C (2012) The effect of an educational programme on attitudes of nurses and medical residents towards the benefits of positive communication and collaboration Journal Of Advanced Nursing 68(2) 293-301 doi101111j1365-2648201105736x

Nieswiadomy R M (2012) Foundations of Nursing Research (6th Ed) Upper Saddle River New Jersey Prentice Hall

Rosenstein A amp ODaniel M (2008) A survey of the impact of disruptive behaviors and communication defects on patient safety Joint Commission Journal On Quality amp Patient Safety 34(8) 464-471

Rothstein W amp Hannum S (2007) Profession and gender in relationships between advanced practice nurses and physicians Journal Of Professional Nursing 23(4) 235-240 doi101016jprofnurs200701008

Saxton R Hines T amp Enriquez M (2009) The negative impact of nurse-physician disruptive behavior on patient safety A review of the literature Journal of Patient Safety 5(3) 180-183

Stone P W (2002) Popping the PICO question in research and evidence-based practice Applied Nursing Research 16(2) 197-198

Schmalenberg C amp Kramer M (2009) Nurse-physician relationships in hospitals 20 000 nurses tell their story Critical Care Nurse 29(1) 74-83 doi104037ccn2009436

Zwarenstein M Goldman J amp Reeves S (2009) Interprofessional collaboration Effects of practice-based interventions on professional practice and healthcare outcomes Cochrane Database Of Systematic Reviews (3) 1-31 doi10100214651858CD000072

NURS 350 Evidence-Based Nursing Practice (Group paper plus Group Powerpoint presentation)

Total group grade 100Instructorrsquos comments Excellent paper I think your group

should consider submitting it for publication if you could flesh out the details on improving collaborative communication

• Ferris State University NURS 350 Evidence-Based Nursing Practic
• ldquoCommunication--the human connection--is the key to pers
• Slide 3
• What is patient safety
• What is acute care
• What is Professional Communication
• Communication between medical professionals is not just a local
• PICO Question
• Definitions
• A Survey of the Impacts of Disruptive Behaviors and Communicat
• A Survey of the Impacts of Disruptive Behaviors and Communicat (2)
• Literature Review (Level One Evidence)
• Literature Review (Level Three Evidence)
• Literature Review (Level Four Evidence)
• Literature Review (Level Four Evidence continued)
• Literature Review (Level Six Evidence)
• Analysis of Evidence
• Slide 18
• Slide 19
• Article 1 ldquoConflict management training and nurse-physician
• Article 2 ldquoNine structures and leadership practices essentia
• Slide 22
• Article 3 ldquoThe effect of an educational programme on attitud
• Article 4 ldquoNurse-physician relationships in hospitals 2000
• Percentage of staff nurses responding affirmatively to nurse-ph
• Application of Evidence for oncology nursing practice (Lai Har
• Application of Evidence at the Cardiovascular Department (Marg
• Application of Evidence into the Surgical Setting (Gary Webste
• Slide 29
• Summary Statements
• References
• References (2)
• NURS 350 Evidence-Based Nursing Practice (Group paper plus Gr

What is acute carebull Taking care of patients who are having a ldquonowrdquo type of medical conditionbull ldquoA pattern of health care in which a patient is treated for a brief but severe

episode of illness for the sequelae of an accident or other trauma or during recovery from surgery Acute care is usually given in a hospital by specialized personnel using complex and sophisticated technical equipment and materials and it may involve intensive or emergency care This pattern of care is often necessary for only a short time unlike chronic carerdquo (Mosbys Medical Dictionary 2009)

What is Professional Communication

Verbal communication is basic conversation of words that people say to one another Simple words or technical jargon Difficult if the nurse or doctor has English as

a second language if the terms in the technical jargon are not shared by either the doctor or nurse

Nonverbal communication is body language and written communication

body language and written communication can be taken positively or negatively

Communication between medical professionals is not just a local problem but is a problem found throughout the entire medical community

PICO Question

For adult patients in an acute care setting what does the literature reveal about the DIFFERENCE in communication styles (collaboration interdisciplinary versus segmented authoritarian) between physicians and nurses on indicators of nurse satisfaction rates and patient safety outcomes

Definitions

bull According to the American Nurses Association ldquocollaborationrdquo is ldquoa true partnership in which the power on both sides is valued by both with recognition and acceptance of separate and combined practice spheres of activity and responsibility mutual safeguarding of the legitimate interests of each party and a commonality of goals that is recognized by both partiesrdquo (Hendel Fish amp Berger 2007 p 251)

bull Ballou and Landreneau (2010) discuss that ldquoauthoritarian persons typify an outlook that is ethnocentric rigid and anti-democraticrdquo (p 71)

bull ldquoSegmentedrdquo ldquodivided into or composed of segments or sectionsrdquo ldquoAuthoritarianrdquo ldquoof relating to or favoring blind submission to authorityrdquo (Merriam-Webster Dictionary 2012)

A Survey of the Impacts of Disruptive Behaviors and Communication Defects on Patient Safety

Sample size N= 4530 From January 2004 to March 2007How often do you think disruptive behavior results in the following at your hospital

(Sometimes Frequent and Constant)

How often do you think that there is a link between disruptive behavior and the following

clinical outcomes at your hospital (Sometimes Frequent and Constant)

Adver

se E

vent

s

Error

s

Patient

Saf

ety

Qualit

y of

Car

e

Patient

Mor

talit

y

6771

51

71

27

Stres

s

Frustra

tion

Loss o

f con

cent

ratio

n

Reduc

ed te

am col

labo

ratio

n

Reduc

ed in

form

atio

n tran

sfer

Reduc

ed com

mun

icat

ion

Impa

ired

RNM

D

94 94

83

8987

91

99

A Survey of the Impacts of Disruptive Behaviors and Communication Defects on Patient Safety

Sample size N= 4530 From January 2004 to March 2007

Have your ever witnessed any disruptive behavior from a physician at your hospital

Have you ever witnessed any disruptive behavior from a nurse at your hospital

Aggre

gate

MD

(ph

ysician)

RN (

nurs

e)

Admin

stra

tive ex

ecut

ives

Other

77

51

88

78

66

Aggre

gate

MD

(ph

ysician)

RN (

nurs

e)

Admin

istra

tive ex

ecut

ives

Other

65

48

7377

64

Literature Review (Level One Evidence)Research Articles

Research Methods

Theoretical frameworksMeasurement Instruments

Samples Data AnalysesStudy Findings

Kramer Schmalenbeg amp Maguire (2010)

Meta-analysis of multiple published studies

Donabedianrsquos conceptual framework of structure process and outcome

Heberlein and Baumgartnerrsquosmethodology

12 publications from 7 professional and regulatory organizations

18 publications from studies using the Essential of Magnetism (including 1300 interviews with nurses physicians and mangers)

positive physician-nurse communication collaborative leadership and autonomy in Magnet hospitals (Kramer et al p 11)

Nursesrsquo autonomous role in identifying patientsrsquo worsening conditions (need to rescueNTR) for reducing the rates of mortality or adverse patient outcomes (Kramer et al p 11)

Schmalenberg amp Kramer (2009)

Review of six research studies

Essentials of Magnetism

Concepts of nurse-physician relationship(collegial collaborative student-teacher friendly stranger hostileadversarial

3602 staff nurses in 16 Magnet and 10 non-Magnet hospitals in the 2003 study

10514 staff nurses in 18 Magnet and 16 non-Magnet hospitals in the 2007 study

In 2003 physician-nurse relationship scores in Magnet hospitals were statistically significant and higher when compared to non-Magnet hospitals (F ratio 21279 P less than 0001)

In 2007 the higher scores in Magnet hospitals were also statistically significant (F ratio 14446 P less than 0001)(Schmalenberg pp 78-79)

Zwarenstein Goldman amp Reeves (2009)

Cochrane Systematic Review

Not specifically mentioned

Five studies about collaborative interventions

interprofessional roundsmeetings

externally facilitated interprofessional audit

no randomized controlled studies about the impacts of interdisciplinary collaboration (Zwarenstein et al p 8)

ldquoProblems with conceptualising and measuring collaborationrdquo No ldquogeneralizable inferences about interprofessional collaborationrdquo (Zwarenstein et al p 2)

Literature Review (Level Three Evidence)

Research Articles

Research Methods

Theoretical frameworksMeasurement Instruments

Samples Data AnalysesStudy Findings

Boone King Gresham Wahl amp Suh (2008)

Quasi-experimental (Pre- and Post- Test for the training in assertiveness and cooperation)

Kilmann and Thomasrsquo model of conflict resolution (accommodating avoidance competition compromise collaboration)

Collaborative Behavior Scale

9 nurses from the cardiovascular laboratory (experimental group) and 18 nurses from the telemetry unit (control group)

Non-probability sampling in an American hospital

No statistical significance for the Collaborative Behavior Scale beforeafter the training between the experimental group and the control group ldquop more than 005rdquo (Boone et al p 172)

the communication style of ldquoavoidancerdquo was associated with increased nursesrsquo emotional stress (Boone et al p 173)

Implication explore barriers before training programs involve physiciansrsquo participations

McCaffrey HayesCassell Miller-Reyes Donaldson amp Ferrell (2012)

Quasi-experimental (Pre- and Post-test for training in communication skills)

Jefferson Scale of Attitudes

68 nurses and 47 medical residents in a Florida hospital

Non-probability sampling

statistical significance (P=0001) of the T-test before and after the 6-month educational program for enhancing physician-nurse collegiality communication skills mutual decision-making processes (McCaffrey et al p 298)

Literature Review (Level Four Evidence)Research Articles

Research Studies

Theoretical Frameworks

Measurement Instruments

Samples Data AnalysesStudy Findings

Hendel Fish amp Berger (2007)

Cross-sectional Correlational study

Thomas-Kilman Model of Conflict Resolution

Conflict Mode Instrument (MODE)

75 physicians 54 charge nurses at 5 acute care hospitals in Israel

Non-probability sampling

charge nurses were more likely to use the ldquocollaboratingrdquo communication style when compared to physicians (P=0001) (Hendel et al p 249)

Karanikola et al (2012)

Descriptive Correlational study

Hamiltonrsquos Anxiety Scale

Stamprsquos Index of Work Satisfaction

2-stage random probability sampling

11 hospitals randomly selected in Greece then 229 nurses at intensive care units randomly selected

Satisfaction in physician communication was statistically significant and negatively associated with intensive care nursesrsquo anxiety level ldquocorrelation coefficient Kendall = -0160 P=0001rdquo and depressed mood ldquocorrelation coefficient = -0148 P=0005rdquo (p 41)

Limitations confounding variables of nursesrsquo personal psychiatric or psychological histories

Manojlovich amp DeCicco (2007)

Descriptive Cross-sectional Non-experimental

Concepts of workplace empowerment ICU Nurse-Physician QuestionnairePractice Environment Scale of the Nursing Work Index

462 nursesrsquo perceptions in 25 intensive care units from 8 Michigan hospitals

Non-probability sampling

statistical significance for the positive correlation of physician-nurse miscommunication to the perceived outcomes in medication errors (p 542)

Limitation not generalized findings not reflect cause-effect relationships

Literature Review (Level Four Evidence continued)

Research Articles

Research Studies

Theoretical Framework

Measurement Instruments

Samples Data AnalysesStudy Findings

Rosenstein amp ODaniel (2008)

Non-experimentalstudy quantitative and qualitative approach

Instrument ldquoNurse-Physician Impact of disruptive Behavior on Patient Carerdquo

Convenience samples 2846 nurses 944 physicians from 102 not-for-profit VHA member hospitals in the US from 2004 to 2007

physician-nurse disturbing behaviors are likely to reduce patient safety outcomes and nurse satisfaction Narrative data eg ldquoafraid to call Drrdquo ldquoget yelled atrdquo ldquopoor communication postoprdquo (Rosenstein amp OrsquoDaniel p 467)

67 respondents perceived that disruptive behaviors were associated with adverse patient outcomes (medical errors and patient mortality) (Rosenstein amp OrsquoDaniel p 464)

Limitation theoretical framework not specifically describedStrength large sample size

Rothsteinamp Hannum (2007)

Cross-sectional

Gender model (male physician dominance and nurse deference)

Professional model

self-reported close-ended questionnaire on nurse-physician relationship

125 advanced practice nursesAPN at a statewide professional conference

non-probability sampling

statistical significance for APNrsquo s positive attitudecommunication with female physicians (less than 50 years old) and male physicians (of all ages) male and female physicians are also likely to be positive and respectful about APNrsquos knowledge in patient care (2-tailed t test and one-way analysis of variance P value less than 005) (Rothstein amp Hannum p 238)

The gender model for the authoritative dominance of male physicians is not applicable to the female APNs who have at least a masterrsquos degree in nursing (p 235)

Limitation confounding variables not measured ldquotype and size of the work organization nurse and physician specialties and patient illness and social characteristicsrdquo (p 239)

Literature Review (Level Six Evidence)

Research

Article

Research Method

Theoretical Framework

Sample Study Findings

Gardezi Lingard Espin Whyte Orser amp Baker (2009)

Qualitative study

Ethnographic approach

Retrospective study

Critical Theory about silence in communication

observed physician-nurse communications over 700 surgeries at 3 acute care hospitals from 2005 to 2007 in Canada

Narrative and descriptive data about conflicts in physician-nurse communication styles at operating rooms due to nursesrsquo gap in knowledge about surgical procedures and surgeonsrsquo dominant authoritative power

Nursesrsquo passivesilent communication method had negative impacts on patient safety during surgeries (Gardezi et al p 1391)

Limitations evidence-based practice cannot be based on one qualitative study

Strengths explore the descriptive lived experiences about physician-nurse communication barriers over 2 years

Analysis of Evidence

The ability to critically analyze evidence presented in various research projects is necessary to evaluate the work for applicability and use in evidence based nursing practice ldquoTo use research evidence one must be able to evaluate this evidencerdquo (Nieswiadomy 2012 p 298)

bull STRENGTH OF EVIDENCEbull LEVEL 1 (HIGHEST)bull EXPERIMENTAL STUDY (RANDOMIZED CONTROLLED TRAIL OR RCT)bull bull Study participants (subjects) are randomly assigned to either a treatment (TX) or

controlbull (non-treatment) groupbull bull May bebull o Blind neither subject nor investigator knows which TX subject is receivingbull o Double-blind neither subject nor investigator knows which TX subject is receivingbull o Non-blind both subject and investigator know which TX subject is receiving usedbull when it is felt that the knowledge of treatment is unimportantbull META-ANALYSIS OF RCTSbull bull Quantitatively synthesizes and analyzes results of multiple primary studies addressing

abull similar research questionbull bull Statistically pools results from independent but combinable studiesbull bull Summary statistic (effect size) is expressed in terms of direction (positive negative

orbull zero) and magnitude (high medium small)

bull LEVEL 2bull QUASI-EXPERIMENTAL STUDYbull bull Always includes manipulation of an independent variablebull bull Lacks either random assignment or control groupbull bull Findings must be considered in light of threats to validity (particularly selection)

bull LEVEL 3bull NON-EXPERIMENTAL STUDYbull bull No manipulation of the independent variablebull bull Can be descriptive comparative or relationalbull bull Often uses secondary databull bull Findings must be considered in light of threats to validity (particularly selection lack

ofbull severity or co-morbidity adjustment)

bull QUALITATIVE STUDYbull 1048707 Explorative in nature such as interviews observations or focus groupsbull 1048707 Starting point for studies of questions for which little research currently existsbull 1048707 Sample sizes are usually small and study results are used to design stronger studies

thatbull are more objective and quantifiable

bull META-SYNTHESISbull 1048707 Research technique that critically analyzes and synthesizes findings from qualitativebull researchbull 1048707 Identifies key concepts and metaphors and determines their relationships to each

otherbull 1048707 Aim is not to produce a summary statistic but rather to interpret and

translate findings

JHNEBP Research Evidence Appraisal

The Johns Hopkins HospitalThe Johns Hopkins University

QUALITY RATING (SCIENTIFIC EVIDENCE)

A High quality consistent results sufficient sample size adequate control and

bull definitive conclusions consistent recommendations based on extensive literature

bull review that includes thoughtful reference to scientific evidence

B Good quality reasonably consistent results sufficient sample size some control

bull and fairly definitive conclusions reasonably consistent recommendations based

bull on fairly comprehensive literature review that includes some reference to

bull scientific evidence

C Low quality or major flaws little evidence with inconsistent results insufficient

bull sample size conclusions cannot be drawn

Article 1 ldquoConflict management training and nurse-physician collaborative behaviorsrdquo(Boone et al 2008)bull Quantitative quasi-experimental designbull The researchers are highly qualified and experiencedbull Convenience sample which closely approximates the real world experiencebull This study is ethically sound as a written explanation of the study was provided and

informed consent was obtainedbull The problem is clearly stated to examine a knowledge gap between a unit specific

intervention (conflict management training) and improved communication and collaboration between physicians and nurses

bull Theoretical framework Kilmann and Thomas conflict resolution theory (Boone et al 2008 p 168)

bull Findings reveal that the intervention was unsuccessful (The null hypothesis not rejected)

bull The importance of continued research for interventions that promote quality communication and collaboration is stressed

bull Creating a culture that values quality communication and collaboration forms the basis for developing a healthy work environment

bull Level of evidence varies by tool used but is evaluated as II or III Both levels are credible for utilization in evidence based care

bull Informed consent was obtained from all participants

Article 2 ldquoNine structures and leadership practices essential for a magnetic (healthy) work environmentrdquo (Kramer et al 2010)

bull This is a quantitative meta-analysis of thirty professional publications bull The problem is clearly stated to identify what structures and leadership

practices are necessary to support a healthy work environmentbull The researchers are experienced and well qualifiedbull The sample size was good Over 1300 interviews of expert nurses nurse

managers and physicians were compiled for comparison to findings from regulatory and professional organizations

bull The theoretical framework is based on the Donabedian model (httpwwwahrqgovqualmedteammedteamfig2htm) of patient safety

bull Healthy work environments lead to improved patient and nurse outcomesbull Creating a culture of interdisciplinary collaboration and teamwork through

shared power and administrative support were important themesbull This is a valid level I for evidence by all methods (course modules interview

with hospital research specialist and Johns Hopkins Nursing Research Evidence Appraisal) Level I is the highest level of evidence for utilization in evidence based practice

Structuresbest leadership practices essential for healthy work environments

Quality leadership at all levels in the organization

Availability of and support for education career performance and competence development

Administrative sanction for autonomous and collaborative practice

Evidence-based practice education and operational supports

Culture practice and opportunity to learn interdisciplinary collaboration

Empowered shared decision-making structures for control of the context of nursing practice

Generation and nurturance of a patient-centered culture

Staffing structures that take into account RN competence patient acuity and teamwork

Development and support of intradisciplinary teamwork

Article 3 ldquoThe effect of an educational programme on attitudes of nurses and medical residents towards the benefit of positive communication and collaborationrdquo(McCaffrey et al 2012)bull This is a quasi-experimental study based on a convenience sample of nurses and

medical residents bull The researchers are experienced and well qualifiedbull The research question is clearly statedbull Ethical research guidelines are carefully adhered tobull A pre and post-test design based on the Jefferson Scale of Attitudes towards

Physician-Nurse Collaboration and the Communication Collaboration and Critical Thinking for Quality Patient Outcomes tools Both tools are proven to be reliable and valid (the Cronbachrsquos alpha coefficient of 087-092)

bull A critical finding in this study is that ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Statistical findings reveal that the chosen intervention of an educational programme to improve physician-nurse communication and collaboration was beneficial

bull This study is evaluated as evidence level III due to lack of a control group by two methods (Ford 2012 C Bongiorno personal communication November 26 2012) Alternatively it is rated as level II on the Johns Hopkins scale (JHNEBP Research Evidence Appraisal nd)

Article 4 ldquoNurse-physician relationships in hospitals 20000 nurses tell their storyrdquo (Schmalenberg amp Kramer 2009)

bull This study is a quantitative synthesis of the findings of six research studies based on the Essentials of Magnetism

bull The researchers are experienced and highly qualifiedbull The purpose of the study is several fold 1) To discern what constitutes quality

communication and collaboration between physicians and nurses 2) Define types of nurse-physician relationships 3) Define organizational structures and leadership practices that help develop collaborative nurse-physician relationships and 4) Study differences in nurse-physician relationships between magnet and comparison hospitals

bull The sample size of 20616 staff nurses is excellentbull Thorough literature review is the foundation for this studybull It was consistently reported that nurses at magnet hospitals reported higher quality

relationships with physicians than the comparison hospitalsbull Structures that improve relationships and are supported by magnet institutions are

keep the patient first develop constructive conflict resolution techniques and have collaborative interdisciplinary patient rounds

bull Nurses can play an active role in bringing about these interventionsbull This is a double blinded peer review of six studies clearly making it evidence level I by

all methods

Percentage of staff nurses responding affirmatively to nurse-physician relationship types by magnet

and comparison hospitals and by period

Application of Evidence for oncology nursing practice (Lai Harper)

bull Utilize the Cochrane Database or the ldquoJHNEBP Research Evidence Appraisalrdquo as the research tools effectively communicate and collaborate with oncologists about the nursing perspective on evidence-based practice

bull Ongoing literature review for the most current credible and high-quality evidence-based practice for reducing oncology patientsrsquo physical psychological and emotional issues (such as pain nausea anxiety or depression)

bull Recommend the hospital nursing research committee to initiate a survey to explore possible physician-nurse communication barriers at an oncology unit

bull Recommend the implementation of the low-cost convenient computer-based training in physician-nurse communication skills

Application of Evidence at the Cardiovascular Department (Margaret Siler)

bull High quality communication and collaboration make a great difference in the cardiac catheterization laboratory (Boone King Gresham Wahl amp Suh 2008 p 168)

bull Experience and a broad knowledge base bring confidence to our daily work (Schmalenberg amp Kramer 2009 p 82)

bull All involved parties (patient nurse physician healthcare system) can reap the benefits of collaborative practice (Kramer et al 2012 p 7)

bull There are many educational opportunities available to improve interdisciplinary and interdepartmental communication Many are quite costly Some that may make the biggest difference are fairly inexpensive including Unit Action Council work and interdepartmental job shadowing (McCaffery et al 2012)

Application of Evidence into the Surgical Setting (Gary Webster)

Intra-operative settings place nurses and physicians in close collaborative work

settings The typical communication style is authoritarian Schmalenberg and

Kramer (2009) stated that physicians felt the nurse-physician relation to be more

collaborative than nurse did I can see that being true in my work environment

The Boone et al (2008) and McCaffrey (2011) articles combined are very

valuable Together the articles show a successful attempt to increase collaboration

and some pitfalls to avoid These can help direct any programs to support an

increase in collaboration

Application of Evidence (Jamie Ziemba)

bull Poor communication between nurses and physicians related to language and cultural barriers

bull Physiciansrsquo dysfunctional or authoritarian communication style (eg instruct nurses not to call at night unless it is a life-and-death emergency) is a major patient safety issue

bull As the patient advocate nurses have an important role of communicating with physicians to verify medication orders clinical procedures and improve patient outcomes

bull Hospital training programs in communication skills and cultural diversities are recommended for physicians and nurses with different culturalethnic backgrounds

Summary Statements

bull Meta-analytical review of evidence-based research articles support the clinical significance of effective communication styles

bull Authoritarian communication styles increase disruptive behaviors and negative hostile relationships at work environments

bull Healthy work environments have positive effects on nurses physicians patients and healthcare organizations

bull Inter-disciplinary collaboration is an essential aspect of healthy work environmentsbull Evidence-based studies have shown positive patient outcomes nursing job

satisfaction collaborative environments at Magnet hospitalsbull There is a need to address the barriers and incorporate educational programs to teach

effective communication and the need for collaboration Educational training should be re-enforced with weekly discussions ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Educate staff on the 5 types of nurse-physician relationships (collegial collaborative teacher-student friendly-stranger and hostileadversarial relationships)

bull Teach staff how to utilize positive relationships and change negative onesbull Training should avoid focusing on negative behaviorsbull Training should focus creating cooperative behaviors

ReferencesAgency for Healthcare Research and Quality (nd) Medical teamwork and patient safety The Donabedian model of patient safety Retrieved

from httpwwwahrqgovqualmedteammedteamfig2htm

American Nurses Association (1980) Nursing A social policy statement Washington DC American Nurses Association

Ballou K amp Landreneau K (2010) The authoritarian reign in American health care Policy Politics amp Nursing Practice 11(1) 71-79

doi1011771527154410372973

Boone B King M Gresham L Wahl P amp Suh E (2008) Conflict management training and nurse-physician collaborative behaviors

Journal For Nurses In Staff Development 24(4) 168-175 doi10109701NND00003206705641591

Burns N amp Grove S (2007) Understanding Nursing Research Building an Evidence Based Practice (4th Ed) St Louis Missouri Saunders

Elsevier Publishing

Ford L (2012) Week 8 amp 9 Critique of Research Retrieved from httpsfsulearnferriseduwebappsportalframesetjsp

tab_tab_group_id=_2_1ampurl=2Fwebapps2Fblackboard2Fexecute2Flauncher3Ftype3DCourseampid3D_2241_1ampurl3D

Gardezi F Lingard L Espin S Whyte S Orser B amp Baker G (2009) Silence power and communication in the operating room

Journal Of Advanced Nursing 65(7) 1390-1399 doi101111j1365-2648200904994x

Hendel T Fish M amp Berger O (2007) Nursephysician conflict management mode choices implications for improved collaborative

practice Nursing Administration Quarterly 31(3) 244-253

John Hopkins UniversityJohn Hopkins Hospital (nd) JHNEBP Research Evidence Appraisal Retrieved from

httpwwwnursingworldorgDocumentVaultNursingPracticeResearch-ToolkitJHNEBP-Research-Evidence-Appraisalpdf

Karanikola M Papathanassoglou E Kalafati M Stathopoulou H Mpouzika M amp Goutsikas C G (2012) Exploration of the

Association Between Professional Interactions and Emotional Distress of Intensive Care Unit Nursing Personnel Dimensions Of Critical

Care Nursing 31(1) 37-45 doi101097DCC0b013e31823a55b8

ReferencesKramer M Schmalenberg C amp Maguire P (2010) Nine structures and leadership practices essential for a magnetic (healthy)

work environment Nursing Administration Quarterly 34(1) 4-17 doi101097NAQ0b013e3181c95ef4

Manojlovich M amp DeCicco B (2007) Healthy work environments nurse-physician communication and patients outcome American Journal Of Critical Care 16(6) 536-543

McCaffrey R Hayes R Cassell A Miller-Reyes S Donaldson A amp Ferrell C (2012) The effect of an educational programme on attitudes of nurses and medical residents towards the benefits of positive communication and collaboration Journal Of Advanced Nursing 68(2) 293-301 doi101111j1365-2648201105736x

Nieswiadomy R M (2012) Foundations of Nursing Research (6th Ed) Upper Saddle River New Jersey Prentice Hall

Rosenstein A amp ODaniel M (2008) A survey of the impact of disruptive behaviors and communication defects on patient safety Joint Commission Journal On Quality amp Patient Safety 34(8) 464-471

Rothstein W amp Hannum S (2007) Profession and gender in relationships between advanced practice nurses and physicians Journal Of Professional Nursing 23(4) 235-240 doi101016jprofnurs200701008

Saxton R Hines T amp Enriquez M (2009) The negative impact of nurse-physician disruptive behavior on patient safety A review of the literature Journal of Patient Safety 5(3) 180-183

Stone P W (2002) Popping the PICO question in research and evidence-based practice Applied Nursing Research 16(2) 197-198

Schmalenberg C amp Kramer M (2009) Nurse-physician relationships in hospitals 20 000 nurses tell their story Critical Care Nurse 29(1) 74-83 doi104037ccn2009436

Zwarenstein M Goldman J amp Reeves S (2009) Interprofessional collaboration Effects of practice-based interventions on professional practice and healthcare outcomes Cochrane Database Of Systematic Reviews (3) 1-31 doi10100214651858CD000072

NURS 350 Evidence-Based Nursing Practice (Group paper plus Group Powerpoint presentation)

Total group grade 100Instructorrsquos comments Excellent paper I think your group

should consider submitting it for publication if you could flesh out the details on improving collaborative communication

• Ferris State University NURS 350 Evidence-Based Nursing Practic
• ldquoCommunication--the human connection--is the key to pers
• Slide 3
• What is patient safety
• What is acute care
• What is Professional Communication
• Communication between medical professionals is not just a local
• PICO Question
• Definitions
• A Survey of the Impacts of Disruptive Behaviors and Communicat
• A Survey of the Impacts of Disruptive Behaviors and Communicat (2)
• Literature Review (Level One Evidence)
• Literature Review (Level Three Evidence)
• Literature Review (Level Four Evidence)
• Literature Review (Level Four Evidence continued)
• Literature Review (Level Six Evidence)
• Analysis of Evidence
• Slide 18
• Slide 19
• Article 1 ldquoConflict management training and nurse-physician
• Article 2 ldquoNine structures and leadership practices essentia
• Slide 22
• Article 3 ldquoThe effect of an educational programme on attitud
• Article 4 ldquoNurse-physician relationships in hospitals 2000
• Percentage of staff nurses responding affirmatively to nurse-ph
• Application of Evidence for oncology nursing practice (Lai Har
• Application of Evidence at the Cardiovascular Department (Marg
• Application of Evidence into the Surgical Setting (Gary Webste
• Slide 29
• Summary Statements
• References
• References (2)
• NURS 350 Evidence-Based Nursing Practice (Group paper plus Gr

What is Professional Communication

Verbal communication is basic conversation of words that people say to one another Simple words or technical jargon Difficult if the nurse or doctor has English as

a second language if the terms in the technical jargon are not shared by either the doctor or nurse

Nonverbal communication is body language and written communication

body language and written communication can be taken positively or negatively

Communication between medical professionals is not just a local problem but is a problem found throughout the entire medical community

PICO Question

For adult patients in an acute care setting what does the literature reveal about the DIFFERENCE in communication styles (collaboration interdisciplinary versus segmented authoritarian) between physicians and nurses on indicators of nurse satisfaction rates and patient safety outcomes

Definitions

bull According to the American Nurses Association ldquocollaborationrdquo is ldquoa true partnership in which the power on both sides is valued by both with recognition and acceptance of separate and combined practice spheres of activity and responsibility mutual safeguarding of the legitimate interests of each party and a commonality of goals that is recognized by both partiesrdquo (Hendel Fish amp Berger 2007 p 251)

bull Ballou and Landreneau (2010) discuss that ldquoauthoritarian persons typify an outlook that is ethnocentric rigid and anti-democraticrdquo (p 71)

bull ldquoSegmentedrdquo ldquodivided into or composed of segments or sectionsrdquo ldquoAuthoritarianrdquo ldquoof relating to or favoring blind submission to authorityrdquo (Merriam-Webster Dictionary 2012)

A Survey of the Impacts of Disruptive Behaviors and Communication Defects on Patient Safety

Sample size N= 4530 From January 2004 to March 2007How often do you think disruptive behavior results in the following at your hospital

(Sometimes Frequent and Constant)

How often do you think that there is a link between disruptive behavior and the following

clinical outcomes at your hospital (Sometimes Frequent and Constant)

Adver

se E

vent

s

Error

s

Patient

Saf

ety

Qualit

y of

Car

e

Patient

Mor

talit

y

6771

51

71

27

Stres

s

Frustra

tion

Loss o

f con

cent

ratio

n

Reduc

ed te

am col

labo

ratio

n

Reduc

ed in

form

atio

n tran

sfer

Reduc

ed com

mun

icat

ion

Impa

ired

RNM

D

94 94

83

8987

91

99

A Survey of the Impacts of Disruptive Behaviors and Communication Defects on Patient Safety

Sample size N= 4530 From January 2004 to March 2007

Have your ever witnessed any disruptive behavior from a physician at your hospital

Have you ever witnessed any disruptive behavior from a nurse at your hospital

Aggre

gate

MD

(ph

ysician)

RN (

nurs

e)

Admin

stra

tive ex

ecut

ives

Other

77

51

88

78

66

Aggre

gate

MD

(ph

ysician)

RN (

nurs

e)

Admin

istra

tive ex

ecut

ives

Other

65

48

7377

64

Literature Review (Level One Evidence)Research Articles

Research Methods

Theoretical frameworksMeasurement Instruments

Samples Data AnalysesStudy Findings

Kramer Schmalenbeg amp Maguire (2010)

Meta-analysis of multiple published studies

Donabedianrsquos conceptual framework of structure process and outcome

Heberlein and Baumgartnerrsquosmethodology

12 publications from 7 professional and regulatory organizations

18 publications from studies using the Essential of Magnetism (including 1300 interviews with nurses physicians and mangers)

positive physician-nurse communication collaborative leadership and autonomy in Magnet hospitals (Kramer et al p 11)

Nursesrsquo autonomous role in identifying patientsrsquo worsening conditions (need to rescueNTR) for reducing the rates of mortality or adverse patient outcomes (Kramer et al p 11)

Schmalenberg amp Kramer (2009)

Review of six research studies

Essentials of Magnetism

Concepts of nurse-physician relationship(collegial collaborative student-teacher friendly stranger hostileadversarial

3602 staff nurses in 16 Magnet and 10 non-Magnet hospitals in the 2003 study

10514 staff nurses in 18 Magnet and 16 non-Magnet hospitals in the 2007 study

In 2003 physician-nurse relationship scores in Magnet hospitals were statistically significant and higher when compared to non-Magnet hospitals (F ratio 21279 P less than 0001)

In 2007 the higher scores in Magnet hospitals were also statistically significant (F ratio 14446 P less than 0001)(Schmalenberg pp 78-79)

Zwarenstein Goldman amp Reeves (2009)

Cochrane Systematic Review

Not specifically mentioned

Five studies about collaborative interventions

interprofessional roundsmeetings

externally facilitated interprofessional audit

no randomized controlled studies about the impacts of interdisciplinary collaboration (Zwarenstein et al p 8)

ldquoProblems with conceptualising and measuring collaborationrdquo No ldquogeneralizable inferences about interprofessional collaborationrdquo (Zwarenstein et al p 2)

Literature Review (Level Three Evidence)

Research Articles

Research Methods

Theoretical frameworksMeasurement Instruments

Samples Data AnalysesStudy Findings

Boone King Gresham Wahl amp Suh (2008)

Quasi-experimental (Pre- and Post- Test for the training in assertiveness and cooperation)

Kilmann and Thomasrsquo model of conflict resolution (accommodating avoidance competition compromise collaboration)

Collaborative Behavior Scale

9 nurses from the cardiovascular laboratory (experimental group) and 18 nurses from the telemetry unit (control group)

Non-probability sampling in an American hospital

No statistical significance for the Collaborative Behavior Scale beforeafter the training between the experimental group and the control group ldquop more than 005rdquo (Boone et al p 172)

the communication style of ldquoavoidancerdquo was associated with increased nursesrsquo emotional stress (Boone et al p 173)

Implication explore barriers before training programs involve physiciansrsquo participations

McCaffrey HayesCassell Miller-Reyes Donaldson amp Ferrell (2012)

Quasi-experimental (Pre- and Post-test for training in communication skills)

Jefferson Scale of Attitudes

68 nurses and 47 medical residents in a Florida hospital

Non-probability sampling

statistical significance (P=0001) of the T-test before and after the 6-month educational program for enhancing physician-nurse collegiality communication skills mutual decision-making processes (McCaffrey et al p 298)

Literature Review (Level Four Evidence)Research Articles

Research Studies

Theoretical Frameworks

Measurement Instruments

Samples Data AnalysesStudy Findings

Hendel Fish amp Berger (2007)

Cross-sectional Correlational study

Thomas-Kilman Model of Conflict Resolution

Conflict Mode Instrument (MODE)

75 physicians 54 charge nurses at 5 acute care hospitals in Israel

Non-probability sampling

charge nurses were more likely to use the ldquocollaboratingrdquo communication style when compared to physicians (P=0001) (Hendel et al p 249)

Karanikola et al (2012)

Descriptive Correlational study

Hamiltonrsquos Anxiety Scale

Stamprsquos Index of Work Satisfaction

2-stage random probability sampling

11 hospitals randomly selected in Greece then 229 nurses at intensive care units randomly selected

Satisfaction in physician communication was statistically significant and negatively associated with intensive care nursesrsquo anxiety level ldquocorrelation coefficient Kendall = -0160 P=0001rdquo and depressed mood ldquocorrelation coefficient = -0148 P=0005rdquo (p 41)

Limitations confounding variables of nursesrsquo personal psychiatric or psychological histories

Manojlovich amp DeCicco (2007)

Descriptive Cross-sectional Non-experimental

Concepts of workplace empowerment ICU Nurse-Physician QuestionnairePractice Environment Scale of the Nursing Work Index

462 nursesrsquo perceptions in 25 intensive care units from 8 Michigan hospitals

Non-probability sampling

statistical significance for the positive correlation of physician-nurse miscommunication to the perceived outcomes in medication errors (p 542)

Limitation not generalized findings not reflect cause-effect relationships

Literature Review (Level Four Evidence continued)

Research Articles

Research Studies

Theoretical Framework

Measurement Instruments

Samples Data AnalysesStudy Findings

Rosenstein amp ODaniel (2008)

Non-experimentalstudy quantitative and qualitative approach

Instrument ldquoNurse-Physician Impact of disruptive Behavior on Patient Carerdquo

Convenience samples 2846 nurses 944 physicians from 102 not-for-profit VHA member hospitals in the US from 2004 to 2007

physician-nurse disturbing behaviors are likely to reduce patient safety outcomes and nurse satisfaction Narrative data eg ldquoafraid to call Drrdquo ldquoget yelled atrdquo ldquopoor communication postoprdquo (Rosenstein amp OrsquoDaniel p 467)

67 respondents perceived that disruptive behaviors were associated with adverse patient outcomes (medical errors and patient mortality) (Rosenstein amp OrsquoDaniel p 464)

Limitation theoretical framework not specifically describedStrength large sample size

Rothsteinamp Hannum (2007)

Cross-sectional

Gender model (male physician dominance and nurse deference)

Professional model

self-reported close-ended questionnaire on nurse-physician relationship

125 advanced practice nursesAPN at a statewide professional conference

non-probability sampling

statistical significance for APNrsquo s positive attitudecommunication with female physicians (less than 50 years old) and male physicians (of all ages) male and female physicians are also likely to be positive and respectful about APNrsquos knowledge in patient care (2-tailed t test and one-way analysis of variance P value less than 005) (Rothstein amp Hannum p 238)

The gender model for the authoritative dominance of male physicians is not applicable to the female APNs who have at least a masterrsquos degree in nursing (p 235)

Limitation confounding variables not measured ldquotype and size of the work organization nurse and physician specialties and patient illness and social characteristicsrdquo (p 239)

Literature Review (Level Six Evidence)

Research

Article

Research Method

Theoretical Framework

Sample Study Findings

Gardezi Lingard Espin Whyte Orser amp Baker (2009)

Qualitative study

Ethnographic approach

Retrospective study

Critical Theory about silence in communication

observed physician-nurse communications over 700 surgeries at 3 acute care hospitals from 2005 to 2007 in Canada

Narrative and descriptive data about conflicts in physician-nurse communication styles at operating rooms due to nursesrsquo gap in knowledge about surgical procedures and surgeonsrsquo dominant authoritative power

Nursesrsquo passivesilent communication method had negative impacts on patient safety during surgeries (Gardezi et al p 1391)

Limitations evidence-based practice cannot be based on one qualitative study

Strengths explore the descriptive lived experiences about physician-nurse communication barriers over 2 years

Analysis of Evidence

The ability to critically analyze evidence presented in various research projects is necessary to evaluate the work for applicability and use in evidence based nursing practice ldquoTo use research evidence one must be able to evaluate this evidencerdquo (Nieswiadomy 2012 p 298)

bull STRENGTH OF EVIDENCEbull LEVEL 1 (HIGHEST)bull EXPERIMENTAL STUDY (RANDOMIZED CONTROLLED TRAIL OR RCT)bull bull Study participants (subjects) are randomly assigned to either a treatment (TX) or

controlbull (non-treatment) groupbull bull May bebull o Blind neither subject nor investigator knows which TX subject is receivingbull o Double-blind neither subject nor investigator knows which TX subject is receivingbull o Non-blind both subject and investigator know which TX subject is receiving usedbull when it is felt that the knowledge of treatment is unimportantbull META-ANALYSIS OF RCTSbull bull Quantitatively synthesizes and analyzes results of multiple primary studies addressing

abull similar research questionbull bull Statistically pools results from independent but combinable studiesbull bull Summary statistic (effect size) is expressed in terms of direction (positive negative

orbull zero) and magnitude (high medium small)

bull LEVEL 2bull QUASI-EXPERIMENTAL STUDYbull bull Always includes manipulation of an independent variablebull bull Lacks either random assignment or control groupbull bull Findings must be considered in light of threats to validity (particularly selection)

bull LEVEL 3bull NON-EXPERIMENTAL STUDYbull bull No manipulation of the independent variablebull bull Can be descriptive comparative or relationalbull bull Often uses secondary databull bull Findings must be considered in light of threats to validity (particularly selection lack

ofbull severity or co-morbidity adjustment)

bull QUALITATIVE STUDYbull 1048707 Explorative in nature such as interviews observations or focus groupsbull 1048707 Starting point for studies of questions for which little research currently existsbull 1048707 Sample sizes are usually small and study results are used to design stronger studies

thatbull are more objective and quantifiable

bull META-SYNTHESISbull 1048707 Research technique that critically analyzes and synthesizes findings from qualitativebull researchbull 1048707 Identifies key concepts and metaphors and determines their relationships to each

otherbull 1048707 Aim is not to produce a summary statistic but rather to interpret and

translate findings

JHNEBP Research Evidence Appraisal

The Johns Hopkins HospitalThe Johns Hopkins University

QUALITY RATING (SCIENTIFIC EVIDENCE)

A High quality consistent results sufficient sample size adequate control and

bull definitive conclusions consistent recommendations based on extensive literature

bull review that includes thoughtful reference to scientific evidence

B Good quality reasonably consistent results sufficient sample size some control

bull and fairly definitive conclusions reasonably consistent recommendations based

bull on fairly comprehensive literature review that includes some reference to

bull scientific evidence

C Low quality or major flaws little evidence with inconsistent results insufficient

bull sample size conclusions cannot be drawn

Article 1 ldquoConflict management training and nurse-physician collaborative behaviorsrdquo(Boone et al 2008)bull Quantitative quasi-experimental designbull The researchers are highly qualified and experiencedbull Convenience sample which closely approximates the real world experiencebull This study is ethically sound as a written explanation of the study was provided and

informed consent was obtainedbull The problem is clearly stated to examine a knowledge gap between a unit specific

intervention (conflict management training) and improved communication and collaboration between physicians and nurses

bull Theoretical framework Kilmann and Thomas conflict resolution theory (Boone et al 2008 p 168)

bull Findings reveal that the intervention was unsuccessful (The null hypothesis not rejected)

bull The importance of continued research for interventions that promote quality communication and collaboration is stressed

bull Creating a culture that values quality communication and collaboration forms the basis for developing a healthy work environment

bull Level of evidence varies by tool used but is evaluated as II or III Both levels are credible for utilization in evidence based care

bull Informed consent was obtained from all participants

Article 2 ldquoNine structures and leadership practices essential for a magnetic (healthy) work environmentrdquo (Kramer et al 2010)

bull This is a quantitative meta-analysis of thirty professional publications bull The problem is clearly stated to identify what structures and leadership

practices are necessary to support a healthy work environmentbull The researchers are experienced and well qualifiedbull The sample size was good Over 1300 interviews of expert nurses nurse

managers and physicians were compiled for comparison to findings from regulatory and professional organizations

bull The theoretical framework is based on the Donabedian model (httpwwwahrqgovqualmedteammedteamfig2htm) of patient safety

bull Healthy work environments lead to improved patient and nurse outcomesbull Creating a culture of interdisciplinary collaboration and teamwork through

shared power and administrative support were important themesbull This is a valid level I for evidence by all methods (course modules interview

with hospital research specialist and Johns Hopkins Nursing Research Evidence Appraisal) Level I is the highest level of evidence for utilization in evidence based practice

Structuresbest leadership practices essential for healthy work environments

Quality leadership at all levels in the organization

Availability of and support for education career performance and competence development

Administrative sanction for autonomous and collaborative practice

Evidence-based practice education and operational supports

Culture practice and opportunity to learn interdisciplinary collaboration

Empowered shared decision-making structures for control of the context of nursing practice

Generation and nurturance of a patient-centered culture

Staffing structures that take into account RN competence patient acuity and teamwork

Development and support of intradisciplinary teamwork

Article 3 ldquoThe effect of an educational programme on attitudes of nurses and medical residents towards the benefit of positive communication and collaborationrdquo(McCaffrey et al 2012)bull This is a quasi-experimental study based on a convenience sample of nurses and

medical residents bull The researchers are experienced and well qualifiedbull The research question is clearly statedbull Ethical research guidelines are carefully adhered tobull A pre and post-test design based on the Jefferson Scale of Attitudes towards

Physician-Nurse Collaboration and the Communication Collaboration and Critical Thinking for Quality Patient Outcomes tools Both tools are proven to be reliable and valid (the Cronbachrsquos alpha coefficient of 087-092)

bull A critical finding in this study is that ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Statistical findings reveal that the chosen intervention of an educational programme to improve physician-nurse communication and collaboration was beneficial

bull This study is evaluated as evidence level III due to lack of a control group by two methods (Ford 2012 C Bongiorno personal communication November 26 2012) Alternatively it is rated as level II on the Johns Hopkins scale (JHNEBP Research Evidence Appraisal nd)

Article 4 ldquoNurse-physician relationships in hospitals 20000 nurses tell their storyrdquo (Schmalenberg amp Kramer 2009)

bull This study is a quantitative synthesis of the findings of six research studies based on the Essentials of Magnetism

bull The researchers are experienced and highly qualifiedbull The purpose of the study is several fold 1) To discern what constitutes quality

communication and collaboration between physicians and nurses 2) Define types of nurse-physician relationships 3) Define organizational structures and leadership practices that help develop collaborative nurse-physician relationships and 4) Study differences in nurse-physician relationships between magnet and comparison hospitals

bull The sample size of 20616 staff nurses is excellentbull Thorough literature review is the foundation for this studybull It was consistently reported that nurses at magnet hospitals reported higher quality

relationships with physicians than the comparison hospitalsbull Structures that improve relationships and are supported by magnet institutions are

keep the patient first develop constructive conflict resolution techniques and have collaborative interdisciplinary patient rounds

bull Nurses can play an active role in bringing about these interventionsbull This is a double blinded peer review of six studies clearly making it evidence level I by

all methods

Percentage of staff nurses responding affirmatively to nurse-physician relationship types by magnet

and comparison hospitals and by period

Application of Evidence for oncology nursing practice (Lai Harper)

bull Utilize the Cochrane Database or the ldquoJHNEBP Research Evidence Appraisalrdquo as the research tools effectively communicate and collaborate with oncologists about the nursing perspective on evidence-based practice

bull Ongoing literature review for the most current credible and high-quality evidence-based practice for reducing oncology patientsrsquo physical psychological and emotional issues (such as pain nausea anxiety or depression)

bull Recommend the hospital nursing research committee to initiate a survey to explore possible physician-nurse communication barriers at an oncology unit

bull Recommend the implementation of the low-cost convenient computer-based training in physician-nurse communication skills

Application of Evidence at the Cardiovascular Department (Margaret Siler)

bull High quality communication and collaboration make a great difference in the cardiac catheterization laboratory (Boone King Gresham Wahl amp Suh 2008 p 168)

bull Experience and a broad knowledge base bring confidence to our daily work (Schmalenberg amp Kramer 2009 p 82)

bull All involved parties (patient nurse physician healthcare system) can reap the benefits of collaborative practice (Kramer et al 2012 p 7)

bull There are many educational opportunities available to improve interdisciplinary and interdepartmental communication Many are quite costly Some that may make the biggest difference are fairly inexpensive including Unit Action Council work and interdepartmental job shadowing (McCaffery et al 2012)

Application of Evidence into the Surgical Setting (Gary Webster)

Intra-operative settings place nurses and physicians in close collaborative work

settings The typical communication style is authoritarian Schmalenberg and

Kramer (2009) stated that physicians felt the nurse-physician relation to be more

collaborative than nurse did I can see that being true in my work environment

The Boone et al (2008) and McCaffrey (2011) articles combined are very

valuable Together the articles show a successful attempt to increase collaboration

and some pitfalls to avoid These can help direct any programs to support an

increase in collaboration

Application of Evidence (Jamie Ziemba)

bull Poor communication between nurses and physicians related to language and cultural barriers

bull Physiciansrsquo dysfunctional or authoritarian communication style (eg instruct nurses not to call at night unless it is a life-and-death emergency) is a major patient safety issue

bull As the patient advocate nurses have an important role of communicating with physicians to verify medication orders clinical procedures and improve patient outcomes

bull Hospital training programs in communication skills and cultural diversities are recommended for physicians and nurses with different culturalethnic backgrounds

Summary Statements

bull Meta-analytical review of evidence-based research articles support the clinical significance of effective communication styles

bull Authoritarian communication styles increase disruptive behaviors and negative hostile relationships at work environments

bull Healthy work environments have positive effects on nurses physicians patients and healthcare organizations

bull Inter-disciplinary collaboration is an essential aspect of healthy work environmentsbull Evidence-based studies have shown positive patient outcomes nursing job

satisfaction collaborative environments at Magnet hospitalsbull There is a need to address the barriers and incorporate educational programs to teach

effective communication and the need for collaboration Educational training should be re-enforced with weekly discussions ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Educate staff on the 5 types of nurse-physician relationships (collegial collaborative teacher-student friendly-stranger and hostileadversarial relationships)

bull Teach staff how to utilize positive relationships and change negative onesbull Training should avoid focusing on negative behaviorsbull Training should focus creating cooperative behaviors

ReferencesAgency for Healthcare Research and Quality (nd) Medical teamwork and patient safety The Donabedian model of patient safety Retrieved

from httpwwwahrqgovqualmedteammedteamfig2htm

American Nurses Association (1980) Nursing A social policy statement Washington DC American Nurses Association

Ballou K amp Landreneau K (2010) The authoritarian reign in American health care Policy Politics amp Nursing Practice 11(1) 71-79

doi1011771527154410372973

Boone B King M Gresham L Wahl P amp Suh E (2008) Conflict management training and nurse-physician collaborative behaviors

Journal For Nurses In Staff Development 24(4) 168-175 doi10109701NND00003206705641591

Burns N amp Grove S (2007) Understanding Nursing Research Building an Evidence Based Practice (4th Ed) St Louis Missouri Saunders

Elsevier Publishing

Ford L (2012) Week 8 amp 9 Critique of Research Retrieved from httpsfsulearnferriseduwebappsportalframesetjsp

tab_tab_group_id=_2_1ampurl=2Fwebapps2Fblackboard2Fexecute2Flauncher3Ftype3DCourseampid3D_2241_1ampurl3D

Gardezi F Lingard L Espin S Whyte S Orser B amp Baker G (2009) Silence power and communication in the operating room

Journal Of Advanced Nursing 65(7) 1390-1399 doi101111j1365-2648200904994x

Hendel T Fish M amp Berger O (2007) Nursephysician conflict management mode choices implications for improved collaborative

practice Nursing Administration Quarterly 31(3) 244-253

John Hopkins UniversityJohn Hopkins Hospital (nd) JHNEBP Research Evidence Appraisal Retrieved from

httpwwwnursingworldorgDocumentVaultNursingPracticeResearch-ToolkitJHNEBP-Research-Evidence-Appraisalpdf

Karanikola M Papathanassoglou E Kalafati M Stathopoulou H Mpouzika M amp Goutsikas C G (2012) Exploration of the

Association Between Professional Interactions and Emotional Distress of Intensive Care Unit Nursing Personnel Dimensions Of Critical

Care Nursing 31(1) 37-45 doi101097DCC0b013e31823a55b8

ReferencesKramer M Schmalenberg C amp Maguire P (2010) Nine structures and leadership practices essential for a magnetic (healthy)

work environment Nursing Administration Quarterly 34(1) 4-17 doi101097NAQ0b013e3181c95ef4

Manojlovich M amp DeCicco B (2007) Healthy work environments nurse-physician communication and patients outcome American Journal Of Critical Care 16(6) 536-543

McCaffrey R Hayes R Cassell A Miller-Reyes S Donaldson A amp Ferrell C (2012) The effect of an educational programme on attitudes of nurses and medical residents towards the benefits of positive communication and collaboration Journal Of Advanced Nursing 68(2) 293-301 doi101111j1365-2648201105736x

Nieswiadomy R M (2012) Foundations of Nursing Research (6th Ed) Upper Saddle River New Jersey Prentice Hall

Rosenstein A amp ODaniel M (2008) A survey of the impact of disruptive behaviors and communication defects on patient safety Joint Commission Journal On Quality amp Patient Safety 34(8) 464-471

Rothstein W amp Hannum S (2007) Profession and gender in relationships between advanced practice nurses and physicians Journal Of Professional Nursing 23(4) 235-240 doi101016jprofnurs200701008

Saxton R Hines T amp Enriquez M (2009) The negative impact of nurse-physician disruptive behavior on patient safety A review of the literature Journal of Patient Safety 5(3) 180-183

Stone P W (2002) Popping the PICO question in research and evidence-based practice Applied Nursing Research 16(2) 197-198

Schmalenberg C amp Kramer M (2009) Nurse-physician relationships in hospitals 20 000 nurses tell their story Critical Care Nurse 29(1) 74-83 doi104037ccn2009436

Zwarenstein M Goldman J amp Reeves S (2009) Interprofessional collaboration Effects of practice-based interventions on professional practice and healthcare outcomes Cochrane Database Of Systematic Reviews (3) 1-31 doi10100214651858CD000072

NURS 350 Evidence-Based Nursing Practice (Group paper plus Group Powerpoint presentation)

Total group grade 100Instructorrsquos comments Excellent paper I think your group

should consider submitting it for publication if you could flesh out the details on improving collaborative communication

• Ferris State University NURS 350 Evidence-Based Nursing Practic
• ldquoCommunication--the human connection--is the key to pers
• Slide 3
• What is patient safety
• What is acute care
• What is Professional Communication
• Communication between medical professionals is not just a local
• PICO Question
• Definitions
• A Survey of the Impacts of Disruptive Behaviors and Communicat
• A Survey of the Impacts of Disruptive Behaviors and Communicat (2)
• Literature Review (Level One Evidence)
• Literature Review (Level Three Evidence)
• Literature Review (Level Four Evidence)
• Literature Review (Level Four Evidence continued)
• Literature Review (Level Six Evidence)
• Analysis of Evidence
• Slide 18
• Slide 19
• Article 1 ldquoConflict management training and nurse-physician
• Article 2 ldquoNine structures and leadership practices essentia
• Slide 22
• Article 3 ldquoThe effect of an educational programme on attitud
• Article 4 ldquoNurse-physician relationships in hospitals 2000
• Percentage of staff nurses responding affirmatively to nurse-ph
• Application of Evidence for oncology nursing practice (Lai Har
• Application of Evidence at the Cardiovascular Department (Marg
• Application of Evidence into the Surgical Setting (Gary Webste
• Slide 29
• Summary Statements
• References
• References (2)
• NURS 350 Evidence-Based Nursing Practice (Group paper plus Gr

Communication between medical professionals is not just a local problem but is a problem found throughout the entire medical community

PICO Question

For adult patients in an acute care setting what does the literature reveal about the DIFFERENCE in communication styles (collaboration interdisciplinary versus segmented authoritarian) between physicians and nurses on indicators of nurse satisfaction rates and patient safety outcomes

Definitions

bull According to the American Nurses Association ldquocollaborationrdquo is ldquoa true partnership in which the power on both sides is valued by both with recognition and acceptance of separate and combined practice spheres of activity and responsibility mutual safeguarding of the legitimate interests of each party and a commonality of goals that is recognized by both partiesrdquo (Hendel Fish amp Berger 2007 p 251)

bull Ballou and Landreneau (2010) discuss that ldquoauthoritarian persons typify an outlook that is ethnocentric rigid and anti-democraticrdquo (p 71)

bull ldquoSegmentedrdquo ldquodivided into or composed of segments or sectionsrdquo ldquoAuthoritarianrdquo ldquoof relating to or favoring blind submission to authorityrdquo (Merriam-Webster Dictionary 2012)

A Survey of the Impacts of Disruptive Behaviors and Communication Defects on Patient Safety

Sample size N= 4530 From January 2004 to March 2007How often do you think disruptive behavior results in the following at your hospital

(Sometimes Frequent and Constant)

How often do you think that there is a link between disruptive behavior and the following

clinical outcomes at your hospital (Sometimes Frequent and Constant)

Adver

se E

vent

s

Error

s

Patient

Saf

ety

Qualit

y of

Car

e

Patient

Mor

talit

y

6771

51

71

27

Stres

s

Frustra

tion

Loss o

f con

cent

ratio

n

Reduc

ed te

am col

labo

ratio

n

Reduc

ed in

form

atio

n tran

sfer

Reduc

ed com

mun

icat

ion

Impa

ired

RNM

D

94 94

83

8987

91

99

A Survey of the Impacts of Disruptive Behaviors and Communication Defects on Patient Safety

Sample size N= 4530 From January 2004 to March 2007

Have your ever witnessed any disruptive behavior from a physician at your hospital

Have you ever witnessed any disruptive behavior from a nurse at your hospital

Aggre

gate

MD

(ph

ysician)

RN (

nurs

e)

Admin

stra

tive ex

ecut

ives

Other

77

51

88

78

66

Aggre

gate

MD

(ph

ysician)

RN (

nurs

e)

Admin

istra

tive ex

ecut

ives

Other

65

48

7377

64

Literature Review (Level One Evidence)Research Articles

Research Methods

Theoretical frameworksMeasurement Instruments

Samples Data AnalysesStudy Findings

Kramer Schmalenbeg amp Maguire (2010)

Meta-analysis of multiple published studies

Donabedianrsquos conceptual framework of structure process and outcome

Heberlein and Baumgartnerrsquosmethodology

12 publications from 7 professional and regulatory organizations

18 publications from studies using the Essential of Magnetism (including 1300 interviews with nurses physicians and mangers)

positive physician-nurse communication collaborative leadership and autonomy in Magnet hospitals (Kramer et al p 11)

Nursesrsquo autonomous role in identifying patientsrsquo worsening conditions (need to rescueNTR) for reducing the rates of mortality or adverse patient outcomes (Kramer et al p 11)

Schmalenberg amp Kramer (2009)

Review of six research studies

Essentials of Magnetism

Concepts of nurse-physician relationship(collegial collaborative student-teacher friendly stranger hostileadversarial

3602 staff nurses in 16 Magnet and 10 non-Magnet hospitals in the 2003 study

10514 staff nurses in 18 Magnet and 16 non-Magnet hospitals in the 2007 study

In 2003 physician-nurse relationship scores in Magnet hospitals were statistically significant and higher when compared to non-Magnet hospitals (F ratio 21279 P less than 0001)

In 2007 the higher scores in Magnet hospitals were also statistically significant (F ratio 14446 P less than 0001)(Schmalenberg pp 78-79)

Zwarenstein Goldman amp Reeves (2009)

Cochrane Systematic Review

Not specifically mentioned

Five studies about collaborative interventions

interprofessional roundsmeetings

externally facilitated interprofessional audit

no randomized controlled studies about the impacts of interdisciplinary collaboration (Zwarenstein et al p 8)

ldquoProblems with conceptualising and measuring collaborationrdquo No ldquogeneralizable inferences about interprofessional collaborationrdquo (Zwarenstein et al p 2)

Literature Review (Level Three Evidence)

Research Articles

Research Methods

Theoretical frameworksMeasurement Instruments

Samples Data AnalysesStudy Findings

Boone King Gresham Wahl amp Suh (2008)

Quasi-experimental (Pre- and Post- Test for the training in assertiveness and cooperation)

Kilmann and Thomasrsquo model of conflict resolution (accommodating avoidance competition compromise collaboration)

Collaborative Behavior Scale

9 nurses from the cardiovascular laboratory (experimental group) and 18 nurses from the telemetry unit (control group)

Non-probability sampling in an American hospital

No statistical significance for the Collaborative Behavior Scale beforeafter the training between the experimental group and the control group ldquop more than 005rdquo (Boone et al p 172)

the communication style of ldquoavoidancerdquo was associated with increased nursesrsquo emotional stress (Boone et al p 173)

Implication explore barriers before training programs involve physiciansrsquo participations

McCaffrey HayesCassell Miller-Reyes Donaldson amp Ferrell (2012)

Quasi-experimental (Pre- and Post-test for training in communication skills)

Jefferson Scale of Attitudes

68 nurses and 47 medical residents in a Florida hospital

Non-probability sampling

statistical significance (P=0001) of the T-test before and after the 6-month educational program for enhancing physician-nurse collegiality communication skills mutual decision-making processes (McCaffrey et al p 298)

Literature Review (Level Four Evidence)Research Articles

Research Studies

Theoretical Frameworks

Measurement Instruments

Samples Data AnalysesStudy Findings

Hendel Fish amp Berger (2007)

Cross-sectional Correlational study

Thomas-Kilman Model of Conflict Resolution

Conflict Mode Instrument (MODE)

75 physicians 54 charge nurses at 5 acute care hospitals in Israel

Non-probability sampling

charge nurses were more likely to use the ldquocollaboratingrdquo communication style when compared to physicians (P=0001) (Hendel et al p 249)

Karanikola et al (2012)

Descriptive Correlational study

Hamiltonrsquos Anxiety Scale

Stamprsquos Index of Work Satisfaction

2-stage random probability sampling

11 hospitals randomly selected in Greece then 229 nurses at intensive care units randomly selected

Satisfaction in physician communication was statistically significant and negatively associated with intensive care nursesrsquo anxiety level ldquocorrelation coefficient Kendall = -0160 P=0001rdquo and depressed mood ldquocorrelation coefficient = -0148 P=0005rdquo (p 41)

Limitations confounding variables of nursesrsquo personal psychiatric or psychological histories

Manojlovich amp DeCicco (2007)

Descriptive Cross-sectional Non-experimental

Concepts of workplace empowerment ICU Nurse-Physician QuestionnairePractice Environment Scale of the Nursing Work Index

462 nursesrsquo perceptions in 25 intensive care units from 8 Michigan hospitals

Non-probability sampling

statistical significance for the positive correlation of physician-nurse miscommunication to the perceived outcomes in medication errors (p 542)

Limitation not generalized findings not reflect cause-effect relationships

Literature Review (Level Four Evidence continued)

Research Articles

Research Studies

Theoretical Framework

Measurement Instruments

Samples Data AnalysesStudy Findings

Rosenstein amp ODaniel (2008)

Non-experimentalstudy quantitative and qualitative approach

Instrument ldquoNurse-Physician Impact of disruptive Behavior on Patient Carerdquo

Convenience samples 2846 nurses 944 physicians from 102 not-for-profit VHA member hospitals in the US from 2004 to 2007

physician-nurse disturbing behaviors are likely to reduce patient safety outcomes and nurse satisfaction Narrative data eg ldquoafraid to call Drrdquo ldquoget yelled atrdquo ldquopoor communication postoprdquo (Rosenstein amp OrsquoDaniel p 467)

67 respondents perceived that disruptive behaviors were associated with adverse patient outcomes (medical errors and patient mortality) (Rosenstein amp OrsquoDaniel p 464)

Limitation theoretical framework not specifically describedStrength large sample size

Rothsteinamp Hannum (2007)

Cross-sectional

Gender model (male physician dominance and nurse deference)

Professional model

self-reported close-ended questionnaire on nurse-physician relationship

125 advanced practice nursesAPN at a statewide professional conference

non-probability sampling

statistical significance for APNrsquo s positive attitudecommunication with female physicians (less than 50 years old) and male physicians (of all ages) male and female physicians are also likely to be positive and respectful about APNrsquos knowledge in patient care (2-tailed t test and one-way analysis of variance P value less than 005) (Rothstein amp Hannum p 238)

The gender model for the authoritative dominance of male physicians is not applicable to the female APNs who have at least a masterrsquos degree in nursing (p 235)

Limitation confounding variables not measured ldquotype and size of the work organization nurse and physician specialties and patient illness and social characteristicsrdquo (p 239)

Literature Review (Level Six Evidence)

Research

Article

Research Method

Theoretical Framework

Sample Study Findings

Gardezi Lingard Espin Whyte Orser amp Baker (2009)

Qualitative study

Ethnographic approach

Retrospective study

Critical Theory about silence in communication

observed physician-nurse communications over 700 surgeries at 3 acute care hospitals from 2005 to 2007 in Canada

Narrative and descriptive data about conflicts in physician-nurse communication styles at operating rooms due to nursesrsquo gap in knowledge about surgical procedures and surgeonsrsquo dominant authoritative power

Nursesrsquo passivesilent communication method had negative impacts on patient safety during surgeries (Gardezi et al p 1391)

Limitations evidence-based practice cannot be based on one qualitative study

Strengths explore the descriptive lived experiences about physician-nurse communication barriers over 2 years

Analysis of Evidence

The ability to critically analyze evidence presented in various research projects is necessary to evaluate the work for applicability and use in evidence based nursing practice ldquoTo use research evidence one must be able to evaluate this evidencerdquo (Nieswiadomy 2012 p 298)

bull STRENGTH OF EVIDENCEbull LEVEL 1 (HIGHEST)bull EXPERIMENTAL STUDY (RANDOMIZED CONTROLLED TRAIL OR RCT)bull bull Study participants (subjects) are randomly assigned to either a treatment (TX) or

controlbull (non-treatment) groupbull bull May bebull o Blind neither subject nor investigator knows which TX subject is receivingbull o Double-blind neither subject nor investigator knows which TX subject is receivingbull o Non-blind both subject and investigator know which TX subject is receiving usedbull when it is felt that the knowledge of treatment is unimportantbull META-ANALYSIS OF RCTSbull bull Quantitatively synthesizes and analyzes results of multiple primary studies addressing

abull similar research questionbull bull Statistically pools results from independent but combinable studiesbull bull Summary statistic (effect size) is expressed in terms of direction (positive negative

orbull zero) and magnitude (high medium small)

bull LEVEL 2bull QUASI-EXPERIMENTAL STUDYbull bull Always includes manipulation of an independent variablebull bull Lacks either random assignment or control groupbull bull Findings must be considered in light of threats to validity (particularly selection)

bull LEVEL 3bull NON-EXPERIMENTAL STUDYbull bull No manipulation of the independent variablebull bull Can be descriptive comparative or relationalbull bull Often uses secondary databull bull Findings must be considered in light of threats to validity (particularly selection lack

ofbull severity or co-morbidity adjustment)

bull QUALITATIVE STUDYbull 1048707 Explorative in nature such as interviews observations or focus groupsbull 1048707 Starting point for studies of questions for which little research currently existsbull 1048707 Sample sizes are usually small and study results are used to design stronger studies

thatbull are more objective and quantifiable

bull META-SYNTHESISbull 1048707 Research technique that critically analyzes and synthesizes findings from qualitativebull researchbull 1048707 Identifies key concepts and metaphors and determines their relationships to each

otherbull 1048707 Aim is not to produce a summary statistic but rather to interpret and

translate findings

JHNEBP Research Evidence Appraisal

The Johns Hopkins HospitalThe Johns Hopkins University

QUALITY RATING (SCIENTIFIC EVIDENCE)

A High quality consistent results sufficient sample size adequate control and

bull definitive conclusions consistent recommendations based on extensive literature

bull review that includes thoughtful reference to scientific evidence

B Good quality reasonably consistent results sufficient sample size some control

bull and fairly definitive conclusions reasonably consistent recommendations based

bull on fairly comprehensive literature review that includes some reference to

bull scientific evidence

C Low quality or major flaws little evidence with inconsistent results insufficient

bull sample size conclusions cannot be drawn

Article 1 ldquoConflict management training and nurse-physician collaborative behaviorsrdquo(Boone et al 2008)bull Quantitative quasi-experimental designbull The researchers are highly qualified and experiencedbull Convenience sample which closely approximates the real world experiencebull This study is ethically sound as a written explanation of the study was provided and

informed consent was obtainedbull The problem is clearly stated to examine a knowledge gap between a unit specific

intervention (conflict management training) and improved communication and collaboration between physicians and nurses

bull Theoretical framework Kilmann and Thomas conflict resolution theory (Boone et al 2008 p 168)

bull Findings reveal that the intervention was unsuccessful (The null hypothesis not rejected)

bull The importance of continued research for interventions that promote quality communication and collaboration is stressed

bull Creating a culture that values quality communication and collaboration forms the basis for developing a healthy work environment

bull Level of evidence varies by tool used but is evaluated as II or III Both levels are credible for utilization in evidence based care

bull Informed consent was obtained from all participants

Article 2 ldquoNine structures and leadership practices essential for a magnetic (healthy) work environmentrdquo (Kramer et al 2010)

bull This is a quantitative meta-analysis of thirty professional publications bull The problem is clearly stated to identify what structures and leadership

practices are necessary to support a healthy work environmentbull The researchers are experienced and well qualifiedbull The sample size was good Over 1300 interviews of expert nurses nurse

managers and physicians were compiled for comparison to findings from regulatory and professional organizations

bull The theoretical framework is based on the Donabedian model (httpwwwahrqgovqualmedteammedteamfig2htm) of patient safety

bull Healthy work environments lead to improved patient and nurse outcomesbull Creating a culture of interdisciplinary collaboration and teamwork through

shared power and administrative support were important themesbull This is a valid level I for evidence by all methods (course modules interview

with hospital research specialist and Johns Hopkins Nursing Research Evidence Appraisal) Level I is the highest level of evidence for utilization in evidence based practice

Structuresbest leadership practices essential for healthy work environments

Quality leadership at all levels in the organization

Availability of and support for education career performance and competence development

Administrative sanction for autonomous and collaborative practice

Evidence-based practice education and operational supports

Culture practice and opportunity to learn interdisciplinary collaboration

Empowered shared decision-making structures for control of the context of nursing practice

Generation and nurturance of a patient-centered culture

Staffing structures that take into account RN competence patient acuity and teamwork

Development and support of intradisciplinary teamwork

Article 3 ldquoThe effect of an educational programme on attitudes of nurses and medical residents towards the benefit of positive communication and collaborationrdquo(McCaffrey et al 2012)bull This is a quasi-experimental study based on a convenience sample of nurses and

medical residents bull The researchers are experienced and well qualifiedbull The research question is clearly statedbull Ethical research guidelines are carefully adhered tobull A pre and post-test design based on the Jefferson Scale of Attitudes towards

Physician-Nurse Collaboration and the Communication Collaboration and Critical Thinking for Quality Patient Outcomes tools Both tools are proven to be reliable and valid (the Cronbachrsquos alpha coefficient of 087-092)

bull A critical finding in this study is that ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Statistical findings reveal that the chosen intervention of an educational programme to improve physician-nurse communication and collaboration was beneficial

bull This study is evaluated as evidence level III due to lack of a control group by two methods (Ford 2012 C Bongiorno personal communication November 26 2012) Alternatively it is rated as level II on the Johns Hopkins scale (JHNEBP Research Evidence Appraisal nd)

Article 4 ldquoNurse-physician relationships in hospitals 20000 nurses tell their storyrdquo (Schmalenberg amp Kramer 2009)

bull This study is a quantitative synthesis of the findings of six research studies based on the Essentials of Magnetism

bull The researchers are experienced and highly qualifiedbull The purpose of the study is several fold 1) To discern what constitutes quality

communication and collaboration between physicians and nurses 2) Define types of nurse-physician relationships 3) Define organizational structures and leadership practices that help develop collaborative nurse-physician relationships and 4) Study differences in nurse-physician relationships between magnet and comparison hospitals

bull The sample size of 20616 staff nurses is excellentbull Thorough literature review is the foundation for this studybull It was consistently reported that nurses at magnet hospitals reported higher quality

relationships with physicians than the comparison hospitalsbull Structures that improve relationships and are supported by magnet institutions are

keep the patient first develop constructive conflict resolution techniques and have collaborative interdisciplinary patient rounds

bull Nurses can play an active role in bringing about these interventionsbull This is a double blinded peer review of six studies clearly making it evidence level I by

all methods

Percentage of staff nurses responding affirmatively to nurse-physician relationship types by magnet

and comparison hospitals and by period

Application of Evidence for oncology nursing practice (Lai Harper)

bull Utilize the Cochrane Database or the ldquoJHNEBP Research Evidence Appraisalrdquo as the research tools effectively communicate and collaborate with oncologists about the nursing perspective on evidence-based practice

bull Ongoing literature review for the most current credible and high-quality evidence-based practice for reducing oncology patientsrsquo physical psychological and emotional issues (such as pain nausea anxiety or depression)

bull Recommend the hospital nursing research committee to initiate a survey to explore possible physician-nurse communication barriers at an oncology unit

bull Recommend the implementation of the low-cost convenient computer-based training in physician-nurse communication skills

Application of Evidence at the Cardiovascular Department (Margaret Siler)

bull High quality communication and collaboration make a great difference in the cardiac catheterization laboratory (Boone King Gresham Wahl amp Suh 2008 p 168)

bull Experience and a broad knowledge base bring confidence to our daily work (Schmalenberg amp Kramer 2009 p 82)

bull All involved parties (patient nurse physician healthcare system) can reap the benefits of collaborative practice (Kramer et al 2012 p 7)

bull There are many educational opportunities available to improve interdisciplinary and interdepartmental communication Many are quite costly Some that may make the biggest difference are fairly inexpensive including Unit Action Council work and interdepartmental job shadowing (McCaffery et al 2012)

Application of Evidence into the Surgical Setting (Gary Webster)

Intra-operative settings place nurses and physicians in close collaborative work

settings The typical communication style is authoritarian Schmalenberg and

Kramer (2009) stated that physicians felt the nurse-physician relation to be more

collaborative than nurse did I can see that being true in my work environment

The Boone et al (2008) and McCaffrey (2011) articles combined are very

valuable Together the articles show a successful attempt to increase collaboration

and some pitfalls to avoid These can help direct any programs to support an

increase in collaboration

Application of Evidence (Jamie Ziemba)

bull Poor communication between nurses and physicians related to language and cultural barriers

bull Physiciansrsquo dysfunctional or authoritarian communication style (eg instruct nurses not to call at night unless it is a life-and-death emergency) is a major patient safety issue

bull As the patient advocate nurses have an important role of communicating with physicians to verify medication orders clinical procedures and improve patient outcomes

bull Hospital training programs in communication skills and cultural diversities are recommended for physicians and nurses with different culturalethnic backgrounds

Summary Statements

bull Meta-analytical review of evidence-based research articles support the clinical significance of effective communication styles

bull Authoritarian communication styles increase disruptive behaviors and negative hostile relationships at work environments

bull Healthy work environments have positive effects on nurses physicians patients and healthcare organizations

bull Inter-disciplinary collaboration is an essential aspect of healthy work environmentsbull Evidence-based studies have shown positive patient outcomes nursing job

satisfaction collaborative environments at Magnet hospitalsbull There is a need to address the barriers and incorporate educational programs to teach

effective communication and the need for collaboration Educational training should be re-enforced with weekly discussions ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Educate staff on the 5 types of nurse-physician relationships (collegial collaborative teacher-student friendly-stranger and hostileadversarial relationships)

bull Teach staff how to utilize positive relationships and change negative onesbull Training should avoid focusing on negative behaviorsbull Training should focus creating cooperative behaviors

ReferencesAgency for Healthcare Research and Quality (nd) Medical teamwork and patient safety The Donabedian model of patient safety Retrieved

from httpwwwahrqgovqualmedteammedteamfig2htm

American Nurses Association (1980) Nursing A social policy statement Washington DC American Nurses Association

Ballou K amp Landreneau K (2010) The authoritarian reign in American health care Policy Politics amp Nursing Practice 11(1) 71-79

doi1011771527154410372973

Boone B King M Gresham L Wahl P amp Suh E (2008) Conflict management training and nurse-physician collaborative behaviors

Journal For Nurses In Staff Development 24(4) 168-175 doi10109701NND00003206705641591

Burns N amp Grove S (2007) Understanding Nursing Research Building an Evidence Based Practice (4th Ed) St Louis Missouri Saunders

Elsevier Publishing

Ford L (2012) Week 8 amp 9 Critique of Research Retrieved from httpsfsulearnferriseduwebappsportalframesetjsp

tab_tab_group_id=_2_1ampurl=2Fwebapps2Fblackboard2Fexecute2Flauncher3Ftype3DCourseampid3D_2241_1ampurl3D

Gardezi F Lingard L Espin S Whyte S Orser B amp Baker G (2009) Silence power and communication in the operating room

Journal Of Advanced Nursing 65(7) 1390-1399 doi101111j1365-2648200904994x

Hendel T Fish M amp Berger O (2007) Nursephysician conflict management mode choices implications for improved collaborative

practice Nursing Administration Quarterly 31(3) 244-253

John Hopkins UniversityJohn Hopkins Hospital (nd) JHNEBP Research Evidence Appraisal Retrieved from

httpwwwnursingworldorgDocumentVaultNursingPracticeResearch-ToolkitJHNEBP-Research-Evidence-Appraisalpdf

Karanikola M Papathanassoglou E Kalafati M Stathopoulou H Mpouzika M amp Goutsikas C G (2012) Exploration of the

Association Between Professional Interactions and Emotional Distress of Intensive Care Unit Nursing Personnel Dimensions Of Critical

Care Nursing 31(1) 37-45 doi101097DCC0b013e31823a55b8

ReferencesKramer M Schmalenberg C amp Maguire P (2010) Nine structures and leadership practices essential for a magnetic (healthy)

work environment Nursing Administration Quarterly 34(1) 4-17 doi101097NAQ0b013e3181c95ef4

Manojlovich M amp DeCicco B (2007) Healthy work environments nurse-physician communication and patients outcome American Journal Of Critical Care 16(6) 536-543

McCaffrey R Hayes R Cassell A Miller-Reyes S Donaldson A amp Ferrell C (2012) The effect of an educational programme on attitudes of nurses and medical residents towards the benefits of positive communication and collaboration Journal Of Advanced Nursing 68(2) 293-301 doi101111j1365-2648201105736x

Nieswiadomy R M (2012) Foundations of Nursing Research (6th Ed) Upper Saddle River New Jersey Prentice Hall

Rosenstein A amp ODaniel M (2008) A survey of the impact of disruptive behaviors and communication defects on patient safety Joint Commission Journal On Quality amp Patient Safety 34(8) 464-471

Rothstein W amp Hannum S (2007) Profession and gender in relationships between advanced practice nurses and physicians Journal Of Professional Nursing 23(4) 235-240 doi101016jprofnurs200701008

Saxton R Hines T amp Enriquez M (2009) The negative impact of nurse-physician disruptive behavior on patient safety A review of the literature Journal of Patient Safety 5(3) 180-183

Stone P W (2002) Popping the PICO question in research and evidence-based practice Applied Nursing Research 16(2) 197-198

Schmalenberg C amp Kramer M (2009) Nurse-physician relationships in hospitals 20 000 nurses tell their story Critical Care Nurse 29(1) 74-83 doi104037ccn2009436

Zwarenstein M Goldman J amp Reeves S (2009) Interprofessional collaboration Effects of practice-based interventions on professional practice and healthcare outcomes Cochrane Database Of Systematic Reviews (3) 1-31 doi10100214651858CD000072

NURS 350 Evidence-Based Nursing Practice (Group paper plus Group Powerpoint presentation)

Total group grade 100Instructorrsquos comments Excellent paper I think your group

should consider submitting it for publication if you could flesh out the details on improving collaborative communication

• Ferris State University NURS 350 Evidence-Based Nursing Practic
• ldquoCommunication--the human connection--is the key to pers
• Slide 3
• What is patient safety
• What is acute care
• What is Professional Communication
• Communication between medical professionals is not just a local
• PICO Question
• Definitions
• A Survey of the Impacts of Disruptive Behaviors and Communicat
• A Survey of the Impacts of Disruptive Behaviors and Communicat (2)
• Literature Review (Level One Evidence)
• Literature Review (Level Three Evidence)
• Literature Review (Level Four Evidence)
• Literature Review (Level Four Evidence continued)
• Literature Review (Level Six Evidence)
• Analysis of Evidence
• Slide 18
• Slide 19
• Article 1 ldquoConflict management training and nurse-physician
• Article 2 ldquoNine structures and leadership practices essentia
• Slide 22
• Article 3 ldquoThe effect of an educational programme on attitud
• Article 4 ldquoNurse-physician relationships in hospitals 2000
• Percentage of staff nurses responding affirmatively to nurse-ph
• Application of Evidence for oncology nursing practice (Lai Har
• Application of Evidence at the Cardiovascular Department (Marg
• Application of Evidence into the Surgical Setting (Gary Webste
• Slide 29
• Summary Statements
• References
• References (2)
• NURS 350 Evidence-Based Nursing Practice (Group paper plus Gr

PICO Question

For adult patients in an acute care setting what does the literature reveal about the DIFFERENCE in communication styles (collaboration interdisciplinary versus segmented authoritarian) between physicians and nurses on indicators of nurse satisfaction rates and patient safety outcomes

Definitions

bull According to the American Nurses Association ldquocollaborationrdquo is ldquoa true partnership in which the power on both sides is valued by both with recognition and acceptance of separate and combined practice spheres of activity and responsibility mutual safeguarding of the legitimate interests of each party and a commonality of goals that is recognized by both partiesrdquo (Hendel Fish amp Berger 2007 p 251)

bull Ballou and Landreneau (2010) discuss that ldquoauthoritarian persons typify an outlook that is ethnocentric rigid and anti-democraticrdquo (p 71)

bull ldquoSegmentedrdquo ldquodivided into or composed of segments or sectionsrdquo ldquoAuthoritarianrdquo ldquoof relating to or favoring blind submission to authorityrdquo (Merriam-Webster Dictionary 2012)

A Survey of the Impacts of Disruptive Behaviors and Communication Defects on Patient Safety

Sample size N= 4530 From January 2004 to March 2007How often do you think disruptive behavior results in the following at your hospital

(Sometimes Frequent and Constant)

How often do you think that there is a link between disruptive behavior and the following

clinical outcomes at your hospital (Sometimes Frequent and Constant)

Adver

se E

vent

s

Error

s

Patient

Saf

ety

Qualit

y of

Car

e

Patient

Mor

talit

y

6771

51

71

27

Stres

s

Frustra

tion

Loss o

f con

cent

ratio

n

Reduc

ed te

am col

labo

ratio

n

Reduc

ed in

form

atio

n tran

sfer

Reduc

ed com

mun

icat

ion

Impa

ired

RNM

D

94 94

83

8987

91

99

A Survey of the Impacts of Disruptive Behaviors and Communication Defects on Patient Safety

Sample size N= 4530 From January 2004 to March 2007

Have your ever witnessed any disruptive behavior from a physician at your hospital

Have you ever witnessed any disruptive behavior from a nurse at your hospital

Aggre

gate

MD

(ph

ysician)

RN (

nurs

e)

Admin

stra

tive ex

ecut

ives

Other

77

51

88

78

66

Aggre

gate

MD

(ph

ysician)

RN (

nurs

e)

Admin

istra

tive ex

ecut

ives

Other

65

48

7377

64

Literature Review (Level One Evidence)Research Articles

Research Methods

Theoretical frameworksMeasurement Instruments

Samples Data AnalysesStudy Findings

Kramer Schmalenbeg amp Maguire (2010)

Meta-analysis of multiple published studies

Donabedianrsquos conceptual framework of structure process and outcome

Heberlein and Baumgartnerrsquosmethodology

12 publications from 7 professional and regulatory organizations

18 publications from studies using the Essential of Magnetism (including 1300 interviews with nurses physicians and mangers)

positive physician-nurse communication collaborative leadership and autonomy in Magnet hospitals (Kramer et al p 11)

Nursesrsquo autonomous role in identifying patientsrsquo worsening conditions (need to rescueNTR) for reducing the rates of mortality or adverse patient outcomes (Kramer et al p 11)

Schmalenberg amp Kramer (2009)

Review of six research studies

Essentials of Magnetism

Concepts of nurse-physician relationship(collegial collaborative student-teacher friendly stranger hostileadversarial

3602 staff nurses in 16 Magnet and 10 non-Magnet hospitals in the 2003 study

10514 staff nurses in 18 Magnet and 16 non-Magnet hospitals in the 2007 study

In 2003 physician-nurse relationship scores in Magnet hospitals were statistically significant and higher when compared to non-Magnet hospitals (F ratio 21279 P less than 0001)

In 2007 the higher scores in Magnet hospitals were also statistically significant (F ratio 14446 P less than 0001)(Schmalenberg pp 78-79)

Zwarenstein Goldman amp Reeves (2009)

Cochrane Systematic Review

Not specifically mentioned

Five studies about collaborative interventions

interprofessional roundsmeetings

externally facilitated interprofessional audit

no randomized controlled studies about the impacts of interdisciplinary collaboration (Zwarenstein et al p 8)

ldquoProblems with conceptualising and measuring collaborationrdquo No ldquogeneralizable inferences about interprofessional collaborationrdquo (Zwarenstein et al p 2)

Literature Review (Level Three Evidence)

Research Articles

Research Methods

Theoretical frameworksMeasurement Instruments

Samples Data AnalysesStudy Findings

Boone King Gresham Wahl amp Suh (2008)

Quasi-experimental (Pre- and Post- Test for the training in assertiveness and cooperation)

Kilmann and Thomasrsquo model of conflict resolution (accommodating avoidance competition compromise collaboration)

Collaborative Behavior Scale

9 nurses from the cardiovascular laboratory (experimental group) and 18 nurses from the telemetry unit (control group)

Non-probability sampling in an American hospital

No statistical significance for the Collaborative Behavior Scale beforeafter the training between the experimental group and the control group ldquop more than 005rdquo (Boone et al p 172)

the communication style of ldquoavoidancerdquo was associated with increased nursesrsquo emotional stress (Boone et al p 173)

Implication explore barriers before training programs involve physiciansrsquo participations

McCaffrey HayesCassell Miller-Reyes Donaldson amp Ferrell (2012)

Quasi-experimental (Pre- and Post-test for training in communication skills)

Jefferson Scale of Attitudes

68 nurses and 47 medical residents in a Florida hospital

Non-probability sampling

statistical significance (P=0001) of the T-test before and after the 6-month educational program for enhancing physician-nurse collegiality communication skills mutual decision-making processes (McCaffrey et al p 298)

Literature Review (Level Four Evidence)Research Articles

Research Studies

Theoretical Frameworks

Measurement Instruments

Samples Data AnalysesStudy Findings

Hendel Fish amp Berger (2007)

Cross-sectional Correlational study

Thomas-Kilman Model of Conflict Resolution

Conflict Mode Instrument (MODE)

75 physicians 54 charge nurses at 5 acute care hospitals in Israel

Non-probability sampling

charge nurses were more likely to use the ldquocollaboratingrdquo communication style when compared to physicians (P=0001) (Hendel et al p 249)

Karanikola et al (2012)

Descriptive Correlational study

Hamiltonrsquos Anxiety Scale

Stamprsquos Index of Work Satisfaction

2-stage random probability sampling

11 hospitals randomly selected in Greece then 229 nurses at intensive care units randomly selected

Satisfaction in physician communication was statistically significant and negatively associated with intensive care nursesrsquo anxiety level ldquocorrelation coefficient Kendall = -0160 P=0001rdquo and depressed mood ldquocorrelation coefficient = -0148 P=0005rdquo (p 41)

Limitations confounding variables of nursesrsquo personal psychiatric or psychological histories

Manojlovich amp DeCicco (2007)

Descriptive Cross-sectional Non-experimental

Concepts of workplace empowerment ICU Nurse-Physician QuestionnairePractice Environment Scale of the Nursing Work Index

462 nursesrsquo perceptions in 25 intensive care units from 8 Michigan hospitals

Non-probability sampling

statistical significance for the positive correlation of physician-nurse miscommunication to the perceived outcomes in medication errors (p 542)

Limitation not generalized findings not reflect cause-effect relationships

Literature Review (Level Four Evidence continued)

Research Articles

Research Studies

Theoretical Framework

Measurement Instruments

Samples Data AnalysesStudy Findings

Rosenstein amp ODaniel (2008)

Non-experimentalstudy quantitative and qualitative approach

Instrument ldquoNurse-Physician Impact of disruptive Behavior on Patient Carerdquo

Convenience samples 2846 nurses 944 physicians from 102 not-for-profit VHA member hospitals in the US from 2004 to 2007

physician-nurse disturbing behaviors are likely to reduce patient safety outcomes and nurse satisfaction Narrative data eg ldquoafraid to call Drrdquo ldquoget yelled atrdquo ldquopoor communication postoprdquo (Rosenstein amp OrsquoDaniel p 467)

67 respondents perceived that disruptive behaviors were associated with adverse patient outcomes (medical errors and patient mortality) (Rosenstein amp OrsquoDaniel p 464)

Limitation theoretical framework not specifically describedStrength large sample size

Rothsteinamp Hannum (2007)

Cross-sectional

Gender model (male physician dominance and nurse deference)

Professional model

self-reported close-ended questionnaire on nurse-physician relationship

125 advanced practice nursesAPN at a statewide professional conference

non-probability sampling

statistical significance for APNrsquo s positive attitudecommunication with female physicians (less than 50 years old) and male physicians (of all ages) male and female physicians are also likely to be positive and respectful about APNrsquos knowledge in patient care (2-tailed t test and one-way analysis of variance P value less than 005) (Rothstein amp Hannum p 238)

The gender model for the authoritative dominance of male physicians is not applicable to the female APNs who have at least a masterrsquos degree in nursing (p 235)

Limitation confounding variables not measured ldquotype and size of the work organization nurse and physician specialties and patient illness and social characteristicsrdquo (p 239)

Literature Review (Level Six Evidence)

Research

Article

Research Method

Theoretical Framework

Sample Study Findings

Gardezi Lingard Espin Whyte Orser amp Baker (2009)

Qualitative study

Ethnographic approach

Retrospective study

Critical Theory about silence in communication

observed physician-nurse communications over 700 surgeries at 3 acute care hospitals from 2005 to 2007 in Canada

Narrative and descriptive data about conflicts in physician-nurse communication styles at operating rooms due to nursesrsquo gap in knowledge about surgical procedures and surgeonsrsquo dominant authoritative power

Nursesrsquo passivesilent communication method had negative impacts on patient safety during surgeries (Gardezi et al p 1391)

Limitations evidence-based practice cannot be based on one qualitative study

Strengths explore the descriptive lived experiences about physician-nurse communication barriers over 2 years

Analysis of Evidence

The ability to critically analyze evidence presented in various research projects is necessary to evaluate the work for applicability and use in evidence based nursing practice ldquoTo use research evidence one must be able to evaluate this evidencerdquo (Nieswiadomy 2012 p 298)

bull STRENGTH OF EVIDENCEbull LEVEL 1 (HIGHEST)bull EXPERIMENTAL STUDY (RANDOMIZED CONTROLLED TRAIL OR RCT)bull bull Study participants (subjects) are randomly assigned to either a treatment (TX) or

controlbull (non-treatment) groupbull bull May bebull o Blind neither subject nor investigator knows which TX subject is receivingbull o Double-blind neither subject nor investigator knows which TX subject is receivingbull o Non-blind both subject and investigator know which TX subject is receiving usedbull when it is felt that the knowledge of treatment is unimportantbull META-ANALYSIS OF RCTSbull bull Quantitatively synthesizes and analyzes results of multiple primary studies addressing

abull similar research questionbull bull Statistically pools results from independent but combinable studiesbull bull Summary statistic (effect size) is expressed in terms of direction (positive negative

orbull zero) and magnitude (high medium small)

bull LEVEL 2bull QUASI-EXPERIMENTAL STUDYbull bull Always includes manipulation of an independent variablebull bull Lacks either random assignment or control groupbull bull Findings must be considered in light of threats to validity (particularly selection)

bull LEVEL 3bull NON-EXPERIMENTAL STUDYbull bull No manipulation of the independent variablebull bull Can be descriptive comparative or relationalbull bull Often uses secondary databull bull Findings must be considered in light of threats to validity (particularly selection lack

ofbull severity or co-morbidity adjustment)

bull QUALITATIVE STUDYbull 1048707 Explorative in nature such as interviews observations or focus groupsbull 1048707 Starting point for studies of questions for which little research currently existsbull 1048707 Sample sizes are usually small and study results are used to design stronger studies

thatbull are more objective and quantifiable

bull META-SYNTHESISbull 1048707 Research technique that critically analyzes and synthesizes findings from qualitativebull researchbull 1048707 Identifies key concepts and metaphors and determines their relationships to each

otherbull 1048707 Aim is not to produce a summary statistic but rather to interpret and

translate findings

JHNEBP Research Evidence Appraisal

The Johns Hopkins HospitalThe Johns Hopkins University

QUALITY RATING (SCIENTIFIC EVIDENCE)

A High quality consistent results sufficient sample size adequate control and

bull definitive conclusions consistent recommendations based on extensive literature

bull review that includes thoughtful reference to scientific evidence

B Good quality reasonably consistent results sufficient sample size some control

bull and fairly definitive conclusions reasonably consistent recommendations based

bull on fairly comprehensive literature review that includes some reference to

bull scientific evidence

C Low quality or major flaws little evidence with inconsistent results insufficient

bull sample size conclusions cannot be drawn

Article 1 ldquoConflict management training and nurse-physician collaborative behaviorsrdquo(Boone et al 2008)bull Quantitative quasi-experimental designbull The researchers are highly qualified and experiencedbull Convenience sample which closely approximates the real world experiencebull This study is ethically sound as a written explanation of the study was provided and

informed consent was obtainedbull The problem is clearly stated to examine a knowledge gap between a unit specific

intervention (conflict management training) and improved communication and collaboration between physicians and nurses

bull Theoretical framework Kilmann and Thomas conflict resolution theory (Boone et al 2008 p 168)

bull Findings reveal that the intervention was unsuccessful (The null hypothesis not rejected)

bull The importance of continued research for interventions that promote quality communication and collaboration is stressed

bull Creating a culture that values quality communication and collaboration forms the basis for developing a healthy work environment

bull Level of evidence varies by tool used but is evaluated as II or III Both levels are credible for utilization in evidence based care

bull Informed consent was obtained from all participants

Article 2 ldquoNine structures and leadership practices essential for a magnetic (healthy) work environmentrdquo (Kramer et al 2010)

bull This is a quantitative meta-analysis of thirty professional publications bull The problem is clearly stated to identify what structures and leadership

practices are necessary to support a healthy work environmentbull The researchers are experienced and well qualifiedbull The sample size was good Over 1300 interviews of expert nurses nurse

managers and physicians were compiled for comparison to findings from regulatory and professional organizations

bull The theoretical framework is based on the Donabedian model (httpwwwahrqgovqualmedteammedteamfig2htm) of patient safety

bull Healthy work environments lead to improved patient and nurse outcomesbull Creating a culture of interdisciplinary collaboration and teamwork through

shared power and administrative support were important themesbull This is a valid level I for evidence by all methods (course modules interview

with hospital research specialist and Johns Hopkins Nursing Research Evidence Appraisal) Level I is the highest level of evidence for utilization in evidence based practice

Structuresbest leadership practices essential for healthy work environments

Quality leadership at all levels in the organization

Availability of and support for education career performance and competence development

Administrative sanction for autonomous and collaborative practice

Evidence-based practice education and operational supports

Culture practice and opportunity to learn interdisciplinary collaboration

Empowered shared decision-making structures for control of the context of nursing practice

Generation and nurturance of a patient-centered culture

Staffing structures that take into account RN competence patient acuity and teamwork

Development and support of intradisciplinary teamwork

Article 3 ldquoThe effect of an educational programme on attitudes of nurses and medical residents towards the benefit of positive communication and collaborationrdquo(McCaffrey et al 2012)bull This is a quasi-experimental study based on a convenience sample of nurses and

medical residents bull The researchers are experienced and well qualifiedbull The research question is clearly statedbull Ethical research guidelines are carefully adhered tobull A pre and post-test design based on the Jefferson Scale of Attitudes towards

Physician-Nurse Collaboration and the Communication Collaboration and Critical Thinking for Quality Patient Outcomes tools Both tools are proven to be reliable and valid (the Cronbachrsquos alpha coefficient of 087-092)

bull A critical finding in this study is that ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Statistical findings reveal that the chosen intervention of an educational programme to improve physician-nurse communication and collaboration was beneficial

bull This study is evaluated as evidence level III due to lack of a control group by two methods (Ford 2012 C Bongiorno personal communication November 26 2012) Alternatively it is rated as level II on the Johns Hopkins scale (JHNEBP Research Evidence Appraisal nd)

Article 4 ldquoNurse-physician relationships in hospitals 20000 nurses tell their storyrdquo (Schmalenberg amp Kramer 2009)

bull This study is a quantitative synthesis of the findings of six research studies based on the Essentials of Magnetism

bull The researchers are experienced and highly qualifiedbull The purpose of the study is several fold 1) To discern what constitutes quality

communication and collaboration between physicians and nurses 2) Define types of nurse-physician relationships 3) Define organizational structures and leadership practices that help develop collaborative nurse-physician relationships and 4) Study differences in nurse-physician relationships between magnet and comparison hospitals

bull The sample size of 20616 staff nurses is excellentbull Thorough literature review is the foundation for this studybull It was consistently reported that nurses at magnet hospitals reported higher quality

relationships with physicians than the comparison hospitalsbull Structures that improve relationships and are supported by magnet institutions are

keep the patient first develop constructive conflict resolution techniques and have collaborative interdisciplinary patient rounds

bull Nurses can play an active role in bringing about these interventionsbull This is a double blinded peer review of six studies clearly making it evidence level I by

all methods

Percentage of staff nurses responding affirmatively to nurse-physician relationship types by magnet

and comparison hospitals and by period

Application of Evidence for oncology nursing practice (Lai Harper)

bull Utilize the Cochrane Database or the ldquoJHNEBP Research Evidence Appraisalrdquo as the research tools effectively communicate and collaborate with oncologists about the nursing perspective on evidence-based practice

bull Ongoing literature review for the most current credible and high-quality evidence-based practice for reducing oncology patientsrsquo physical psychological and emotional issues (such as pain nausea anxiety or depression)

bull Recommend the hospital nursing research committee to initiate a survey to explore possible physician-nurse communication barriers at an oncology unit

bull Recommend the implementation of the low-cost convenient computer-based training in physician-nurse communication skills

Application of Evidence at the Cardiovascular Department (Margaret Siler)

bull High quality communication and collaboration make a great difference in the cardiac catheterization laboratory (Boone King Gresham Wahl amp Suh 2008 p 168)

bull Experience and a broad knowledge base bring confidence to our daily work (Schmalenberg amp Kramer 2009 p 82)

bull All involved parties (patient nurse physician healthcare system) can reap the benefits of collaborative practice (Kramer et al 2012 p 7)

bull There are many educational opportunities available to improve interdisciplinary and interdepartmental communication Many are quite costly Some that may make the biggest difference are fairly inexpensive including Unit Action Council work and interdepartmental job shadowing (McCaffery et al 2012)

Application of Evidence into the Surgical Setting (Gary Webster)

Intra-operative settings place nurses and physicians in close collaborative work

settings The typical communication style is authoritarian Schmalenberg and

Kramer (2009) stated that physicians felt the nurse-physician relation to be more

collaborative than nurse did I can see that being true in my work environment

The Boone et al (2008) and McCaffrey (2011) articles combined are very

valuable Together the articles show a successful attempt to increase collaboration

and some pitfalls to avoid These can help direct any programs to support an

increase in collaboration

Application of Evidence (Jamie Ziemba)

bull Poor communication between nurses and physicians related to language and cultural barriers

bull Physiciansrsquo dysfunctional or authoritarian communication style (eg instruct nurses not to call at night unless it is a life-and-death emergency) is a major patient safety issue

bull As the patient advocate nurses have an important role of communicating with physicians to verify medication orders clinical procedures and improve patient outcomes

bull Hospital training programs in communication skills and cultural diversities are recommended for physicians and nurses with different culturalethnic backgrounds

Summary Statements

bull Meta-analytical review of evidence-based research articles support the clinical significance of effective communication styles

bull Authoritarian communication styles increase disruptive behaviors and negative hostile relationships at work environments

bull Healthy work environments have positive effects on nurses physicians patients and healthcare organizations

bull Inter-disciplinary collaboration is an essential aspect of healthy work environmentsbull Evidence-based studies have shown positive patient outcomes nursing job

satisfaction collaborative environments at Magnet hospitalsbull There is a need to address the barriers and incorporate educational programs to teach

effective communication and the need for collaboration Educational training should be re-enforced with weekly discussions ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Educate staff on the 5 types of nurse-physician relationships (collegial collaborative teacher-student friendly-stranger and hostileadversarial relationships)

bull Teach staff how to utilize positive relationships and change negative onesbull Training should avoid focusing on negative behaviorsbull Training should focus creating cooperative behaviors

ReferencesAgency for Healthcare Research and Quality (nd) Medical teamwork and patient safety The Donabedian model of patient safety Retrieved

from httpwwwahrqgovqualmedteammedteamfig2htm

American Nurses Association (1980) Nursing A social policy statement Washington DC American Nurses Association

Ballou K amp Landreneau K (2010) The authoritarian reign in American health care Policy Politics amp Nursing Practice 11(1) 71-79

doi1011771527154410372973

Boone B King M Gresham L Wahl P amp Suh E (2008) Conflict management training and nurse-physician collaborative behaviors

Journal For Nurses In Staff Development 24(4) 168-175 doi10109701NND00003206705641591

Burns N amp Grove S (2007) Understanding Nursing Research Building an Evidence Based Practice (4th Ed) St Louis Missouri Saunders

Elsevier Publishing

Ford L (2012) Week 8 amp 9 Critique of Research Retrieved from httpsfsulearnferriseduwebappsportalframesetjsp

tab_tab_group_id=_2_1ampurl=2Fwebapps2Fblackboard2Fexecute2Flauncher3Ftype3DCourseampid3D_2241_1ampurl3D

Gardezi F Lingard L Espin S Whyte S Orser B amp Baker G (2009) Silence power and communication in the operating room

Journal Of Advanced Nursing 65(7) 1390-1399 doi101111j1365-2648200904994x

Hendel T Fish M amp Berger O (2007) Nursephysician conflict management mode choices implications for improved collaborative

practice Nursing Administration Quarterly 31(3) 244-253

John Hopkins UniversityJohn Hopkins Hospital (nd) JHNEBP Research Evidence Appraisal Retrieved from

httpwwwnursingworldorgDocumentVaultNursingPracticeResearch-ToolkitJHNEBP-Research-Evidence-Appraisalpdf

Karanikola M Papathanassoglou E Kalafati M Stathopoulou H Mpouzika M amp Goutsikas C G (2012) Exploration of the

Association Between Professional Interactions and Emotional Distress of Intensive Care Unit Nursing Personnel Dimensions Of Critical

Care Nursing 31(1) 37-45 doi101097DCC0b013e31823a55b8

ReferencesKramer M Schmalenberg C amp Maguire P (2010) Nine structures and leadership practices essential for a magnetic (healthy)

work environment Nursing Administration Quarterly 34(1) 4-17 doi101097NAQ0b013e3181c95ef4

Manojlovich M amp DeCicco B (2007) Healthy work environments nurse-physician communication and patients outcome American Journal Of Critical Care 16(6) 536-543

McCaffrey R Hayes R Cassell A Miller-Reyes S Donaldson A amp Ferrell C (2012) The effect of an educational programme on attitudes of nurses and medical residents towards the benefits of positive communication and collaboration Journal Of Advanced Nursing 68(2) 293-301 doi101111j1365-2648201105736x

Nieswiadomy R M (2012) Foundations of Nursing Research (6th Ed) Upper Saddle River New Jersey Prentice Hall

Rosenstein A amp ODaniel M (2008) A survey of the impact of disruptive behaviors and communication defects on patient safety Joint Commission Journal On Quality amp Patient Safety 34(8) 464-471

Rothstein W amp Hannum S (2007) Profession and gender in relationships between advanced practice nurses and physicians Journal Of Professional Nursing 23(4) 235-240 doi101016jprofnurs200701008

Saxton R Hines T amp Enriquez M (2009) The negative impact of nurse-physician disruptive behavior on patient safety A review of the literature Journal of Patient Safety 5(3) 180-183

Stone P W (2002) Popping the PICO question in research and evidence-based practice Applied Nursing Research 16(2) 197-198

Schmalenberg C amp Kramer M (2009) Nurse-physician relationships in hospitals 20 000 nurses tell their story Critical Care Nurse 29(1) 74-83 doi104037ccn2009436

Zwarenstein M Goldman J amp Reeves S (2009) Interprofessional collaboration Effects of practice-based interventions on professional practice and healthcare outcomes Cochrane Database Of Systematic Reviews (3) 1-31 doi10100214651858CD000072

NURS 350 Evidence-Based Nursing Practice (Group paper plus Group Powerpoint presentation)

Total group grade 100Instructorrsquos comments Excellent paper I think your group

should consider submitting it for publication if you could flesh out the details on improving collaborative communication

• Ferris State University NURS 350 Evidence-Based Nursing Practic
• ldquoCommunication--the human connection--is the key to pers
• Slide 3
• What is patient safety
• What is acute care
• What is Professional Communication
• Communication between medical professionals is not just a local
• PICO Question
• Definitions
• A Survey of the Impacts of Disruptive Behaviors and Communicat
• A Survey of the Impacts of Disruptive Behaviors and Communicat (2)
• Literature Review (Level One Evidence)
• Literature Review (Level Three Evidence)
• Literature Review (Level Four Evidence)
• Literature Review (Level Four Evidence continued)
• Literature Review (Level Six Evidence)
• Analysis of Evidence
• Slide 18
• Slide 19
• Article 1 ldquoConflict management training and nurse-physician
• Article 2 ldquoNine structures and leadership practices essentia
• Slide 22
• Article 3 ldquoThe effect of an educational programme on attitud
• Article 4 ldquoNurse-physician relationships in hospitals 2000
• Percentage of staff nurses responding affirmatively to nurse-ph
• Application of Evidence for oncology nursing practice (Lai Har
• Application of Evidence at the Cardiovascular Department (Marg
• Application of Evidence into the Surgical Setting (Gary Webste
• Slide 29
• Summary Statements
• References
• References (2)
• NURS 350 Evidence-Based Nursing Practice (Group paper plus Gr

Definitions

bull According to the American Nurses Association ldquocollaborationrdquo is ldquoa true partnership in which the power on both sides is valued by both with recognition and acceptance of separate and combined practice spheres of activity and responsibility mutual safeguarding of the legitimate interests of each party and a commonality of goals that is recognized by both partiesrdquo (Hendel Fish amp Berger 2007 p 251)

bull Ballou and Landreneau (2010) discuss that ldquoauthoritarian persons typify an outlook that is ethnocentric rigid and anti-democraticrdquo (p 71)

bull ldquoSegmentedrdquo ldquodivided into or composed of segments or sectionsrdquo ldquoAuthoritarianrdquo ldquoof relating to or favoring blind submission to authorityrdquo (Merriam-Webster Dictionary 2012)

A Survey of the Impacts of Disruptive Behaviors and Communication Defects on Patient Safety

Sample size N= 4530 From January 2004 to March 2007How often do you think disruptive behavior results in the following at your hospital

(Sometimes Frequent and Constant)

How often do you think that there is a link between disruptive behavior and the following

clinical outcomes at your hospital (Sometimes Frequent and Constant)

Adver

se E

vent

s

Error

s

Patient

Saf

ety

Qualit

y of

Car

e

Patient

Mor

talit

y

6771

51

71

27

Stres

s

Frustra

tion

Loss o

f con

cent

ratio

n

Reduc

ed te

am col

labo

ratio

n

Reduc

ed in

form

atio

n tran

sfer

Reduc

ed com

mun

icat

ion

Impa

ired

RNM

D

94 94

83

8987

91

99

A Survey of the Impacts of Disruptive Behaviors and Communication Defects on Patient Safety

Sample size N= 4530 From January 2004 to March 2007

Have your ever witnessed any disruptive behavior from a physician at your hospital

Have you ever witnessed any disruptive behavior from a nurse at your hospital

Aggre

gate

MD

(ph

ysician)

RN (

nurs

e)

Admin

stra

tive ex

ecut

ives

Other

77

51

88

78

66

Aggre

gate

MD

(ph

ysician)

RN (

nurs

e)

Admin

istra

tive ex

ecut

ives

Other

65

48

7377

64

Literature Review (Level One Evidence)Research Articles

Research Methods

Theoretical frameworksMeasurement Instruments

Samples Data AnalysesStudy Findings

Kramer Schmalenbeg amp Maguire (2010)

Meta-analysis of multiple published studies

Donabedianrsquos conceptual framework of structure process and outcome

Heberlein and Baumgartnerrsquosmethodology

12 publications from 7 professional and regulatory organizations

18 publications from studies using the Essential of Magnetism (including 1300 interviews with nurses physicians and mangers)

positive physician-nurse communication collaborative leadership and autonomy in Magnet hospitals (Kramer et al p 11)

Nursesrsquo autonomous role in identifying patientsrsquo worsening conditions (need to rescueNTR) for reducing the rates of mortality or adverse patient outcomes (Kramer et al p 11)

Schmalenberg amp Kramer (2009)

Review of six research studies

Essentials of Magnetism

Concepts of nurse-physician relationship(collegial collaborative student-teacher friendly stranger hostileadversarial

3602 staff nurses in 16 Magnet and 10 non-Magnet hospitals in the 2003 study

10514 staff nurses in 18 Magnet and 16 non-Magnet hospitals in the 2007 study

In 2003 physician-nurse relationship scores in Magnet hospitals were statistically significant and higher when compared to non-Magnet hospitals (F ratio 21279 P less than 0001)

In 2007 the higher scores in Magnet hospitals were also statistically significant (F ratio 14446 P less than 0001)(Schmalenberg pp 78-79)

Zwarenstein Goldman amp Reeves (2009)

Cochrane Systematic Review

Not specifically mentioned

Five studies about collaborative interventions

interprofessional roundsmeetings

externally facilitated interprofessional audit

no randomized controlled studies about the impacts of interdisciplinary collaboration (Zwarenstein et al p 8)

ldquoProblems with conceptualising and measuring collaborationrdquo No ldquogeneralizable inferences about interprofessional collaborationrdquo (Zwarenstein et al p 2)

Literature Review (Level Three Evidence)

Research Articles

Research Methods

Theoretical frameworksMeasurement Instruments

Samples Data AnalysesStudy Findings

Boone King Gresham Wahl amp Suh (2008)

Quasi-experimental (Pre- and Post- Test for the training in assertiveness and cooperation)

Kilmann and Thomasrsquo model of conflict resolution (accommodating avoidance competition compromise collaboration)

Collaborative Behavior Scale

9 nurses from the cardiovascular laboratory (experimental group) and 18 nurses from the telemetry unit (control group)

Non-probability sampling in an American hospital

No statistical significance for the Collaborative Behavior Scale beforeafter the training between the experimental group and the control group ldquop more than 005rdquo (Boone et al p 172)

the communication style of ldquoavoidancerdquo was associated with increased nursesrsquo emotional stress (Boone et al p 173)

Implication explore barriers before training programs involve physiciansrsquo participations

McCaffrey HayesCassell Miller-Reyes Donaldson amp Ferrell (2012)

Quasi-experimental (Pre- and Post-test for training in communication skills)

Jefferson Scale of Attitudes

68 nurses and 47 medical residents in a Florida hospital

Non-probability sampling

statistical significance (P=0001) of the T-test before and after the 6-month educational program for enhancing physician-nurse collegiality communication skills mutual decision-making processes (McCaffrey et al p 298)

Literature Review (Level Four Evidence)Research Articles

Research Studies

Theoretical Frameworks

Measurement Instruments

Samples Data AnalysesStudy Findings

Hendel Fish amp Berger (2007)

Cross-sectional Correlational study

Thomas-Kilman Model of Conflict Resolution

Conflict Mode Instrument (MODE)

75 physicians 54 charge nurses at 5 acute care hospitals in Israel

Non-probability sampling

charge nurses were more likely to use the ldquocollaboratingrdquo communication style when compared to physicians (P=0001) (Hendel et al p 249)

Karanikola et al (2012)

Descriptive Correlational study

Hamiltonrsquos Anxiety Scale

Stamprsquos Index of Work Satisfaction

2-stage random probability sampling

11 hospitals randomly selected in Greece then 229 nurses at intensive care units randomly selected

Satisfaction in physician communication was statistically significant and negatively associated with intensive care nursesrsquo anxiety level ldquocorrelation coefficient Kendall = -0160 P=0001rdquo and depressed mood ldquocorrelation coefficient = -0148 P=0005rdquo (p 41)

Limitations confounding variables of nursesrsquo personal psychiatric or psychological histories

Manojlovich amp DeCicco (2007)

Descriptive Cross-sectional Non-experimental

Concepts of workplace empowerment ICU Nurse-Physician QuestionnairePractice Environment Scale of the Nursing Work Index

462 nursesrsquo perceptions in 25 intensive care units from 8 Michigan hospitals

Non-probability sampling

statistical significance for the positive correlation of physician-nurse miscommunication to the perceived outcomes in medication errors (p 542)

Limitation not generalized findings not reflect cause-effect relationships

Literature Review (Level Four Evidence continued)

Research Articles

Research Studies

Theoretical Framework

Measurement Instruments

Samples Data AnalysesStudy Findings

Rosenstein amp ODaniel (2008)

Non-experimentalstudy quantitative and qualitative approach

Instrument ldquoNurse-Physician Impact of disruptive Behavior on Patient Carerdquo

Convenience samples 2846 nurses 944 physicians from 102 not-for-profit VHA member hospitals in the US from 2004 to 2007

physician-nurse disturbing behaviors are likely to reduce patient safety outcomes and nurse satisfaction Narrative data eg ldquoafraid to call Drrdquo ldquoget yelled atrdquo ldquopoor communication postoprdquo (Rosenstein amp OrsquoDaniel p 467)

67 respondents perceived that disruptive behaviors were associated with adverse patient outcomes (medical errors and patient mortality) (Rosenstein amp OrsquoDaniel p 464)

Limitation theoretical framework not specifically describedStrength large sample size

Rothsteinamp Hannum (2007)

Cross-sectional

Gender model (male physician dominance and nurse deference)

Professional model

self-reported close-ended questionnaire on nurse-physician relationship

125 advanced practice nursesAPN at a statewide professional conference

non-probability sampling

statistical significance for APNrsquo s positive attitudecommunication with female physicians (less than 50 years old) and male physicians (of all ages) male and female physicians are also likely to be positive and respectful about APNrsquos knowledge in patient care (2-tailed t test and one-way analysis of variance P value less than 005) (Rothstein amp Hannum p 238)

The gender model for the authoritative dominance of male physicians is not applicable to the female APNs who have at least a masterrsquos degree in nursing (p 235)

Limitation confounding variables not measured ldquotype and size of the work organization nurse and physician specialties and patient illness and social characteristicsrdquo (p 239)

Literature Review (Level Six Evidence)

Research

Article

Research Method

Theoretical Framework

Sample Study Findings

Gardezi Lingard Espin Whyte Orser amp Baker (2009)

Qualitative study

Ethnographic approach

Retrospective study

Critical Theory about silence in communication

observed physician-nurse communications over 700 surgeries at 3 acute care hospitals from 2005 to 2007 in Canada

Narrative and descriptive data about conflicts in physician-nurse communication styles at operating rooms due to nursesrsquo gap in knowledge about surgical procedures and surgeonsrsquo dominant authoritative power

Nursesrsquo passivesilent communication method had negative impacts on patient safety during surgeries (Gardezi et al p 1391)

Limitations evidence-based practice cannot be based on one qualitative study

Strengths explore the descriptive lived experiences about physician-nurse communication barriers over 2 years

Analysis of Evidence

The ability to critically analyze evidence presented in various research projects is necessary to evaluate the work for applicability and use in evidence based nursing practice ldquoTo use research evidence one must be able to evaluate this evidencerdquo (Nieswiadomy 2012 p 298)

bull STRENGTH OF EVIDENCEbull LEVEL 1 (HIGHEST)bull EXPERIMENTAL STUDY (RANDOMIZED CONTROLLED TRAIL OR RCT)bull bull Study participants (subjects) are randomly assigned to either a treatment (TX) or

controlbull (non-treatment) groupbull bull May bebull o Blind neither subject nor investigator knows which TX subject is receivingbull o Double-blind neither subject nor investigator knows which TX subject is receivingbull o Non-blind both subject and investigator know which TX subject is receiving usedbull when it is felt that the knowledge of treatment is unimportantbull META-ANALYSIS OF RCTSbull bull Quantitatively synthesizes and analyzes results of multiple primary studies addressing

abull similar research questionbull bull Statistically pools results from independent but combinable studiesbull bull Summary statistic (effect size) is expressed in terms of direction (positive negative

orbull zero) and magnitude (high medium small)

bull LEVEL 2bull QUASI-EXPERIMENTAL STUDYbull bull Always includes manipulation of an independent variablebull bull Lacks either random assignment or control groupbull bull Findings must be considered in light of threats to validity (particularly selection)

bull LEVEL 3bull NON-EXPERIMENTAL STUDYbull bull No manipulation of the independent variablebull bull Can be descriptive comparative or relationalbull bull Often uses secondary databull bull Findings must be considered in light of threats to validity (particularly selection lack

ofbull severity or co-morbidity adjustment)

bull QUALITATIVE STUDYbull 1048707 Explorative in nature such as interviews observations or focus groupsbull 1048707 Starting point for studies of questions for which little research currently existsbull 1048707 Sample sizes are usually small and study results are used to design stronger studies

thatbull are more objective and quantifiable

bull META-SYNTHESISbull 1048707 Research technique that critically analyzes and synthesizes findings from qualitativebull researchbull 1048707 Identifies key concepts and metaphors and determines their relationships to each

otherbull 1048707 Aim is not to produce a summary statistic but rather to interpret and

translate findings

JHNEBP Research Evidence Appraisal

The Johns Hopkins HospitalThe Johns Hopkins University

QUALITY RATING (SCIENTIFIC EVIDENCE)

A High quality consistent results sufficient sample size adequate control and

bull definitive conclusions consistent recommendations based on extensive literature

bull review that includes thoughtful reference to scientific evidence

B Good quality reasonably consistent results sufficient sample size some control

bull and fairly definitive conclusions reasonably consistent recommendations based

bull on fairly comprehensive literature review that includes some reference to

bull scientific evidence

C Low quality or major flaws little evidence with inconsistent results insufficient

bull sample size conclusions cannot be drawn

Article 1 ldquoConflict management training and nurse-physician collaborative behaviorsrdquo(Boone et al 2008)bull Quantitative quasi-experimental designbull The researchers are highly qualified and experiencedbull Convenience sample which closely approximates the real world experiencebull This study is ethically sound as a written explanation of the study was provided and

informed consent was obtainedbull The problem is clearly stated to examine a knowledge gap between a unit specific

intervention (conflict management training) and improved communication and collaboration between physicians and nurses

bull Theoretical framework Kilmann and Thomas conflict resolution theory (Boone et al 2008 p 168)

bull Findings reveal that the intervention was unsuccessful (The null hypothesis not rejected)

bull The importance of continued research for interventions that promote quality communication and collaboration is stressed

bull Creating a culture that values quality communication and collaboration forms the basis for developing a healthy work environment

bull Level of evidence varies by tool used but is evaluated as II or III Both levels are credible for utilization in evidence based care

bull Informed consent was obtained from all participants

Article 2 ldquoNine structures and leadership practices essential for a magnetic (healthy) work environmentrdquo (Kramer et al 2010)

bull This is a quantitative meta-analysis of thirty professional publications bull The problem is clearly stated to identify what structures and leadership

practices are necessary to support a healthy work environmentbull The researchers are experienced and well qualifiedbull The sample size was good Over 1300 interviews of expert nurses nurse

managers and physicians were compiled for comparison to findings from regulatory and professional organizations

bull The theoretical framework is based on the Donabedian model (httpwwwahrqgovqualmedteammedteamfig2htm) of patient safety

bull Healthy work environments lead to improved patient and nurse outcomesbull Creating a culture of interdisciplinary collaboration and teamwork through

shared power and administrative support were important themesbull This is a valid level I for evidence by all methods (course modules interview

with hospital research specialist and Johns Hopkins Nursing Research Evidence Appraisal) Level I is the highest level of evidence for utilization in evidence based practice

Structuresbest leadership practices essential for healthy work environments

Quality leadership at all levels in the organization

Availability of and support for education career performance and competence development

Administrative sanction for autonomous and collaborative practice

Evidence-based practice education and operational supports

Culture practice and opportunity to learn interdisciplinary collaboration

Empowered shared decision-making structures for control of the context of nursing practice

Generation and nurturance of a patient-centered culture

Staffing structures that take into account RN competence patient acuity and teamwork

Development and support of intradisciplinary teamwork

Article 3 ldquoThe effect of an educational programme on attitudes of nurses and medical residents towards the benefit of positive communication and collaborationrdquo(McCaffrey et al 2012)bull This is a quasi-experimental study based on a convenience sample of nurses and

medical residents bull The researchers are experienced and well qualifiedbull The research question is clearly statedbull Ethical research guidelines are carefully adhered tobull A pre and post-test design based on the Jefferson Scale of Attitudes towards

Physician-Nurse Collaboration and the Communication Collaboration and Critical Thinking for Quality Patient Outcomes tools Both tools are proven to be reliable and valid (the Cronbachrsquos alpha coefficient of 087-092)

bull A critical finding in this study is that ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Statistical findings reveal that the chosen intervention of an educational programme to improve physician-nurse communication and collaboration was beneficial

bull This study is evaluated as evidence level III due to lack of a control group by two methods (Ford 2012 C Bongiorno personal communication November 26 2012) Alternatively it is rated as level II on the Johns Hopkins scale (JHNEBP Research Evidence Appraisal nd)

Article 4 ldquoNurse-physician relationships in hospitals 20000 nurses tell their storyrdquo (Schmalenberg amp Kramer 2009)

bull This study is a quantitative synthesis of the findings of six research studies based on the Essentials of Magnetism

bull The researchers are experienced and highly qualifiedbull The purpose of the study is several fold 1) To discern what constitutes quality

communication and collaboration between physicians and nurses 2) Define types of nurse-physician relationships 3) Define organizational structures and leadership practices that help develop collaborative nurse-physician relationships and 4) Study differences in nurse-physician relationships between magnet and comparison hospitals

bull The sample size of 20616 staff nurses is excellentbull Thorough literature review is the foundation for this studybull It was consistently reported that nurses at magnet hospitals reported higher quality

relationships with physicians than the comparison hospitalsbull Structures that improve relationships and are supported by magnet institutions are

keep the patient first develop constructive conflict resolution techniques and have collaborative interdisciplinary patient rounds

bull Nurses can play an active role in bringing about these interventionsbull This is a double blinded peer review of six studies clearly making it evidence level I by

all methods

Percentage of staff nurses responding affirmatively to nurse-physician relationship types by magnet

and comparison hospitals and by period

Application of Evidence for oncology nursing practice (Lai Harper)

bull Utilize the Cochrane Database or the ldquoJHNEBP Research Evidence Appraisalrdquo as the research tools effectively communicate and collaborate with oncologists about the nursing perspective on evidence-based practice

bull Ongoing literature review for the most current credible and high-quality evidence-based practice for reducing oncology patientsrsquo physical psychological and emotional issues (such as pain nausea anxiety or depression)

bull Recommend the hospital nursing research committee to initiate a survey to explore possible physician-nurse communication barriers at an oncology unit

bull Recommend the implementation of the low-cost convenient computer-based training in physician-nurse communication skills

Application of Evidence at the Cardiovascular Department (Margaret Siler)

bull High quality communication and collaboration make a great difference in the cardiac catheterization laboratory (Boone King Gresham Wahl amp Suh 2008 p 168)

bull Experience and a broad knowledge base bring confidence to our daily work (Schmalenberg amp Kramer 2009 p 82)

bull All involved parties (patient nurse physician healthcare system) can reap the benefits of collaborative practice (Kramer et al 2012 p 7)

bull There are many educational opportunities available to improve interdisciplinary and interdepartmental communication Many are quite costly Some that may make the biggest difference are fairly inexpensive including Unit Action Council work and interdepartmental job shadowing (McCaffery et al 2012)

Application of Evidence into the Surgical Setting (Gary Webster)

Intra-operative settings place nurses and physicians in close collaborative work

settings The typical communication style is authoritarian Schmalenberg and

Kramer (2009) stated that physicians felt the nurse-physician relation to be more

collaborative than nurse did I can see that being true in my work environment

The Boone et al (2008) and McCaffrey (2011) articles combined are very

valuable Together the articles show a successful attempt to increase collaboration

and some pitfalls to avoid These can help direct any programs to support an

increase in collaboration

Application of Evidence (Jamie Ziemba)

bull Poor communication between nurses and physicians related to language and cultural barriers

bull Physiciansrsquo dysfunctional or authoritarian communication style (eg instruct nurses not to call at night unless it is a life-and-death emergency) is a major patient safety issue

bull As the patient advocate nurses have an important role of communicating with physicians to verify medication orders clinical procedures and improve patient outcomes

bull Hospital training programs in communication skills and cultural diversities are recommended for physicians and nurses with different culturalethnic backgrounds

Summary Statements

bull Meta-analytical review of evidence-based research articles support the clinical significance of effective communication styles

bull Authoritarian communication styles increase disruptive behaviors and negative hostile relationships at work environments

bull Healthy work environments have positive effects on nurses physicians patients and healthcare organizations

bull Inter-disciplinary collaboration is an essential aspect of healthy work environmentsbull Evidence-based studies have shown positive patient outcomes nursing job

satisfaction collaborative environments at Magnet hospitalsbull There is a need to address the barriers and incorporate educational programs to teach

effective communication and the need for collaboration Educational training should be re-enforced with weekly discussions ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Educate staff on the 5 types of nurse-physician relationships (collegial collaborative teacher-student friendly-stranger and hostileadversarial relationships)

bull Teach staff how to utilize positive relationships and change negative onesbull Training should avoid focusing on negative behaviorsbull Training should focus creating cooperative behaviors

ReferencesAgency for Healthcare Research and Quality (nd) Medical teamwork and patient safety The Donabedian model of patient safety Retrieved

from httpwwwahrqgovqualmedteammedteamfig2htm

American Nurses Association (1980) Nursing A social policy statement Washington DC American Nurses Association

Ballou K amp Landreneau K (2010) The authoritarian reign in American health care Policy Politics amp Nursing Practice 11(1) 71-79

doi1011771527154410372973

Boone B King M Gresham L Wahl P amp Suh E (2008) Conflict management training and nurse-physician collaborative behaviors

Journal For Nurses In Staff Development 24(4) 168-175 doi10109701NND00003206705641591

Burns N amp Grove S (2007) Understanding Nursing Research Building an Evidence Based Practice (4th Ed) St Louis Missouri Saunders

Elsevier Publishing

Ford L (2012) Week 8 amp 9 Critique of Research Retrieved from httpsfsulearnferriseduwebappsportalframesetjsp

tab_tab_group_id=_2_1ampurl=2Fwebapps2Fblackboard2Fexecute2Flauncher3Ftype3DCourseampid3D_2241_1ampurl3D

Gardezi F Lingard L Espin S Whyte S Orser B amp Baker G (2009) Silence power and communication in the operating room

Journal Of Advanced Nursing 65(7) 1390-1399 doi101111j1365-2648200904994x

Hendel T Fish M amp Berger O (2007) Nursephysician conflict management mode choices implications for improved collaborative

practice Nursing Administration Quarterly 31(3) 244-253

John Hopkins UniversityJohn Hopkins Hospital (nd) JHNEBP Research Evidence Appraisal Retrieved from

httpwwwnursingworldorgDocumentVaultNursingPracticeResearch-ToolkitJHNEBP-Research-Evidence-Appraisalpdf

Karanikola M Papathanassoglou E Kalafati M Stathopoulou H Mpouzika M amp Goutsikas C G (2012) Exploration of the

Association Between Professional Interactions and Emotional Distress of Intensive Care Unit Nursing Personnel Dimensions Of Critical

Care Nursing 31(1) 37-45 doi101097DCC0b013e31823a55b8

ReferencesKramer M Schmalenberg C amp Maguire P (2010) Nine structures and leadership practices essential for a magnetic (healthy)

work environment Nursing Administration Quarterly 34(1) 4-17 doi101097NAQ0b013e3181c95ef4

Manojlovich M amp DeCicco B (2007) Healthy work environments nurse-physician communication and patients outcome American Journal Of Critical Care 16(6) 536-543

McCaffrey R Hayes R Cassell A Miller-Reyes S Donaldson A amp Ferrell C (2012) The effect of an educational programme on attitudes of nurses and medical residents towards the benefits of positive communication and collaboration Journal Of Advanced Nursing 68(2) 293-301 doi101111j1365-2648201105736x

Nieswiadomy R M (2012) Foundations of Nursing Research (6th Ed) Upper Saddle River New Jersey Prentice Hall

Rosenstein A amp ODaniel M (2008) A survey of the impact of disruptive behaviors and communication defects on patient safety Joint Commission Journal On Quality amp Patient Safety 34(8) 464-471

Rothstein W amp Hannum S (2007) Profession and gender in relationships between advanced practice nurses and physicians Journal Of Professional Nursing 23(4) 235-240 doi101016jprofnurs200701008

Saxton R Hines T amp Enriquez M (2009) The negative impact of nurse-physician disruptive behavior on patient safety A review of the literature Journal of Patient Safety 5(3) 180-183

Stone P W (2002) Popping the PICO question in research and evidence-based practice Applied Nursing Research 16(2) 197-198

Schmalenberg C amp Kramer M (2009) Nurse-physician relationships in hospitals 20 000 nurses tell their story Critical Care Nurse 29(1) 74-83 doi104037ccn2009436

Zwarenstein M Goldman J amp Reeves S (2009) Interprofessional collaboration Effects of practice-based interventions on professional practice and healthcare outcomes Cochrane Database Of Systematic Reviews (3) 1-31 doi10100214651858CD000072

NURS 350 Evidence-Based Nursing Practice (Group paper plus Group Powerpoint presentation)

Total group grade 100Instructorrsquos comments Excellent paper I think your group

should consider submitting it for publication if you could flesh out the details on improving collaborative communication

• Ferris State University NURS 350 Evidence-Based Nursing Practic
• ldquoCommunication--the human connection--is the key to pers
• Slide 3
• What is patient safety
• What is acute care
• What is Professional Communication
• Communication between medical professionals is not just a local
• PICO Question
• Definitions
• A Survey of the Impacts of Disruptive Behaviors and Communicat
• A Survey of the Impacts of Disruptive Behaviors and Communicat (2)
• Literature Review (Level One Evidence)
• Literature Review (Level Three Evidence)
• Literature Review (Level Four Evidence)
• Literature Review (Level Four Evidence continued)
• Literature Review (Level Six Evidence)
• Analysis of Evidence
• Slide 18
• Slide 19
• Article 1 ldquoConflict management training and nurse-physician
• Article 2 ldquoNine structures and leadership practices essentia
• Slide 22
• Article 3 ldquoThe effect of an educational programme on attitud
• Article 4 ldquoNurse-physician relationships in hospitals 2000
• Percentage of staff nurses responding affirmatively to nurse-ph
• Application of Evidence for oncology nursing practice (Lai Har
• Application of Evidence at the Cardiovascular Department (Marg
• Application of Evidence into the Surgical Setting (Gary Webste
• Slide 29
• Summary Statements
• References
• References (2)
• NURS 350 Evidence-Based Nursing Practice (Group paper plus Gr

A Survey of the Impacts of Disruptive Behaviors and Communication Defects on Patient Safety

Sample size N= 4530 From January 2004 to March 2007How often do you think disruptive behavior results in the following at your hospital

(Sometimes Frequent and Constant)

How often do you think that there is a link between disruptive behavior and the following

clinical outcomes at your hospital (Sometimes Frequent and Constant)

Adver

se E

vent

s

Error

s

Patient

Saf

ety

Qualit

y of

Car

e

Patient

Mor

talit

y

6771

51

71

27

Stres

s

Frustra

tion

Loss o

f con

cent

ratio

n

Reduc

ed te

am col

labo

ratio

n

Reduc

ed in

form

atio

n tran

sfer

Reduc

ed com

mun

icat

ion

Impa

ired

RNM

D

94 94

83

8987

91

99

A Survey of the Impacts of Disruptive Behaviors and Communication Defects on Patient Safety

Sample size N= 4530 From January 2004 to March 2007

Have your ever witnessed any disruptive behavior from a physician at your hospital

Have you ever witnessed any disruptive behavior from a nurse at your hospital

Aggre

gate

MD

(ph

ysician)

RN (

nurs

e)

Admin

stra

tive ex

ecut

ives

Other

77

51

88

78

66

Aggre

gate

MD

(ph

ysician)

RN (

nurs

e)

Admin

istra

tive ex

ecut

ives

Other

65

48

7377

64

Literature Review (Level One Evidence)Research Articles

Research Methods

Theoretical frameworksMeasurement Instruments

Samples Data AnalysesStudy Findings

Kramer Schmalenbeg amp Maguire (2010)

Meta-analysis of multiple published studies

Donabedianrsquos conceptual framework of structure process and outcome

Heberlein and Baumgartnerrsquosmethodology

12 publications from 7 professional and regulatory organizations

18 publications from studies using the Essential of Magnetism (including 1300 interviews with nurses physicians and mangers)

positive physician-nurse communication collaborative leadership and autonomy in Magnet hospitals (Kramer et al p 11)

Nursesrsquo autonomous role in identifying patientsrsquo worsening conditions (need to rescueNTR) for reducing the rates of mortality or adverse patient outcomes (Kramer et al p 11)

Schmalenberg amp Kramer (2009)

Review of six research studies

Essentials of Magnetism

Concepts of nurse-physician relationship(collegial collaborative student-teacher friendly stranger hostileadversarial

3602 staff nurses in 16 Magnet and 10 non-Magnet hospitals in the 2003 study

10514 staff nurses in 18 Magnet and 16 non-Magnet hospitals in the 2007 study

In 2003 physician-nurse relationship scores in Magnet hospitals were statistically significant and higher when compared to non-Magnet hospitals (F ratio 21279 P less than 0001)

In 2007 the higher scores in Magnet hospitals were also statistically significant (F ratio 14446 P less than 0001)(Schmalenberg pp 78-79)

Zwarenstein Goldman amp Reeves (2009)

Cochrane Systematic Review

Not specifically mentioned

Five studies about collaborative interventions

interprofessional roundsmeetings

externally facilitated interprofessional audit

no randomized controlled studies about the impacts of interdisciplinary collaboration (Zwarenstein et al p 8)

ldquoProblems with conceptualising and measuring collaborationrdquo No ldquogeneralizable inferences about interprofessional collaborationrdquo (Zwarenstein et al p 2)

Literature Review (Level Three Evidence)

Research Articles

Research Methods

Theoretical frameworksMeasurement Instruments

Samples Data AnalysesStudy Findings

Boone King Gresham Wahl amp Suh (2008)

Quasi-experimental (Pre- and Post- Test for the training in assertiveness and cooperation)

Kilmann and Thomasrsquo model of conflict resolution (accommodating avoidance competition compromise collaboration)

Collaborative Behavior Scale

9 nurses from the cardiovascular laboratory (experimental group) and 18 nurses from the telemetry unit (control group)

Non-probability sampling in an American hospital

No statistical significance for the Collaborative Behavior Scale beforeafter the training between the experimental group and the control group ldquop more than 005rdquo (Boone et al p 172)

the communication style of ldquoavoidancerdquo was associated with increased nursesrsquo emotional stress (Boone et al p 173)

Implication explore barriers before training programs involve physiciansrsquo participations

McCaffrey HayesCassell Miller-Reyes Donaldson amp Ferrell (2012)

Quasi-experimental (Pre- and Post-test for training in communication skills)

Jefferson Scale of Attitudes

68 nurses and 47 medical residents in a Florida hospital

Non-probability sampling

statistical significance (P=0001) of the T-test before and after the 6-month educational program for enhancing physician-nurse collegiality communication skills mutual decision-making processes (McCaffrey et al p 298)

Literature Review (Level Four Evidence)Research Articles

Research Studies

Theoretical Frameworks

Measurement Instruments

Samples Data AnalysesStudy Findings

Hendel Fish amp Berger (2007)

Cross-sectional Correlational study

Thomas-Kilman Model of Conflict Resolution

Conflict Mode Instrument (MODE)

75 physicians 54 charge nurses at 5 acute care hospitals in Israel

Non-probability sampling

charge nurses were more likely to use the ldquocollaboratingrdquo communication style when compared to physicians (P=0001) (Hendel et al p 249)

Karanikola et al (2012)

Descriptive Correlational study

Hamiltonrsquos Anxiety Scale

Stamprsquos Index of Work Satisfaction

2-stage random probability sampling

11 hospitals randomly selected in Greece then 229 nurses at intensive care units randomly selected

Satisfaction in physician communication was statistically significant and negatively associated with intensive care nursesrsquo anxiety level ldquocorrelation coefficient Kendall = -0160 P=0001rdquo and depressed mood ldquocorrelation coefficient = -0148 P=0005rdquo (p 41)

Limitations confounding variables of nursesrsquo personal psychiatric or psychological histories

Manojlovich amp DeCicco (2007)

Descriptive Cross-sectional Non-experimental

Concepts of workplace empowerment ICU Nurse-Physician QuestionnairePractice Environment Scale of the Nursing Work Index

462 nursesrsquo perceptions in 25 intensive care units from 8 Michigan hospitals

Non-probability sampling

statistical significance for the positive correlation of physician-nurse miscommunication to the perceived outcomes in medication errors (p 542)

Limitation not generalized findings not reflect cause-effect relationships

Literature Review (Level Four Evidence continued)

Research Articles

Research Studies

Theoretical Framework

Measurement Instruments

Samples Data AnalysesStudy Findings

Rosenstein amp ODaniel (2008)

Non-experimentalstudy quantitative and qualitative approach

Instrument ldquoNurse-Physician Impact of disruptive Behavior on Patient Carerdquo

Convenience samples 2846 nurses 944 physicians from 102 not-for-profit VHA member hospitals in the US from 2004 to 2007

physician-nurse disturbing behaviors are likely to reduce patient safety outcomes and nurse satisfaction Narrative data eg ldquoafraid to call Drrdquo ldquoget yelled atrdquo ldquopoor communication postoprdquo (Rosenstein amp OrsquoDaniel p 467)

67 respondents perceived that disruptive behaviors were associated with adverse patient outcomes (medical errors and patient mortality) (Rosenstein amp OrsquoDaniel p 464)

Limitation theoretical framework not specifically describedStrength large sample size

Rothsteinamp Hannum (2007)

Cross-sectional

Gender model (male physician dominance and nurse deference)

Professional model

self-reported close-ended questionnaire on nurse-physician relationship

125 advanced practice nursesAPN at a statewide professional conference

non-probability sampling

statistical significance for APNrsquo s positive attitudecommunication with female physicians (less than 50 years old) and male physicians (of all ages) male and female physicians are also likely to be positive and respectful about APNrsquos knowledge in patient care (2-tailed t test and one-way analysis of variance P value less than 005) (Rothstein amp Hannum p 238)

The gender model for the authoritative dominance of male physicians is not applicable to the female APNs who have at least a masterrsquos degree in nursing (p 235)

Limitation confounding variables not measured ldquotype and size of the work organization nurse and physician specialties and patient illness and social characteristicsrdquo (p 239)

Literature Review (Level Six Evidence)

Research

Article

Research Method

Theoretical Framework

Sample Study Findings

Gardezi Lingard Espin Whyte Orser amp Baker (2009)

Qualitative study

Ethnographic approach

Retrospective study

Critical Theory about silence in communication

observed physician-nurse communications over 700 surgeries at 3 acute care hospitals from 2005 to 2007 in Canada

Narrative and descriptive data about conflicts in physician-nurse communication styles at operating rooms due to nursesrsquo gap in knowledge about surgical procedures and surgeonsrsquo dominant authoritative power

Nursesrsquo passivesilent communication method had negative impacts on patient safety during surgeries (Gardezi et al p 1391)

Limitations evidence-based practice cannot be based on one qualitative study

Strengths explore the descriptive lived experiences about physician-nurse communication barriers over 2 years

Analysis of Evidence

The ability to critically analyze evidence presented in various research projects is necessary to evaluate the work for applicability and use in evidence based nursing practice ldquoTo use research evidence one must be able to evaluate this evidencerdquo (Nieswiadomy 2012 p 298)

bull STRENGTH OF EVIDENCEbull LEVEL 1 (HIGHEST)bull EXPERIMENTAL STUDY (RANDOMIZED CONTROLLED TRAIL OR RCT)bull bull Study participants (subjects) are randomly assigned to either a treatment (TX) or

controlbull (non-treatment) groupbull bull May bebull o Blind neither subject nor investigator knows which TX subject is receivingbull o Double-blind neither subject nor investigator knows which TX subject is receivingbull o Non-blind both subject and investigator know which TX subject is receiving usedbull when it is felt that the knowledge of treatment is unimportantbull META-ANALYSIS OF RCTSbull bull Quantitatively synthesizes and analyzes results of multiple primary studies addressing

abull similar research questionbull bull Statistically pools results from independent but combinable studiesbull bull Summary statistic (effect size) is expressed in terms of direction (positive negative

orbull zero) and magnitude (high medium small)

bull LEVEL 2bull QUASI-EXPERIMENTAL STUDYbull bull Always includes manipulation of an independent variablebull bull Lacks either random assignment or control groupbull bull Findings must be considered in light of threats to validity (particularly selection)

bull LEVEL 3bull NON-EXPERIMENTAL STUDYbull bull No manipulation of the independent variablebull bull Can be descriptive comparative or relationalbull bull Often uses secondary databull bull Findings must be considered in light of threats to validity (particularly selection lack

ofbull severity or co-morbidity adjustment)

bull QUALITATIVE STUDYbull 1048707 Explorative in nature such as interviews observations or focus groupsbull 1048707 Starting point for studies of questions for which little research currently existsbull 1048707 Sample sizes are usually small and study results are used to design stronger studies

thatbull are more objective and quantifiable

bull META-SYNTHESISbull 1048707 Research technique that critically analyzes and synthesizes findings from qualitativebull researchbull 1048707 Identifies key concepts and metaphors and determines their relationships to each

otherbull 1048707 Aim is not to produce a summary statistic but rather to interpret and

translate findings

JHNEBP Research Evidence Appraisal

The Johns Hopkins HospitalThe Johns Hopkins University

QUALITY RATING (SCIENTIFIC EVIDENCE)

A High quality consistent results sufficient sample size adequate control and

bull definitive conclusions consistent recommendations based on extensive literature

bull review that includes thoughtful reference to scientific evidence

B Good quality reasonably consistent results sufficient sample size some control

bull and fairly definitive conclusions reasonably consistent recommendations based

bull on fairly comprehensive literature review that includes some reference to

bull scientific evidence

C Low quality or major flaws little evidence with inconsistent results insufficient

bull sample size conclusions cannot be drawn

Article 1 ldquoConflict management training and nurse-physician collaborative behaviorsrdquo(Boone et al 2008)bull Quantitative quasi-experimental designbull The researchers are highly qualified and experiencedbull Convenience sample which closely approximates the real world experiencebull This study is ethically sound as a written explanation of the study was provided and

informed consent was obtainedbull The problem is clearly stated to examine a knowledge gap between a unit specific

intervention (conflict management training) and improved communication and collaboration between physicians and nurses

bull Theoretical framework Kilmann and Thomas conflict resolution theory (Boone et al 2008 p 168)

bull Findings reveal that the intervention was unsuccessful (The null hypothesis not rejected)

bull The importance of continued research for interventions that promote quality communication and collaboration is stressed

bull Creating a culture that values quality communication and collaboration forms the basis for developing a healthy work environment

bull Level of evidence varies by tool used but is evaluated as II or III Both levels are credible for utilization in evidence based care

bull Informed consent was obtained from all participants

Article 2 ldquoNine structures and leadership practices essential for a magnetic (healthy) work environmentrdquo (Kramer et al 2010)

bull This is a quantitative meta-analysis of thirty professional publications bull The problem is clearly stated to identify what structures and leadership

practices are necessary to support a healthy work environmentbull The researchers are experienced and well qualifiedbull The sample size was good Over 1300 interviews of expert nurses nurse

managers and physicians were compiled for comparison to findings from regulatory and professional organizations

bull The theoretical framework is based on the Donabedian model (httpwwwahrqgovqualmedteammedteamfig2htm) of patient safety

bull Healthy work environments lead to improved patient and nurse outcomesbull Creating a culture of interdisciplinary collaboration and teamwork through

shared power and administrative support were important themesbull This is a valid level I for evidence by all methods (course modules interview

with hospital research specialist and Johns Hopkins Nursing Research Evidence Appraisal) Level I is the highest level of evidence for utilization in evidence based practice

Structuresbest leadership practices essential for healthy work environments

Quality leadership at all levels in the organization

Availability of and support for education career performance and competence development

Administrative sanction for autonomous and collaborative practice

Evidence-based practice education and operational supports

Culture practice and opportunity to learn interdisciplinary collaboration

Empowered shared decision-making structures for control of the context of nursing practice

Generation and nurturance of a patient-centered culture

Staffing structures that take into account RN competence patient acuity and teamwork

Development and support of intradisciplinary teamwork

Article 3 ldquoThe effect of an educational programme on attitudes of nurses and medical residents towards the benefit of positive communication and collaborationrdquo(McCaffrey et al 2012)bull This is a quasi-experimental study based on a convenience sample of nurses and

medical residents bull The researchers are experienced and well qualifiedbull The research question is clearly statedbull Ethical research guidelines are carefully adhered tobull A pre and post-test design based on the Jefferson Scale of Attitudes towards

Physician-Nurse Collaboration and the Communication Collaboration and Critical Thinking for Quality Patient Outcomes tools Both tools are proven to be reliable and valid (the Cronbachrsquos alpha coefficient of 087-092)

bull A critical finding in this study is that ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Statistical findings reveal that the chosen intervention of an educational programme to improve physician-nurse communication and collaboration was beneficial

bull This study is evaluated as evidence level III due to lack of a control group by two methods (Ford 2012 C Bongiorno personal communication November 26 2012) Alternatively it is rated as level II on the Johns Hopkins scale (JHNEBP Research Evidence Appraisal nd)

Article 4 ldquoNurse-physician relationships in hospitals 20000 nurses tell their storyrdquo (Schmalenberg amp Kramer 2009)

bull This study is a quantitative synthesis of the findings of six research studies based on the Essentials of Magnetism

bull The researchers are experienced and highly qualifiedbull The purpose of the study is several fold 1) To discern what constitutes quality

communication and collaboration between physicians and nurses 2) Define types of nurse-physician relationships 3) Define organizational structures and leadership practices that help develop collaborative nurse-physician relationships and 4) Study differences in nurse-physician relationships between magnet and comparison hospitals

bull The sample size of 20616 staff nurses is excellentbull Thorough literature review is the foundation for this studybull It was consistently reported that nurses at magnet hospitals reported higher quality

relationships with physicians than the comparison hospitalsbull Structures that improve relationships and are supported by magnet institutions are

keep the patient first develop constructive conflict resolution techniques and have collaborative interdisciplinary patient rounds

bull Nurses can play an active role in bringing about these interventionsbull This is a double blinded peer review of six studies clearly making it evidence level I by

all methods

Percentage of staff nurses responding affirmatively to nurse-physician relationship types by magnet

and comparison hospitals and by period

Application of Evidence for oncology nursing practice (Lai Harper)

bull Utilize the Cochrane Database or the ldquoJHNEBP Research Evidence Appraisalrdquo as the research tools effectively communicate and collaborate with oncologists about the nursing perspective on evidence-based practice

bull Ongoing literature review for the most current credible and high-quality evidence-based practice for reducing oncology patientsrsquo physical psychological and emotional issues (such as pain nausea anxiety or depression)

bull Recommend the hospital nursing research committee to initiate a survey to explore possible physician-nurse communication barriers at an oncology unit

bull Recommend the implementation of the low-cost convenient computer-based training in physician-nurse communication skills

Application of Evidence at the Cardiovascular Department (Margaret Siler)

bull High quality communication and collaboration make a great difference in the cardiac catheterization laboratory (Boone King Gresham Wahl amp Suh 2008 p 168)

bull Experience and a broad knowledge base bring confidence to our daily work (Schmalenberg amp Kramer 2009 p 82)

bull All involved parties (patient nurse physician healthcare system) can reap the benefits of collaborative practice (Kramer et al 2012 p 7)

bull There are many educational opportunities available to improve interdisciplinary and interdepartmental communication Many are quite costly Some that may make the biggest difference are fairly inexpensive including Unit Action Council work and interdepartmental job shadowing (McCaffery et al 2012)

Application of Evidence into the Surgical Setting (Gary Webster)

Intra-operative settings place nurses and physicians in close collaborative work

settings The typical communication style is authoritarian Schmalenberg and

Kramer (2009) stated that physicians felt the nurse-physician relation to be more

collaborative than nurse did I can see that being true in my work environment

The Boone et al (2008) and McCaffrey (2011) articles combined are very

valuable Together the articles show a successful attempt to increase collaboration

and some pitfalls to avoid These can help direct any programs to support an

increase in collaboration

Application of Evidence (Jamie Ziemba)

bull Poor communication between nurses and physicians related to language and cultural barriers

bull Physiciansrsquo dysfunctional or authoritarian communication style (eg instruct nurses not to call at night unless it is a life-and-death emergency) is a major patient safety issue

bull As the patient advocate nurses have an important role of communicating with physicians to verify medication orders clinical procedures and improve patient outcomes

bull Hospital training programs in communication skills and cultural diversities are recommended for physicians and nurses with different culturalethnic backgrounds

Summary Statements

bull Meta-analytical review of evidence-based research articles support the clinical significance of effective communication styles

bull Authoritarian communication styles increase disruptive behaviors and negative hostile relationships at work environments

bull Healthy work environments have positive effects on nurses physicians patients and healthcare organizations

bull Inter-disciplinary collaboration is an essential aspect of healthy work environmentsbull Evidence-based studies have shown positive patient outcomes nursing job

satisfaction collaborative environments at Magnet hospitalsbull There is a need to address the barriers and incorporate educational programs to teach

effective communication and the need for collaboration Educational training should be re-enforced with weekly discussions ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Educate staff on the 5 types of nurse-physician relationships (collegial collaborative teacher-student friendly-stranger and hostileadversarial relationships)

bull Teach staff how to utilize positive relationships and change negative onesbull Training should avoid focusing on negative behaviorsbull Training should focus creating cooperative behaviors

ReferencesAgency for Healthcare Research and Quality (nd) Medical teamwork and patient safety The Donabedian model of patient safety Retrieved

from httpwwwahrqgovqualmedteammedteamfig2htm

American Nurses Association (1980) Nursing A social policy statement Washington DC American Nurses Association

Ballou K amp Landreneau K (2010) The authoritarian reign in American health care Policy Politics amp Nursing Practice 11(1) 71-79

doi1011771527154410372973

Boone B King M Gresham L Wahl P amp Suh E (2008) Conflict management training and nurse-physician collaborative behaviors

Journal For Nurses In Staff Development 24(4) 168-175 doi10109701NND00003206705641591

Burns N amp Grove S (2007) Understanding Nursing Research Building an Evidence Based Practice (4th Ed) St Louis Missouri Saunders

Elsevier Publishing

Ford L (2012) Week 8 amp 9 Critique of Research Retrieved from httpsfsulearnferriseduwebappsportalframesetjsp

tab_tab_group_id=_2_1ampurl=2Fwebapps2Fblackboard2Fexecute2Flauncher3Ftype3DCourseampid3D_2241_1ampurl3D

Gardezi F Lingard L Espin S Whyte S Orser B amp Baker G (2009) Silence power and communication in the operating room

Journal Of Advanced Nursing 65(7) 1390-1399 doi101111j1365-2648200904994x

Hendel T Fish M amp Berger O (2007) Nursephysician conflict management mode choices implications for improved collaborative

practice Nursing Administration Quarterly 31(3) 244-253

John Hopkins UniversityJohn Hopkins Hospital (nd) JHNEBP Research Evidence Appraisal Retrieved from

httpwwwnursingworldorgDocumentVaultNursingPracticeResearch-ToolkitJHNEBP-Research-Evidence-Appraisalpdf

Karanikola M Papathanassoglou E Kalafati M Stathopoulou H Mpouzika M amp Goutsikas C G (2012) Exploration of the

Association Between Professional Interactions and Emotional Distress of Intensive Care Unit Nursing Personnel Dimensions Of Critical

Care Nursing 31(1) 37-45 doi101097DCC0b013e31823a55b8

ReferencesKramer M Schmalenberg C amp Maguire P (2010) Nine structures and leadership practices essential for a magnetic (healthy)

work environment Nursing Administration Quarterly 34(1) 4-17 doi101097NAQ0b013e3181c95ef4

Manojlovich M amp DeCicco B (2007) Healthy work environments nurse-physician communication and patients outcome American Journal Of Critical Care 16(6) 536-543

McCaffrey R Hayes R Cassell A Miller-Reyes S Donaldson A amp Ferrell C (2012) The effect of an educational programme on attitudes of nurses and medical residents towards the benefits of positive communication and collaboration Journal Of Advanced Nursing 68(2) 293-301 doi101111j1365-2648201105736x

Nieswiadomy R M (2012) Foundations of Nursing Research (6th Ed) Upper Saddle River New Jersey Prentice Hall

Rosenstein A amp ODaniel M (2008) A survey of the impact of disruptive behaviors and communication defects on patient safety Joint Commission Journal On Quality amp Patient Safety 34(8) 464-471

Rothstein W amp Hannum S (2007) Profession and gender in relationships between advanced practice nurses and physicians Journal Of Professional Nursing 23(4) 235-240 doi101016jprofnurs200701008

Saxton R Hines T amp Enriquez M (2009) The negative impact of nurse-physician disruptive behavior on patient safety A review of the literature Journal of Patient Safety 5(3) 180-183

Stone P W (2002) Popping the PICO question in research and evidence-based practice Applied Nursing Research 16(2) 197-198

Schmalenberg C amp Kramer M (2009) Nurse-physician relationships in hospitals 20 000 nurses tell their story Critical Care Nurse 29(1) 74-83 doi104037ccn2009436

Zwarenstein M Goldman J amp Reeves S (2009) Interprofessional collaboration Effects of practice-based interventions on professional practice and healthcare outcomes Cochrane Database Of Systematic Reviews (3) 1-31 doi10100214651858CD000072

NURS 350 Evidence-Based Nursing Practice (Group paper plus Group Powerpoint presentation)

Total group grade 100Instructorrsquos comments Excellent paper I think your group

should consider submitting it for publication if you could flesh out the details on improving collaborative communication

• Ferris State University NURS 350 Evidence-Based Nursing Practic
• ldquoCommunication--the human connection--is the key to pers
• Slide 3
• What is patient safety
• What is acute care
• What is Professional Communication
• Communication between medical professionals is not just a local
• PICO Question
• Definitions
• A Survey of the Impacts of Disruptive Behaviors and Communicat
• A Survey of the Impacts of Disruptive Behaviors and Communicat (2)
• Literature Review (Level One Evidence)
• Literature Review (Level Three Evidence)
• Literature Review (Level Four Evidence)
• Literature Review (Level Four Evidence continued)
• Literature Review (Level Six Evidence)
• Analysis of Evidence
• Slide 18
• Slide 19
• Article 1 ldquoConflict management training and nurse-physician
• Article 2 ldquoNine structures and leadership practices essentia
• Slide 22
• Article 3 ldquoThe effect of an educational programme on attitud
• Article 4 ldquoNurse-physician relationships in hospitals 2000
• Percentage of staff nurses responding affirmatively to nurse-ph
• Application of Evidence for oncology nursing practice (Lai Har
• Application of Evidence at the Cardiovascular Department (Marg
• Application of Evidence into the Surgical Setting (Gary Webste
• Slide 29
• Summary Statements
• References
• References (2)
• NURS 350 Evidence-Based Nursing Practice (Group paper plus Gr

A Survey of the Impacts of Disruptive Behaviors and Communication Defects on Patient Safety

Sample size N= 4530 From January 2004 to March 2007

Have your ever witnessed any disruptive behavior from a physician at your hospital

Have you ever witnessed any disruptive behavior from a nurse at your hospital

Aggre

gate

MD

(ph

ysician)

RN (

nurs

e)

Admin

stra

tive ex

ecut

ives

Other

77

51

88

78

66

Aggre

gate

MD

(ph

ysician)

RN (

nurs

e)

Admin

istra

tive ex

ecut

ives

Other

65

48

7377

64

Literature Review (Level One Evidence)Research Articles

Research Methods

Theoretical frameworksMeasurement Instruments

Samples Data AnalysesStudy Findings

Kramer Schmalenbeg amp Maguire (2010)

Meta-analysis of multiple published studies

Donabedianrsquos conceptual framework of structure process and outcome

Heberlein and Baumgartnerrsquosmethodology

12 publications from 7 professional and regulatory organizations

18 publications from studies using the Essential of Magnetism (including 1300 interviews with nurses physicians and mangers)

positive physician-nurse communication collaborative leadership and autonomy in Magnet hospitals (Kramer et al p 11)

Nursesrsquo autonomous role in identifying patientsrsquo worsening conditions (need to rescueNTR) for reducing the rates of mortality or adverse patient outcomes (Kramer et al p 11)

Schmalenberg amp Kramer (2009)

Review of six research studies

Essentials of Magnetism

Concepts of nurse-physician relationship(collegial collaborative student-teacher friendly stranger hostileadversarial

3602 staff nurses in 16 Magnet and 10 non-Magnet hospitals in the 2003 study

10514 staff nurses in 18 Magnet and 16 non-Magnet hospitals in the 2007 study

In 2003 physician-nurse relationship scores in Magnet hospitals were statistically significant and higher when compared to non-Magnet hospitals (F ratio 21279 P less than 0001)

In 2007 the higher scores in Magnet hospitals were also statistically significant (F ratio 14446 P less than 0001)(Schmalenberg pp 78-79)

Zwarenstein Goldman amp Reeves (2009)

Cochrane Systematic Review

Not specifically mentioned

Five studies about collaborative interventions

interprofessional roundsmeetings

externally facilitated interprofessional audit

no randomized controlled studies about the impacts of interdisciplinary collaboration (Zwarenstein et al p 8)

ldquoProblems with conceptualising and measuring collaborationrdquo No ldquogeneralizable inferences about interprofessional collaborationrdquo (Zwarenstein et al p 2)

Literature Review (Level Three Evidence)

Research Articles

Research Methods

Theoretical frameworksMeasurement Instruments

Samples Data AnalysesStudy Findings

Boone King Gresham Wahl amp Suh (2008)

Quasi-experimental (Pre- and Post- Test for the training in assertiveness and cooperation)

Kilmann and Thomasrsquo model of conflict resolution (accommodating avoidance competition compromise collaboration)

Collaborative Behavior Scale

9 nurses from the cardiovascular laboratory (experimental group) and 18 nurses from the telemetry unit (control group)

Non-probability sampling in an American hospital

No statistical significance for the Collaborative Behavior Scale beforeafter the training between the experimental group and the control group ldquop more than 005rdquo (Boone et al p 172)

the communication style of ldquoavoidancerdquo was associated with increased nursesrsquo emotional stress (Boone et al p 173)

Implication explore barriers before training programs involve physiciansrsquo participations

McCaffrey HayesCassell Miller-Reyes Donaldson amp Ferrell (2012)

Quasi-experimental (Pre- and Post-test for training in communication skills)

Jefferson Scale of Attitudes

68 nurses and 47 medical residents in a Florida hospital

Non-probability sampling

statistical significance (P=0001) of the T-test before and after the 6-month educational program for enhancing physician-nurse collegiality communication skills mutual decision-making processes (McCaffrey et al p 298)

Literature Review (Level Four Evidence)Research Articles

Research Studies

Theoretical Frameworks

Measurement Instruments

Samples Data AnalysesStudy Findings

Hendel Fish amp Berger (2007)

Cross-sectional Correlational study

Thomas-Kilman Model of Conflict Resolution

Conflict Mode Instrument (MODE)

75 physicians 54 charge nurses at 5 acute care hospitals in Israel

Non-probability sampling

charge nurses were more likely to use the ldquocollaboratingrdquo communication style when compared to physicians (P=0001) (Hendel et al p 249)

Karanikola et al (2012)

Descriptive Correlational study

Hamiltonrsquos Anxiety Scale

Stamprsquos Index of Work Satisfaction

2-stage random probability sampling

11 hospitals randomly selected in Greece then 229 nurses at intensive care units randomly selected

Satisfaction in physician communication was statistically significant and negatively associated with intensive care nursesrsquo anxiety level ldquocorrelation coefficient Kendall = -0160 P=0001rdquo and depressed mood ldquocorrelation coefficient = -0148 P=0005rdquo (p 41)

Limitations confounding variables of nursesrsquo personal psychiatric or psychological histories

Manojlovich amp DeCicco (2007)

Descriptive Cross-sectional Non-experimental

Concepts of workplace empowerment ICU Nurse-Physician QuestionnairePractice Environment Scale of the Nursing Work Index

462 nursesrsquo perceptions in 25 intensive care units from 8 Michigan hospitals

Non-probability sampling

statistical significance for the positive correlation of physician-nurse miscommunication to the perceived outcomes in medication errors (p 542)

Limitation not generalized findings not reflect cause-effect relationships

Literature Review (Level Four Evidence continued)

Research Articles

Research Studies

Theoretical Framework

Measurement Instruments

Samples Data AnalysesStudy Findings

Rosenstein amp ODaniel (2008)

Non-experimentalstudy quantitative and qualitative approach

Instrument ldquoNurse-Physician Impact of disruptive Behavior on Patient Carerdquo

Convenience samples 2846 nurses 944 physicians from 102 not-for-profit VHA member hospitals in the US from 2004 to 2007

physician-nurse disturbing behaviors are likely to reduce patient safety outcomes and nurse satisfaction Narrative data eg ldquoafraid to call Drrdquo ldquoget yelled atrdquo ldquopoor communication postoprdquo (Rosenstein amp OrsquoDaniel p 467)

67 respondents perceived that disruptive behaviors were associated with adverse patient outcomes (medical errors and patient mortality) (Rosenstein amp OrsquoDaniel p 464)

Limitation theoretical framework not specifically describedStrength large sample size

Rothsteinamp Hannum (2007)

Cross-sectional

Gender model (male physician dominance and nurse deference)

Professional model

self-reported close-ended questionnaire on nurse-physician relationship

125 advanced practice nursesAPN at a statewide professional conference

non-probability sampling

statistical significance for APNrsquo s positive attitudecommunication with female physicians (less than 50 years old) and male physicians (of all ages) male and female physicians are also likely to be positive and respectful about APNrsquos knowledge in patient care (2-tailed t test and one-way analysis of variance P value less than 005) (Rothstein amp Hannum p 238)

The gender model for the authoritative dominance of male physicians is not applicable to the female APNs who have at least a masterrsquos degree in nursing (p 235)

Limitation confounding variables not measured ldquotype and size of the work organization nurse and physician specialties and patient illness and social characteristicsrdquo (p 239)

Literature Review (Level Six Evidence)

Research

Article

Research Method

Theoretical Framework

Sample Study Findings

Gardezi Lingard Espin Whyte Orser amp Baker (2009)

Qualitative study

Ethnographic approach

Retrospective study

Critical Theory about silence in communication

observed physician-nurse communications over 700 surgeries at 3 acute care hospitals from 2005 to 2007 in Canada

Narrative and descriptive data about conflicts in physician-nurse communication styles at operating rooms due to nursesrsquo gap in knowledge about surgical procedures and surgeonsrsquo dominant authoritative power

Nursesrsquo passivesilent communication method had negative impacts on patient safety during surgeries (Gardezi et al p 1391)

Limitations evidence-based practice cannot be based on one qualitative study

Strengths explore the descriptive lived experiences about physician-nurse communication barriers over 2 years

Analysis of Evidence

The ability to critically analyze evidence presented in various research projects is necessary to evaluate the work for applicability and use in evidence based nursing practice ldquoTo use research evidence one must be able to evaluate this evidencerdquo (Nieswiadomy 2012 p 298)

bull STRENGTH OF EVIDENCEbull LEVEL 1 (HIGHEST)bull EXPERIMENTAL STUDY (RANDOMIZED CONTROLLED TRAIL OR RCT)bull bull Study participants (subjects) are randomly assigned to either a treatment (TX) or

controlbull (non-treatment) groupbull bull May bebull o Blind neither subject nor investigator knows which TX subject is receivingbull o Double-blind neither subject nor investigator knows which TX subject is receivingbull o Non-blind both subject and investigator know which TX subject is receiving usedbull when it is felt that the knowledge of treatment is unimportantbull META-ANALYSIS OF RCTSbull bull Quantitatively synthesizes and analyzes results of multiple primary studies addressing

abull similar research questionbull bull Statistically pools results from independent but combinable studiesbull bull Summary statistic (effect size) is expressed in terms of direction (positive negative

orbull zero) and magnitude (high medium small)

bull LEVEL 2bull QUASI-EXPERIMENTAL STUDYbull bull Always includes manipulation of an independent variablebull bull Lacks either random assignment or control groupbull bull Findings must be considered in light of threats to validity (particularly selection)

bull LEVEL 3bull NON-EXPERIMENTAL STUDYbull bull No manipulation of the independent variablebull bull Can be descriptive comparative or relationalbull bull Often uses secondary databull bull Findings must be considered in light of threats to validity (particularly selection lack

ofbull severity or co-morbidity adjustment)

bull QUALITATIVE STUDYbull 1048707 Explorative in nature such as interviews observations or focus groupsbull 1048707 Starting point for studies of questions for which little research currently existsbull 1048707 Sample sizes are usually small and study results are used to design stronger studies

thatbull are more objective and quantifiable

bull META-SYNTHESISbull 1048707 Research technique that critically analyzes and synthesizes findings from qualitativebull researchbull 1048707 Identifies key concepts and metaphors and determines their relationships to each

otherbull 1048707 Aim is not to produce a summary statistic but rather to interpret and

translate findings

JHNEBP Research Evidence Appraisal

The Johns Hopkins HospitalThe Johns Hopkins University

QUALITY RATING (SCIENTIFIC EVIDENCE)

A High quality consistent results sufficient sample size adequate control and

bull definitive conclusions consistent recommendations based on extensive literature

bull review that includes thoughtful reference to scientific evidence

B Good quality reasonably consistent results sufficient sample size some control

bull and fairly definitive conclusions reasonably consistent recommendations based

bull on fairly comprehensive literature review that includes some reference to

bull scientific evidence

C Low quality or major flaws little evidence with inconsistent results insufficient

bull sample size conclusions cannot be drawn

Article 1 ldquoConflict management training and nurse-physician collaborative behaviorsrdquo(Boone et al 2008)bull Quantitative quasi-experimental designbull The researchers are highly qualified and experiencedbull Convenience sample which closely approximates the real world experiencebull This study is ethically sound as a written explanation of the study was provided and

informed consent was obtainedbull The problem is clearly stated to examine a knowledge gap between a unit specific

intervention (conflict management training) and improved communication and collaboration between physicians and nurses

bull Theoretical framework Kilmann and Thomas conflict resolution theory (Boone et al 2008 p 168)

bull Findings reveal that the intervention was unsuccessful (The null hypothesis not rejected)

bull The importance of continued research for interventions that promote quality communication and collaboration is stressed

bull Creating a culture that values quality communication and collaboration forms the basis for developing a healthy work environment

bull Level of evidence varies by tool used but is evaluated as II or III Both levels are credible for utilization in evidence based care

bull Informed consent was obtained from all participants

Article 2 ldquoNine structures and leadership practices essential for a magnetic (healthy) work environmentrdquo (Kramer et al 2010)

bull This is a quantitative meta-analysis of thirty professional publications bull The problem is clearly stated to identify what structures and leadership

practices are necessary to support a healthy work environmentbull The researchers are experienced and well qualifiedbull The sample size was good Over 1300 interviews of expert nurses nurse

managers and physicians were compiled for comparison to findings from regulatory and professional organizations

bull The theoretical framework is based on the Donabedian model (httpwwwahrqgovqualmedteammedteamfig2htm) of patient safety

bull Healthy work environments lead to improved patient and nurse outcomesbull Creating a culture of interdisciplinary collaboration and teamwork through

shared power and administrative support were important themesbull This is a valid level I for evidence by all methods (course modules interview

with hospital research specialist and Johns Hopkins Nursing Research Evidence Appraisal) Level I is the highest level of evidence for utilization in evidence based practice

Structuresbest leadership practices essential for healthy work environments

Quality leadership at all levels in the organization

Availability of and support for education career performance and competence development

Administrative sanction for autonomous and collaborative practice

Evidence-based practice education and operational supports

Culture practice and opportunity to learn interdisciplinary collaboration

Empowered shared decision-making structures for control of the context of nursing practice

Generation and nurturance of a patient-centered culture

Staffing structures that take into account RN competence patient acuity and teamwork

Development and support of intradisciplinary teamwork

Article 3 ldquoThe effect of an educational programme on attitudes of nurses and medical residents towards the benefit of positive communication and collaborationrdquo(McCaffrey et al 2012)bull This is a quasi-experimental study based on a convenience sample of nurses and

medical residents bull The researchers are experienced and well qualifiedbull The research question is clearly statedbull Ethical research guidelines are carefully adhered tobull A pre and post-test design based on the Jefferson Scale of Attitudes towards

Physician-Nurse Collaboration and the Communication Collaboration and Critical Thinking for Quality Patient Outcomes tools Both tools are proven to be reliable and valid (the Cronbachrsquos alpha coefficient of 087-092)

bull A critical finding in this study is that ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Statistical findings reveal that the chosen intervention of an educational programme to improve physician-nurse communication and collaboration was beneficial

bull This study is evaluated as evidence level III due to lack of a control group by two methods (Ford 2012 C Bongiorno personal communication November 26 2012) Alternatively it is rated as level II on the Johns Hopkins scale (JHNEBP Research Evidence Appraisal nd)

Article 4 ldquoNurse-physician relationships in hospitals 20000 nurses tell their storyrdquo (Schmalenberg amp Kramer 2009)

bull This study is a quantitative synthesis of the findings of six research studies based on the Essentials of Magnetism

bull The researchers are experienced and highly qualifiedbull The purpose of the study is several fold 1) To discern what constitutes quality

communication and collaboration between physicians and nurses 2) Define types of nurse-physician relationships 3) Define organizational structures and leadership practices that help develop collaborative nurse-physician relationships and 4) Study differences in nurse-physician relationships between magnet and comparison hospitals

bull The sample size of 20616 staff nurses is excellentbull Thorough literature review is the foundation for this studybull It was consistently reported that nurses at magnet hospitals reported higher quality

relationships with physicians than the comparison hospitalsbull Structures that improve relationships and are supported by magnet institutions are

keep the patient first develop constructive conflict resolution techniques and have collaborative interdisciplinary patient rounds

bull Nurses can play an active role in bringing about these interventionsbull This is a double blinded peer review of six studies clearly making it evidence level I by

all methods

Percentage of staff nurses responding affirmatively to nurse-physician relationship types by magnet

and comparison hospitals and by period

Application of Evidence for oncology nursing practice (Lai Harper)

bull Utilize the Cochrane Database or the ldquoJHNEBP Research Evidence Appraisalrdquo as the research tools effectively communicate and collaborate with oncologists about the nursing perspective on evidence-based practice

bull Ongoing literature review for the most current credible and high-quality evidence-based practice for reducing oncology patientsrsquo physical psychological and emotional issues (such as pain nausea anxiety or depression)

bull Recommend the hospital nursing research committee to initiate a survey to explore possible physician-nurse communication barriers at an oncology unit

bull Recommend the implementation of the low-cost convenient computer-based training in physician-nurse communication skills

Application of Evidence at the Cardiovascular Department (Margaret Siler)

bull High quality communication and collaboration make a great difference in the cardiac catheterization laboratory (Boone King Gresham Wahl amp Suh 2008 p 168)

bull Experience and a broad knowledge base bring confidence to our daily work (Schmalenberg amp Kramer 2009 p 82)

bull All involved parties (patient nurse physician healthcare system) can reap the benefits of collaborative practice (Kramer et al 2012 p 7)

bull There are many educational opportunities available to improve interdisciplinary and interdepartmental communication Many are quite costly Some that may make the biggest difference are fairly inexpensive including Unit Action Council work and interdepartmental job shadowing (McCaffery et al 2012)

Application of Evidence into the Surgical Setting (Gary Webster)

Intra-operative settings place nurses and physicians in close collaborative work

settings The typical communication style is authoritarian Schmalenberg and

Kramer (2009) stated that physicians felt the nurse-physician relation to be more

collaborative than nurse did I can see that being true in my work environment

The Boone et al (2008) and McCaffrey (2011) articles combined are very

valuable Together the articles show a successful attempt to increase collaboration

and some pitfalls to avoid These can help direct any programs to support an

increase in collaboration

Application of Evidence (Jamie Ziemba)

bull Poor communication between nurses and physicians related to language and cultural barriers

bull Physiciansrsquo dysfunctional or authoritarian communication style (eg instruct nurses not to call at night unless it is a life-and-death emergency) is a major patient safety issue

bull As the patient advocate nurses have an important role of communicating with physicians to verify medication orders clinical procedures and improve patient outcomes

bull Hospital training programs in communication skills and cultural diversities are recommended for physicians and nurses with different culturalethnic backgrounds

Summary Statements

bull Meta-analytical review of evidence-based research articles support the clinical significance of effective communication styles

bull Authoritarian communication styles increase disruptive behaviors and negative hostile relationships at work environments

bull Healthy work environments have positive effects on nurses physicians patients and healthcare organizations

bull Inter-disciplinary collaboration is an essential aspect of healthy work environmentsbull Evidence-based studies have shown positive patient outcomes nursing job

satisfaction collaborative environments at Magnet hospitalsbull There is a need to address the barriers and incorporate educational programs to teach

effective communication and the need for collaboration Educational training should be re-enforced with weekly discussions ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Educate staff on the 5 types of nurse-physician relationships (collegial collaborative teacher-student friendly-stranger and hostileadversarial relationships)

bull Teach staff how to utilize positive relationships and change negative onesbull Training should avoid focusing on negative behaviorsbull Training should focus creating cooperative behaviors

ReferencesAgency for Healthcare Research and Quality (nd) Medical teamwork and patient safety The Donabedian model of patient safety Retrieved

from httpwwwahrqgovqualmedteammedteamfig2htm

American Nurses Association (1980) Nursing A social policy statement Washington DC American Nurses Association

Ballou K amp Landreneau K (2010) The authoritarian reign in American health care Policy Politics amp Nursing Practice 11(1) 71-79

doi1011771527154410372973

Boone B King M Gresham L Wahl P amp Suh E (2008) Conflict management training and nurse-physician collaborative behaviors

Journal For Nurses In Staff Development 24(4) 168-175 doi10109701NND00003206705641591

Burns N amp Grove S (2007) Understanding Nursing Research Building an Evidence Based Practice (4th Ed) St Louis Missouri Saunders

Elsevier Publishing

Ford L (2012) Week 8 amp 9 Critique of Research Retrieved from httpsfsulearnferriseduwebappsportalframesetjsp

tab_tab_group_id=_2_1ampurl=2Fwebapps2Fblackboard2Fexecute2Flauncher3Ftype3DCourseampid3D_2241_1ampurl3D

Gardezi F Lingard L Espin S Whyte S Orser B amp Baker G (2009) Silence power and communication in the operating room

Journal Of Advanced Nursing 65(7) 1390-1399 doi101111j1365-2648200904994x

Hendel T Fish M amp Berger O (2007) Nursephysician conflict management mode choices implications for improved collaborative

practice Nursing Administration Quarterly 31(3) 244-253

John Hopkins UniversityJohn Hopkins Hospital (nd) JHNEBP Research Evidence Appraisal Retrieved from

httpwwwnursingworldorgDocumentVaultNursingPracticeResearch-ToolkitJHNEBP-Research-Evidence-Appraisalpdf

Karanikola M Papathanassoglou E Kalafati M Stathopoulou H Mpouzika M amp Goutsikas C G (2012) Exploration of the

Association Between Professional Interactions and Emotional Distress of Intensive Care Unit Nursing Personnel Dimensions Of Critical

Care Nursing 31(1) 37-45 doi101097DCC0b013e31823a55b8

ReferencesKramer M Schmalenberg C amp Maguire P (2010) Nine structures and leadership practices essential for a magnetic (healthy)

work environment Nursing Administration Quarterly 34(1) 4-17 doi101097NAQ0b013e3181c95ef4

Manojlovich M amp DeCicco B (2007) Healthy work environments nurse-physician communication and patients outcome American Journal Of Critical Care 16(6) 536-543

McCaffrey R Hayes R Cassell A Miller-Reyes S Donaldson A amp Ferrell C (2012) The effect of an educational programme on attitudes of nurses and medical residents towards the benefits of positive communication and collaboration Journal Of Advanced Nursing 68(2) 293-301 doi101111j1365-2648201105736x

Nieswiadomy R M (2012) Foundations of Nursing Research (6th Ed) Upper Saddle River New Jersey Prentice Hall

Rosenstein A amp ODaniel M (2008) A survey of the impact of disruptive behaviors and communication defects on patient safety Joint Commission Journal On Quality amp Patient Safety 34(8) 464-471

Rothstein W amp Hannum S (2007) Profession and gender in relationships between advanced practice nurses and physicians Journal Of Professional Nursing 23(4) 235-240 doi101016jprofnurs200701008

Saxton R Hines T amp Enriquez M (2009) The negative impact of nurse-physician disruptive behavior on patient safety A review of the literature Journal of Patient Safety 5(3) 180-183

Stone P W (2002) Popping the PICO question in research and evidence-based practice Applied Nursing Research 16(2) 197-198

Schmalenberg C amp Kramer M (2009) Nurse-physician relationships in hospitals 20 000 nurses tell their story Critical Care Nurse 29(1) 74-83 doi104037ccn2009436

Zwarenstein M Goldman J amp Reeves S (2009) Interprofessional collaboration Effects of practice-based interventions on professional practice and healthcare outcomes Cochrane Database Of Systematic Reviews (3) 1-31 doi10100214651858CD000072

NURS 350 Evidence-Based Nursing Practice (Group paper plus Group Powerpoint presentation)

Total group grade 100Instructorrsquos comments Excellent paper I think your group

should consider submitting it for publication if you could flesh out the details on improving collaborative communication

• Ferris State University NURS 350 Evidence-Based Nursing Practic
• ldquoCommunication--the human connection--is the key to pers
• Slide 3
• What is patient safety
• What is acute care
• What is Professional Communication
• Communication between medical professionals is not just a local
• PICO Question
• Definitions
• A Survey of the Impacts of Disruptive Behaviors and Communicat
• A Survey of the Impacts of Disruptive Behaviors and Communicat (2)
• Literature Review (Level One Evidence)
• Literature Review (Level Three Evidence)
• Literature Review (Level Four Evidence)
• Literature Review (Level Four Evidence continued)
• Literature Review (Level Six Evidence)
• Analysis of Evidence
• Slide 18
• Slide 19
• Article 1 ldquoConflict management training and nurse-physician
• Article 2 ldquoNine structures and leadership practices essentia
• Slide 22
• Article 3 ldquoThe effect of an educational programme on attitud
• Article 4 ldquoNurse-physician relationships in hospitals 2000
• Percentage of staff nurses responding affirmatively to nurse-ph
• Application of Evidence for oncology nursing practice (Lai Har
• Application of Evidence at the Cardiovascular Department (Marg
• Application of Evidence into the Surgical Setting (Gary Webste
• Slide 29
• Summary Statements
• References
• References (2)
• NURS 350 Evidence-Based Nursing Practice (Group paper plus Gr

Literature Review (Level One Evidence)Research Articles

Research Methods

Theoretical frameworksMeasurement Instruments

Samples Data AnalysesStudy Findings

Kramer Schmalenbeg amp Maguire (2010)

Meta-analysis of multiple published studies

Donabedianrsquos conceptual framework of structure process and outcome

Heberlein and Baumgartnerrsquosmethodology

12 publications from 7 professional and regulatory organizations

18 publications from studies using the Essential of Magnetism (including 1300 interviews with nurses physicians and mangers)

positive physician-nurse communication collaborative leadership and autonomy in Magnet hospitals (Kramer et al p 11)

Nursesrsquo autonomous role in identifying patientsrsquo worsening conditions (need to rescueNTR) for reducing the rates of mortality or adverse patient outcomes (Kramer et al p 11)

Schmalenberg amp Kramer (2009)

Review of six research studies

Essentials of Magnetism

Concepts of nurse-physician relationship(collegial collaborative student-teacher friendly stranger hostileadversarial

3602 staff nurses in 16 Magnet and 10 non-Magnet hospitals in the 2003 study

10514 staff nurses in 18 Magnet and 16 non-Magnet hospitals in the 2007 study

In 2003 physician-nurse relationship scores in Magnet hospitals were statistically significant and higher when compared to non-Magnet hospitals (F ratio 21279 P less than 0001)

In 2007 the higher scores in Magnet hospitals were also statistically significant (F ratio 14446 P less than 0001)(Schmalenberg pp 78-79)

Zwarenstein Goldman amp Reeves (2009)

Cochrane Systematic Review

Not specifically mentioned

Five studies about collaborative interventions

interprofessional roundsmeetings

externally facilitated interprofessional audit

no randomized controlled studies about the impacts of interdisciplinary collaboration (Zwarenstein et al p 8)

ldquoProblems with conceptualising and measuring collaborationrdquo No ldquogeneralizable inferences about interprofessional collaborationrdquo (Zwarenstein et al p 2)

Literature Review (Level Three Evidence)

Research Articles

Research Methods

Theoretical frameworksMeasurement Instruments

Samples Data AnalysesStudy Findings

Boone King Gresham Wahl amp Suh (2008)

Quasi-experimental (Pre- and Post- Test for the training in assertiveness and cooperation)

Kilmann and Thomasrsquo model of conflict resolution (accommodating avoidance competition compromise collaboration)

Collaborative Behavior Scale

9 nurses from the cardiovascular laboratory (experimental group) and 18 nurses from the telemetry unit (control group)

Non-probability sampling in an American hospital

No statistical significance for the Collaborative Behavior Scale beforeafter the training between the experimental group and the control group ldquop more than 005rdquo (Boone et al p 172)

the communication style of ldquoavoidancerdquo was associated with increased nursesrsquo emotional stress (Boone et al p 173)

Implication explore barriers before training programs involve physiciansrsquo participations

McCaffrey HayesCassell Miller-Reyes Donaldson amp Ferrell (2012)

Quasi-experimental (Pre- and Post-test for training in communication skills)

Jefferson Scale of Attitudes

68 nurses and 47 medical residents in a Florida hospital

Non-probability sampling

statistical significance (P=0001) of the T-test before and after the 6-month educational program for enhancing physician-nurse collegiality communication skills mutual decision-making processes (McCaffrey et al p 298)

Literature Review (Level Four Evidence)Research Articles

Research Studies

Theoretical Frameworks

Measurement Instruments

Samples Data AnalysesStudy Findings

Hendel Fish amp Berger (2007)

Cross-sectional Correlational study

Thomas-Kilman Model of Conflict Resolution

Conflict Mode Instrument (MODE)

75 physicians 54 charge nurses at 5 acute care hospitals in Israel

Non-probability sampling

charge nurses were more likely to use the ldquocollaboratingrdquo communication style when compared to physicians (P=0001) (Hendel et al p 249)

Karanikola et al (2012)

Descriptive Correlational study

Hamiltonrsquos Anxiety Scale

Stamprsquos Index of Work Satisfaction

2-stage random probability sampling

11 hospitals randomly selected in Greece then 229 nurses at intensive care units randomly selected

Satisfaction in physician communication was statistically significant and negatively associated with intensive care nursesrsquo anxiety level ldquocorrelation coefficient Kendall = -0160 P=0001rdquo and depressed mood ldquocorrelation coefficient = -0148 P=0005rdquo (p 41)

Limitations confounding variables of nursesrsquo personal psychiatric or psychological histories

Manojlovich amp DeCicco (2007)

Descriptive Cross-sectional Non-experimental

Concepts of workplace empowerment ICU Nurse-Physician QuestionnairePractice Environment Scale of the Nursing Work Index

462 nursesrsquo perceptions in 25 intensive care units from 8 Michigan hospitals

Non-probability sampling

statistical significance for the positive correlation of physician-nurse miscommunication to the perceived outcomes in medication errors (p 542)

Limitation not generalized findings not reflect cause-effect relationships

Literature Review (Level Four Evidence continued)

Research Articles

Research Studies

Theoretical Framework

Measurement Instruments

Samples Data AnalysesStudy Findings

Rosenstein amp ODaniel (2008)

Non-experimentalstudy quantitative and qualitative approach

Instrument ldquoNurse-Physician Impact of disruptive Behavior on Patient Carerdquo

Convenience samples 2846 nurses 944 physicians from 102 not-for-profit VHA member hospitals in the US from 2004 to 2007

physician-nurse disturbing behaviors are likely to reduce patient safety outcomes and nurse satisfaction Narrative data eg ldquoafraid to call Drrdquo ldquoget yelled atrdquo ldquopoor communication postoprdquo (Rosenstein amp OrsquoDaniel p 467)

67 respondents perceived that disruptive behaviors were associated with adverse patient outcomes (medical errors and patient mortality) (Rosenstein amp OrsquoDaniel p 464)

Limitation theoretical framework not specifically describedStrength large sample size

Rothsteinamp Hannum (2007)

Cross-sectional

Gender model (male physician dominance and nurse deference)

Professional model

self-reported close-ended questionnaire on nurse-physician relationship

125 advanced practice nursesAPN at a statewide professional conference

non-probability sampling

statistical significance for APNrsquo s positive attitudecommunication with female physicians (less than 50 years old) and male physicians (of all ages) male and female physicians are also likely to be positive and respectful about APNrsquos knowledge in patient care (2-tailed t test and one-way analysis of variance P value less than 005) (Rothstein amp Hannum p 238)

The gender model for the authoritative dominance of male physicians is not applicable to the female APNs who have at least a masterrsquos degree in nursing (p 235)

Limitation confounding variables not measured ldquotype and size of the work organization nurse and physician specialties and patient illness and social characteristicsrdquo (p 239)

Literature Review (Level Six Evidence)

Research

Article

Research Method

Theoretical Framework

Sample Study Findings

Gardezi Lingard Espin Whyte Orser amp Baker (2009)

Qualitative study

Ethnographic approach

Retrospective study

Critical Theory about silence in communication

observed physician-nurse communications over 700 surgeries at 3 acute care hospitals from 2005 to 2007 in Canada

Narrative and descriptive data about conflicts in physician-nurse communication styles at operating rooms due to nursesrsquo gap in knowledge about surgical procedures and surgeonsrsquo dominant authoritative power

Nursesrsquo passivesilent communication method had negative impacts on patient safety during surgeries (Gardezi et al p 1391)

Limitations evidence-based practice cannot be based on one qualitative study

Strengths explore the descriptive lived experiences about physician-nurse communication barriers over 2 years

Analysis of Evidence

The ability to critically analyze evidence presented in various research projects is necessary to evaluate the work for applicability and use in evidence based nursing practice ldquoTo use research evidence one must be able to evaluate this evidencerdquo (Nieswiadomy 2012 p 298)

bull STRENGTH OF EVIDENCEbull LEVEL 1 (HIGHEST)bull EXPERIMENTAL STUDY (RANDOMIZED CONTROLLED TRAIL OR RCT)bull bull Study participants (subjects) are randomly assigned to either a treatment (TX) or

controlbull (non-treatment) groupbull bull May bebull o Blind neither subject nor investigator knows which TX subject is receivingbull o Double-blind neither subject nor investigator knows which TX subject is receivingbull o Non-blind both subject and investigator know which TX subject is receiving usedbull when it is felt that the knowledge of treatment is unimportantbull META-ANALYSIS OF RCTSbull bull Quantitatively synthesizes and analyzes results of multiple primary studies addressing

abull similar research questionbull bull Statistically pools results from independent but combinable studiesbull bull Summary statistic (effect size) is expressed in terms of direction (positive negative

orbull zero) and magnitude (high medium small)

bull LEVEL 2bull QUASI-EXPERIMENTAL STUDYbull bull Always includes manipulation of an independent variablebull bull Lacks either random assignment or control groupbull bull Findings must be considered in light of threats to validity (particularly selection)

bull LEVEL 3bull NON-EXPERIMENTAL STUDYbull bull No manipulation of the independent variablebull bull Can be descriptive comparative or relationalbull bull Often uses secondary databull bull Findings must be considered in light of threats to validity (particularly selection lack

ofbull severity or co-morbidity adjustment)

bull QUALITATIVE STUDYbull 1048707 Explorative in nature such as interviews observations or focus groupsbull 1048707 Starting point for studies of questions for which little research currently existsbull 1048707 Sample sizes are usually small and study results are used to design stronger studies

thatbull are more objective and quantifiable

bull META-SYNTHESISbull 1048707 Research technique that critically analyzes and synthesizes findings from qualitativebull researchbull 1048707 Identifies key concepts and metaphors and determines their relationships to each

otherbull 1048707 Aim is not to produce a summary statistic but rather to interpret and

translate findings

JHNEBP Research Evidence Appraisal

The Johns Hopkins HospitalThe Johns Hopkins University

QUALITY RATING (SCIENTIFIC EVIDENCE)

A High quality consistent results sufficient sample size adequate control and

bull definitive conclusions consistent recommendations based on extensive literature

bull review that includes thoughtful reference to scientific evidence

B Good quality reasonably consistent results sufficient sample size some control

bull and fairly definitive conclusions reasonably consistent recommendations based

bull on fairly comprehensive literature review that includes some reference to

bull scientific evidence

C Low quality or major flaws little evidence with inconsistent results insufficient

bull sample size conclusions cannot be drawn

Article 1 ldquoConflict management training and nurse-physician collaborative behaviorsrdquo(Boone et al 2008)bull Quantitative quasi-experimental designbull The researchers are highly qualified and experiencedbull Convenience sample which closely approximates the real world experiencebull This study is ethically sound as a written explanation of the study was provided and

informed consent was obtainedbull The problem is clearly stated to examine a knowledge gap between a unit specific

intervention (conflict management training) and improved communication and collaboration between physicians and nurses

bull Theoretical framework Kilmann and Thomas conflict resolution theory (Boone et al 2008 p 168)

bull Findings reveal that the intervention was unsuccessful (The null hypothesis not rejected)

bull The importance of continued research for interventions that promote quality communication and collaboration is stressed

bull Creating a culture that values quality communication and collaboration forms the basis for developing a healthy work environment

bull Level of evidence varies by tool used but is evaluated as II or III Both levels are credible for utilization in evidence based care

bull Informed consent was obtained from all participants

Article 2 ldquoNine structures and leadership practices essential for a magnetic (healthy) work environmentrdquo (Kramer et al 2010)

bull This is a quantitative meta-analysis of thirty professional publications bull The problem is clearly stated to identify what structures and leadership

practices are necessary to support a healthy work environmentbull The researchers are experienced and well qualifiedbull The sample size was good Over 1300 interviews of expert nurses nurse

managers and physicians were compiled for comparison to findings from regulatory and professional organizations

bull The theoretical framework is based on the Donabedian model (httpwwwahrqgovqualmedteammedteamfig2htm) of patient safety

bull Healthy work environments lead to improved patient and nurse outcomesbull Creating a culture of interdisciplinary collaboration and teamwork through

shared power and administrative support were important themesbull This is a valid level I for evidence by all methods (course modules interview

with hospital research specialist and Johns Hopkins Nursing Research Evidence Appraisal) Level I is the highest level of evidence for utilization in evidence based practice

Structuresbest leadership practices essential for healthy work environments

Quality leadership at all levels in the organization

Availability of and support for education career performance and competence development

Administrative sanction for autonomous and collaborative practice

Evidence-based practice education and operational supports

Culture practice and opportunity to learn interdisciplinary collaboration

Empowered shared decision-making structures for control of the context of nursing practice

Generation and nurturance of a patient-centered culture

Staffing structures that take into account RN competence patient acuity and teamwork

Development and support of intradisciplinary teamwork

Article 3 ldquoThe effect of an educational programme on attitudes of nurses and medical residents towards the benefit of positive communication and collaborationrdquo(McCaffrey et al 2012)bull This is a quasi-experimental study based on a convenience sample of nurses and

medical residents bull The researchers are experienced and well qualifiedbull The research question is clearly statedbull Ethical research guidelines are carefully adhered tobull A pre and post-test design based on the Jefferson Scale of Attitudes towards

Physician-Nurse Collaboration and the Communication Collaboration and Critical Thinking for Quality Patient Outcomes tools Both tools are proven to be reliable and valid (the Cronbachrsquos alpha coefficient of 087-092)

bull A critical finding in this study is that ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Statistical findings reveal that the chosen intervention of an educational programme to improve physician-nurse communication and collaboration was beneficial

bull This study is evaluated as evidence level III due to lack of a control group by two methods (Ford 2012 C Bongiorno personal communication November 26 2012) Alternatively it is rated as level II on the Johns Hopkins scale (JHNEBP Research Evidence Appraisal nd)

Article 4 ldquoNurse-physician relationships in hospitals 20000 nurses tell their storyrdquo (Schmalenberg amp Kramer 2009)

bull This study is a quantitative synthesis of the findings of six research studies based on the Essentials of Magnetism

bull The researchers are experienced and highly qualifiedbull The purpose of the study is several fold 1) To discern what constitutes quality

communication and collaboration between physicians and nurses 2) Define types of nurse-physician relationships 3) Define organizational structures and leadership practices that help develop collaborative nurse-physician relationships and 4) Study differences in nurse-physician relationships between magnet and comparison hospitals

bull The sample size of 20616 staff nurses is excellentbull Thorough literature review is the foundation for this studybull It was consistently reported that nurses at magnet hospitals reported higher quality

relationships with physicians than the comparison hospitalsbull Structures that improve relationships and are supported by magnet institutions are

keep the patient first develop constructive conflict resolution techniques and have collaborative interdisciplinary patient rounds

bull Nurses can play an active role in bringing about these interventionsbull This is a double blinded peer review of six studies clearly making it evidence level I by

all methods

Percentage of staff nurses responding affirmatively to nurse-physician relationship types by magnet

and comparison hospitals and by period

Application of Evidence for oncology nursing practice (Lai Harper)

bull Utilize the Cochrane Database or the ldquoJHNEBP Research Evidence Appraisalrdquo as the research tools effectively communicate and collaborate with oncologists about the nursing perspective on evidence-based practice

bull Ongoing literature review for the most current credible and high-quality evidence-based practice for reducing oncology patientsrsquo physical psychological and emotional issues (such as pain nausea anxiety or depression)

bull Recommend the hospital nursing research committee to initiate a survey to explore possible physician-nurse communication barriers at an oncology unit

bull Recommend the implementation of the low-cost convenient computer-based training in physician-nurse communication skills

Application of Evidence at the Cardiovascular Department (Margaret Siler)

bull High quality communication and collaboration make a great difference in the cardiac catheterization laboratory (Boone King Gresham Wahl amp Suh 2008 p 168)

bull Experience and a broad knowledge base bring confidence to our daily work (Schmalenberg amp Kramer 2009 p 82)

bull All involved parties (patient nurse physician healthcare system) can reap the benefits of collaborative practice (Kramer et al 2012 p 7)

bull There are many educational opportunities available to improve interdisciplinary and interdepartmental communication Many are quite costly Some that may make the biggest difference are fairly inexpensive including Unit Action Council work and interdepartmental job shadowing (McCaffery et al 2012)

Application of Evidence into the Surgical Setting (Gary Webster)

Intra-operative settings place nurses and physicians in close collaborative work

settings The typical communication style is authoritarian Schmalenberg and

Kramer (2009) stated that physicians felt the nurse-physician relation to be more

collaborative than nurse did I can see that being true in my work environment

The Boone et al (2008) and McCaffrey (2011) articles combined are very

valuable Together the articles show a successful attempt to increase collaboration

and some pitfalls to avoid These can help direct any programs to support an

increase in collaboration

Application of Evidence (Jamie Ziemba)

bull Poor communication between nurses and physicians related to language and cultural barriers

bull Physiciansrsquo dysfunctional or authoritarian communication style (eg instruct nurses not to call at night unless it is a life-and-death emergency) is a major patient safety issue

bull As the patient advocate nurses have an important role of communicating with physicians to verify medication orders clinical procedures and improve patient outcomes

bull Hospital training programs in communication skills and cultural diversities are recommended for physicians and nurses with different culturalethnic backgrounds

Summary Statements

bull Meta-analytical review of evidence-based research articles support the clinical significance of effective communication styles

bull Authoritarian communication styles increase disruptive behaviors and negative hostile relationships at work environments

bull Healthy work environments have positive effects on nurses physicians patients and healthcare organizations

bull Inter-disciplinary collaboration is an essential aspect of healthy work environmentsbull Evidence-based studies have shown positive patient outcomes nursing job

satisfaction collaborative environments at Magnet hospitalsbull There is a need to address the barriers and incorporate educational programs to teach

effective communication and the need for collaboration Educational training should be re-enforced with weekly discussions ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Educate staff on the 5 types of nurse-physician relationships (collegial collaborative teacher-student friendly-stranger and hostileadversarial relationships)

bull Teach staff how to utilize positive relationships and change negative onesbull Training should avoid focusing on negative behaviorsbull Training should focus creating cooperative behaviors

ReferencesAgency for Healthcare Research and Quality (nd) Medical teamwork and patient safety The Donabedian model of patient safety Retrieved

from httpwwwahrqgovqualmedteammedteamfig2htm

American Nurses Association (1980) Nursing A social policy statement Washington DC American Nurses Association

Ballou K amp Landreneau K (2010) The authoritarian reign in American health care Policy Politics amp Nursing Practice 11(1) 71-79

doi1011771527154410372973

Boone B King M Gresham L Wahl P amp Suh E (2008) Conflict management training and nurse-physician collaborative behaviors

Journal For Nurses In Staff Development 24(4) 168-175 doi10109701NND00003206705641591

Burns N amp Grove S (2007) Understanding Nursing Research Building an Evidence Based Practice (4th Ed) St Louis Missouri Saunders

Elsevier Publishing

Ford L (2012) Week 8 amp 9 Critique of Research Retrieved from httpsfsulearnferriseduwebappsportalframesetjsp

tab_tab_group_id=_2_1ampurl=2Fwebapps2Fblackboard2Fexecute2Flauncher3Ftype3DCourseampid3D_2241_1ampurl3D

Gardezi F Lingard L Espin S Whyte S Orser B amp Baker G (2009) Silence power and communication in the operating room

Journal Of Advanced Nursing 65(7) 1390-1399 doi101111j1365-2648200904994x

Hendel T Fish M amp Berger O (2007) Nursephysician conflict management mode choices implications for improved collaborative

practice Nursing Administration Quarterly 31(3) 244-253

John Hopkins UniversityJohn Hopkins Hospital (nd) JHNEBP Research Evidence Appraisal Retrieved from

httpwwwnursingworldorgDocumentVaultNursingPracticeResearch-ToolkitJHNEBP-Research-Evidence-Appraisalpdf

Karanikola M Papathanassoglou E Kalafati M Stathopoulou H Mpouzika M amp Goutsikas C G (2012) Exploration of the

Association Between Professional Interactions and Emotional Distress of Intensive Care Unit Nursing Personnel Dimensions Of Critical

Care Nursing 31(1) 37-45 doi101097DCC0b013e31823a55b8

ReferencesKramer M Schmalenberg C amp Maguire P (2010) Nine structures and leadership practices essential for a magnetic (healthy)

work environment Nursing Administration Quarterly 34(1) 4-17 doi101097NAQ0b013e3181c95ef4

Manojlovich M amp DeCicco B (2007) Healthy work environments nurse-physician communication and patients outcome American Journal Of Critical Care 16(6) 536-543

McCaffrey R Hayes R Cassell A Miller-Reyes S Donaldson A amp Ferrell C (2012) The effect of an educational programme on attitudes of nurses and medical residents towards the benefits of positive communication and collaboration Journal Of Advanced Nursing 68(2) 293-301 doi101111j1365-2648201105736x

Nieswiadomy R M (2012) Foundations of Nursing Research (6th Ed) Upper Saddle River New Jersey Prentice Hall

Rosenstein A amp ODaniel M (2008) A survey of the impact of disruptive behaviors and communication defects on patient safety Joint Commission Journal On Quality amp Patient Safety 34(8) 464-471

Rothstein W amp Hannum S (2007) Profession and gender in relationships between advanced practice nurses and physicians Journal Of Professional Nursing 23(4) 235-240 doi101016jprofnurs200701008

Saxton R Hines T amp Enriquez M (2009) The negative impact of nurse-physician disruptive behavior on patient safety A review of the literature Journal of Patient Safety 5(3) 180-183

Stone P W (2002) Popping the PICO question in research and evidence-based practice Applied Nursing Research 16(2) 197-198

Schmalenberg C amp Kramer M (2009) Nurse-physician relationships in hospitals 20 000 nurses tell their story Critical Care Nurse 29(1) 74-83 doi104037ccn2009436

Zwarenstein M Goldman J amp Reeves S (2009) Interprofessional collaboration Effects of practice-based interventions on professional practice and healthcare outcomes Cochrane Database Of Systematic Reviews (3) 1-31 doi10100214651858CD000072

NURS 350 Evidence-Based Nursing Practice (Group paper plus Group Powerpoint presentation)

Total group grade 100Instructorrsquos comments Excellent paper I think your group

should consider submitting it for publication if you could flesh out the details on improving collaborative communication

• Ferris State University NURS 350 Evidence-Based Nursing Practic
• ldquoCommunication--the human connection--is the key to pers
• Slide 3
• What is patient safety
• What is acute care
• What is Professional Communication
• Communication between medical professionals is not just a local
• PICO Question
• Definitions
• A Survey of the Impacts of Disruptive Behaviors and Communicat
• A Survey of the Impacts of Disruptive Behaviors and Communicat (2)
• Literature Review (Level One Evidence)
• Literature Review (Level Three Evidence)
• Literature Review (Level Four Evidence)
• Literature Review (Level Four Evidence continued)
• Literature Review (Level Six Evidence)
• Analysis of Evidence
• Slide 18
• Slide 19
• Article 1 ldquoConflict management training and nurse-physician
• Article 2 ldquoNine structures and leadership practices essentia
• Slide 22
• Article 3 ldquoThe effect of an educational programme on attitud
• Article 4 ldquoNurse-physician relationships in hospitals 2000
• Percentage of staff nurses responding affirmatively to nurse-ph
• Application of Evidence for oncology nursing practice (Lai Har
• Application of Evidence at the Cardiovascular Department (Marg
• Application of Evidence into the Surgical Setting (Gary Webste
• Slide 29
• Summary Statements
• References
• References (2)
• NURS 350 Evidence-Based Nursing Practice (Group paper plus Gr

Literature Review (Level Three Evidence)

Research Articles

Research Methods

Theoretical frameworksMeasurement Instruments

Samples Data AnalysesStudy Findings

Boone King Gresham Wahl amp Suh (2008)

Quasi-experimental (Pre- and Post- Test for the training in assertiveness and cooperation)

Kilmann and Thomasrsquo model of conflict resolution (accommodating avoidance competition compromise collaboration)

Collaborative Behavior Scale

9 nurses from the cardiovascular laboratory (experimental group) and 18 nurses from the telemetry unit (control group)

Non-probability sampling in an American hospital

No statistical significance for the Collaborative Behavior Scale beforeafter the training between the experimental group and the control group ldquop more than 005rdquo (Boone et al p 172)

the communication style of ldquoavoidancerdquo was associated with increased nursesrsquo emotional stress (Boone et al p 173)

Implication explore barriers before training programs involve physiciansrsquo participations

McCaffrey HayesCassell Miller-Reyes Donaldson amp Ferrell (2012)

Quasi-experimental (Pre- and Post-test for training in communication skills)

Jefferson Scale of Attitudes

68 nurses and 47 medical residents in a Florida hospital

Non-probability sampling

statistical significance (P=0001) of the T-test before and after the 6-month educational program for enhancing physician-nurse collegiality communication skills mutual decision-making processes (McCaffrey et al p 298)

Literature Review (Level Four Evidence)Research Articles

Research Studies

Theoretical Frameworks

Measurement Instruments

Samples Data AnalysesStudy Findings

Hendel Fish amp Berger (2007)

Cross-sectional Correlational study

Thomas-Kilman Model of Conflict Resolution

Conflict Mode Instrument (MODE)

75 physicians 54 charge nurses at 5 acute care hospitals in Israel

Non-probability sampling

charge nurses were more likely to use the ldquocollaboratingrdquo communication style when compared to physicians (P=0001) (Hendel et al p 249)

Karanikola et al (2012)

Descriptive Correlational study

Hamiltonrsquos Anxiety Scale

Stamprsquos Index of Work Satisfaction

2-stage random probability sampling

11 hospitals randomly selected in Greece then 229 nurses at intensive care units randomly selected

Satisfaction in physician communication was statistically significant and negatively associated with intensive care nursesrsquo anxiety level ldquocorrelation coefficient Kendall = -0160 P=0001rdquo and depressed mood ldquocorrelation coefficient = -0148 P=0005rdquo (p 41)

Limitations confounding variables of nursesrsquo personal psychiatric or psychological histories

Manojlovich amp DeCicco (2007)

Descriptive Cross-sectional Non-experimental

Concepts of workplace empowerment ICU Nurse-Physician QuestionnairePractice Environment Scale of the Nursing Work Index

462 nursesrsquo perceptions in 25 intensive care units from 8 Michigan hospitals

Non-probability sampling

statistical significance for the positive correlation of physician-nurse miscommunication to the perceived outcomes in medication errors (p 542)

Limitation not generalized findings not reflect cause-effect relationships

Literature Review (Level Four Evidence continued)

Research Articles

Research Studies

Theoretical Framework

Measurement Instruments

Samples Data AnalysesStudy Findings

Rosenstein amp ODaniel (2008)

Non-experimentalstudy quantitative and qualitative approach

Instrument ldquoNurse-Physician Impact of disruptive Behavior on Patient Carerdquo

Convenience samples 2846 nurses 944 physicians from 102 not-for-profit VHA member hospitals in the US from 2004 to 2007

physician-nurse disturbing behaviors are likely to reduce patient safety outcomes and nurse satisfaction Narrative data eg ldquoafraid to call Drrdquo ldquoget yelled atrdquo ldquopoor communication postoprdquo (Rosenstein amp OrsquoDaniel p 467)

67 respondents perceived that disruptive behaviors were associated with adverse patient outcomes (medical errors and patient mortality) (Rosenstein amp OrsquoDaniel p 464)

Limitation theoretical framework not specifically describedStrength large sample size

Rothsteinamp Hannum (2007)

Cross-sectional

Gender model (male physician dominance and nurse deference)

Professional model

self-reported close-ended questionnaire on nurse-physician relationship

125 advanced practice nursesAPN at a statewide professional conference

non-probability sampling

statistical significance for APNrsquo s positive attitudecommunication with female physicians (less than 50 years old) and male physicians (of all ages) male and female physicians are also likely to be positive and respectful about APNrsquos knowledge in patient care (2-tailed t test and one-way analysis of variance P value less than 005) (Rothstein amp Hannum p 238)

The gender model for the authoritative dominance of male physicians is not applicable to the female APNs who have at least a masterrsquos degree in nursing (p 235)

Limitation confounding variables not measured ldquotype and size of the work organization nurse and physician specialties and patient illness and social characteristicsrdquo (p 239)

Literature Review (Level Six Evidence)

Research

Article

Research Method

Theoretical Framework

Sample Study Findings

Gardezi Lingard Espin Whyte Orser amp Baker (2009)

Qualitative study

Ethnographic approach

Retrospective study

Critical Theory about silence in communication

observed physician-nurse communications over 700 surgeries at 3 acute care hospitals from 2005 to 2007 in Canada

Narrative and descriptive data about conflicts in physician-nurse communication styles at operating rooms due to nursesrsquo gap in knowledge about surgical procedures and surgeonsrsquo dominant authoritative power

Nursesrsquo passivesilent communication method had negative impacts on patient safety during surgeries (Gardezi et al p 1391)

Limitations evidence-based practice cannot be based on one qualitative study

Strengths explore the descriptive lived experiences about physician-nurse communication barriers over 2 years

Analysis of Evidence

The ability to critically analyze evidence presented in various research projects is necessary to evaluate the work for applicability and use in evidence based nursing practice ldquoTo use research evidence one must be able to evaluate this evidencerdquo (Nieswiadomy 2012 p 298)

bull STRENGTH OF EVIDENCEbull LEVEL 1 (HIGHEST)bull EXPERIMENTAL STUDY (RANDOMIZED CONTROLLED TRAIL OR RCT)bull bull Study participants (subjects) are randomly assigned to either a treatment (TX) or

controlbull (non-treatment) groupbull bull May bebull o Blind neither subject nor investigator knows which TX subject is receivingbull o Double-blind neither subject nor investigator knows which TX subject is receivingbull o Non-blind both subject and investigator know which TX subject is receiving usedbull when it is felt that the knowledge of treatment is unimportantbull META-ANALYSIS OF RCTSbull bull Quantitatively synthesizes and analyzes results of multiple primary studies addressing

abull similar research questionbull bull Statistically pools results from independent but combinable studiesbull bull Summary statistic (effect size) is expressed in terms of direction (positive negative

orbull zero) and magnitude (high medium small)

bull LEVEL 2bull QUASI-EXPERIMENTAL STUDYbull bull Always includes manipulation of an independent variablebull bull Lacks either random assignment or control groupbull bull Findings must be considered in light of threats to validity (particularly selection)

bull LEVEL 3bull NON-EXPERIMENTAL STUDYbull bull No manipulation of the independent variablebull bull Can be descriptive comparative or relationalbull bull Often uses secondary databull bull Findings must be considered in light of threats to validity (particularly selection lack

ofbull severity or co-morbidity adjustment)

bull QUALITATIVE STUDYbull 1048707 Explorative in nature such as interviews observations or focus groupsbull 1048707 Starting point for studies of questions for which little research currently existsbull 1048707 Sample sizes are usually small and study results are used to design stronger studies

thatbull are more objective and quantifiable

bull META-SYNTHESISbull 1048707 Research technique that critically analyzes and synthesizes findings from qualitativebull researchbull 1048707 Identifies key concepts and metaphors and determines their relationships to each

otherbull 1048707 Aim is not to produce a summary statistic but rather to interpret and

translate findings

JHNEBP Research Evidence Appraisal

The Johns Hopkins HospitalThe Johns Hopkins University

QUALITY RATING (SCIENTIFIC EVIDENCE)

A High quality consistent results sufficient sample size adequate control and

bull definitive conclusions consistent recommendations based on extensive literature

bull review that includes thoughtful reference to scientific evidence

B Good quality reasonably consistent results sufficient sample size some control

bull and fairly definitive conclusions reasonably consistent recommendations based

bull on fairly comprehensive literature review that includes some reference to

bull scientific evidence

C Low quality or major flaws little evidence with inconsistent results insufficient

bull sample size conclusions cannot be drawn

Article 1 ldquoConflict management training and nurse-physician collaborative behaviorsrdquo(Boone et al 2008)bull Quantitative quasi-experimental designbull The researchers are highly qualified and experiencedbull Convenience sample which closely approximates the real world experiencebull This study is ethically sound as a written explanation of the study was provided and

informed consent was obtainedbull The problem is clearly stated to examine a knowledge gap between a unit specific

intervention (conflict management training) and improved communication and collaboration between physicians and nurses

bull Theoretical framework Kilmann and Thomas conflict resolution theory (Boone et al 2008 p 168)

bull Findings reveal that the intervention was unsuccessful (The null hypothesis not rejected)

bull The importance of continued research for interventions that promote quality communication and collaboration is stressed

bull Creating a culture that values quality communication and collaboration forms the basis for developing a healthy work environment

bull Level of evidence varies by tool used but is evaluated as II or III Both levels are credible for utilization in evidence based care

bull Informed consent was obtained from all participants

Article 2 ldquoNine structures and leadership practices essential for a magnetic (healthy) work environmentrdquo (Kramer et al 2010)

bull This is a quantitative meta-analysis of thirty professional publications bull The problem is clearly stated to identify what structures and leadership

practices are necessary to support a healthy work environmentbull The researchers are experienced and well qualifiedbull The sample size was good Over 1300 interviews of expert nurses nurse

managers and physicians were compiled for comparison to findings from regulatory and professional organizations

bull The theoretical framework is based on the Donabedian model (httpwwwahrqgovqualmedteammedteamfig2htm) of patient safety

bull Healthy work environments lead to improved patient and nurse outcomesbull Creating a culture of interdisciplinary collaboration and teamwork through

shared power and administrative support were important themesbull This is a valid level I for evidence by all methods (course modules interview

with hospital research specialist and Johns Hopkins Nursing Research Evidence Appraisal) Level I is the highest level of evidence for utilization in evidence based practice

Structuresbest leadership practices essential for healthy work environments

Quality leadership at all levels in the organization

Availability of and support for education career performance and competence development

Administrative sanction for autonomous and collaborative practice

Evidence-based practice education and operational supports

Culture practice and opportunity to learn interdisciplinary collaboration

Empowered shared decision-making structures for control of the context of nursing practice

Generation and nurturance of a patient-centered culture

Staffing structures that take into account RN competence patient acuity and teamwork

Development and support of intradisciplinary teamwork

Article 3 ldquoThe effect of an educational programme on attitudes of nurses and medical residents towards the benefit of positive communication and collaborationrdquo(McCaffrey et al 2012)bull This is a quasi-experimental study based on a convenience sample of nurses and

medical residents bull The researchers are experienced and well qualifiedbull The research question is clearly statedbull Ethical research guidelines are carefully adhered tobull A pre and post-test design based on the Jefferson Scale of Attitudes towards

Physician-Nurse Collaboration and the Communication Collaboration and Critical Thinking for Quality Patient Outcomes tools Both tools are proven to be reliable and valid (the Cronbachrsquos alpha coefficient of 087-092)

bull A critical finding in this study is that ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Statistical findings reveal that the chosen intervention of an educational programme to improve physician-nurse communication and collaboration was beneficial

bull This study is evaluated as evidence level III due to lack of a control group by two methods (Ford 2012 C Bongiorno personal communication November 26 2012) Alternatively it is rated as level II on the Johns Hopkins scale (JHNEBP Research Evidence Appraisal nd)

Article 4 ldquoNurse-physician relationships in hospitals 20000 nurses tell their storyrdquo (Schmalenberg amp Kramer 2009)

bull This study is a quantitative synthesis of the findings of six research studies based on the Essentials of Magnetism

bull The researchers are experienced and highly qualifiedbull The purpose of the study is several fold 1) To discern what constitutes quality

communication and collaboration between physicians and nurses 2) Define types of nurse-physician relationships 3) Define organizational structures and leadership practices that help develop collaborative nurse-physician relationships and 4) Study differences in nurse-physician relationships between magnet and comparison hospitals

bull The sample size of 20616 staff nurses is excellentbull Thorough literature review is the foundation for this studybull It was consistently reported that nurses at magnet hospitals reported higher quality

relationships with physicians than the comparison hospitalsbull Structures that improve relationships and are supported by magnet institutions are

keep the patient first develop constructive conflict resolution techniques and have collaborative interdisciplinary patient rounds

bull Nurses can play an active role in bringing about these interventionsbull This is a double blinded peer review of six studies clearly making it evidence level I by

all methods

Percentage of staff nurses responding affirmatively to nurse-physician relationship types by magnet

and comparison hospitals and by period

Application of Evidence for oncology nursing practice (Lai Harper)

bull Utilize the Cochrane Database or the ldquoJHNEBP Research Evidence Appraisalrdquo as the research tools effectively communicate and collaborate with oncologists about the nursing perspective on evidence-based practice

bull Ongoing literature review for the most current credible and high-quality evidence-based practice for reducing oncology patientsrsquo physical psychological and emotional issues (such as pain nausea anxiety or depression)

bull Recommend the hospital nursing research committee to initiate a survey to explore possible physician-nurse communication barriers at an oncology unit

bull Recommend the implementation of the low-cost convenient computer-based training in physician-nurse communication skills

Application of Evidence at the Cardiovascular Department (Margaret Siler)

bull High quality communication and collaboration make a great difference in the cardiac catheterization laboratory (Boone King Gresham Wahl amp Suh 2008 p 168)

bull Experience and a broad knowledge base bring confidence to our daily work (Schmalenberg amp Kramer 2009 p 82)

bull All involved parties (patient nurse physician healthcare system) can reap the benefits of collaborative practice (Kramer et al 2012 p 7)

bull There are many educational opportunities available to improve interdisciplinary and interdepartmental communication Many are quite costly Some that may make the biggest difference are fairly inexpensive including Unit Action Council work and interdepartmental job shadowing (McCaffery et al 2012)

Application of Evidence into the Surgical Setting (Gary Webster)

Intra-operative settings place nurses and physicians in close collaborative work

settings The typical communication style is authoritarian Schmalenberg and

Kramer (2009) stated that physicians felt the nurse-physician relation to be more

collaborative than nurse did I can see that being true in my work environment

The Boone et al (2008) and McCaffrey (2011) articles combined are very

valuable Together the articles show a successful attempt to increase collaboration

and some pitfalls to avoid These can help direct any programs to support an

increase in collaboration

Application of Evidence (Jamie Ziemba)

bull Poor communication between nurses and physicians related to language and cultural barriers

bull Physiciansrsquo dysfunctional or authoritarian communication style (eg instruct nurses not to call at night unless it is a life-and-death emergency) is a major patient safety issue

bull As the patient advocate nurses have an important role of communicating with physicians to verify medication orders clinical procedures and improve patient outcomes

bull Hospital training programs in communication skills and cultural diversities are recommended for physicians and nurses with different culturalethnic backgrounds

Summary Statements

bull Meta-analytical review of evidence-based research articles support the clinical significance of effective communication styles

bull Authoritarian communication styles increase disruptive behaviors and negative hostile relationships at work environments

bull Healthy work environments have positive effects on nurses physicians patients and healthcare organizations

bull Inter-disciplinary collaboration is an essential aspect of healthy work environmentsbull Evidence-based studies have shown positive patient outcomes nursing job

satisfaction collaborative environments at Magnet hospitalsbull There is a need to address the barriers and incorporate educational programs to teach

effective communication and the need for collaboration Educational training should be re-enforced with weekly discussions ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Educate staff on the 5 types of nurse-physician relationships (collegial collaborative teacher-student friendly-stranger and hostileadversarial relationships)

bull Teach staff how to utilize positive relationships and change negative onesbull Training should avoid focusing on negative behaviorsbull Training should focus creating cooperative behaviors

ReferencesAgency for Healthcare Research and Quality (nd) Medical teamwork and patient safety The Donabedian model of patient safety Retrieved

from httpwwwahrqgovqualmedteammedteamfig2htm

American Nurses Association (1980) Nursing A social policy statement Washington DC American Nurses Association

Ballou K amp Landreneau K (2010) The authoritarian reign in American health care Policy Politics amp Nursing Practice 11(1) 71-79

doi1011771527154410372973

Boone B King M Gresham L Wahl P amp Suh E (2008) Conflict management training and nurse-physician collaborative behaviors

Journal For Nurses In Staff Development 24(4) 168-175 doi10109701NND00003206705641591

Burns N amp Grove S (2007) Understanding Nursing Research Building an Evidence Based Practice (4th Ed) St Louis Missouri Saunders

Elsevier Publishing

Ford L (2012) Week 8 amp 9 Critique of Research Retrieved from httpsfsulearnferriseduwebappsportalframesetjsp

tab_tab_group_id=_2_1ampurl=2Fwebapps2Fblackboard2Fexecute2Flauncher3Ftype3DCourseampid3D_2241_1ampurl3D

Gardezi F Lingard L Espin S Whyte S Orser B amp Baker G (2009) Silence power and communication in the operating room

Journal Of Advanced Nursing 65(7) 1390-1399 doi101111j1365-2648200904994x

Hendel T Fish M amp Berger O (2007) Nursephysician conflict management mode choices implications for improved collaborative

practice Nursing Administration Quarterly 31(3) 244-253

John Hopkins UniversityJohn Hopkins Hospital (nd) JHNEBP Research Evidence Appraisal Retrieved from

httpwwwnursingworldorgDocumentVaultNursingPracticeResearch-ToolkitJHNEBP-Research-Evidence-Appraisalpdf

Karanikola M Papathanassoglou E Kalafati M Stathopoulou H Mpouzika M amp Goutsikas C G (2012) Exploration of the

Association Between Professional Interactions and Emotional Distress of Intensive Care Unit Nursing Personnel Dimensions Of Critical

Care Nursing 31(1) 37-45 doi101097DCC0b013e31823a55b8

ReferencesKramer M Schmalenberg C amp Maguire P (2010) Nine structures and leadership practices essential for a magnetic (healthy)

work environment Nursing Administration Quarterly 34(1) 4-17 doi101097NAQ0b013e3181c95ef4

Manojlovich M amp DeCicco B (2007) Healthy work environments nurse-physician communication and patients outcome American Journal Of Critical Care 16(6) 536-543

McCaffrey R Hayes R Cassell A Miller-Reyes S Donaldson A amp Ferrell C (2012) The effect of an educational programme on attitudes of nurses and medical residents towards the benefits of positive communication and collaboration Journal Of Advanced Nursing 68(2) 293-301 doi101111j1365-2648201105736x

Nieswiadomy R M (2012) Foundations of Nursing Research (6th Ed) Upper Saddle River New Jersey Prentice Hall

Rosenstein A amp ODaniel M (2008) A survey of the impact of disruptive behaviors and communication defects on patient safety Joint Commission Journal On Quality amp Patient Safety 34(8) 464-471

Rothstein W amp Hannum S (2007) Profession and gender in relationships between advanced practice nurses and physicians Journal Of Professional Nursing 23(4) 235-240 doi101016jprofnurs200701008

Saxton R Hines T amp Enriquez M (2009) The negative impact of nurse-physician disruptive behavior on patient safety A review of the literature Journal of Patient Safety 5(3) 180-183

Stone P W (2002) Popping the PICO question in research and evidence-based practice Applied Nursing Research 16(2) 197-198

Schmalenberg C amp Kramer M (2009) Nurse-physician relationships in hospitals 20 000 nurses tell their story Critical Care Nurse 29(1) 74-83 doi104037ccn2009436

Zwarenstein M Goldman J amp Reeves S (2009) Interprofessional collaboration Effects of practice-based interventions on professional practice and healthcare outcomes Cochrane Database Of Systematic Reviews (3) 1-31 doi10100214651858CD000072

NURS 350 Evidence-Based Nursing Practice (Group paper plus Group Powerpoint presentation)

Total group grade 100Instructorrsquos comments Excellent paper I think your group

should consider submitting it for publication if you could flesh out the details on improving collaborative communication

• Ferris State University NURS 350 Evidence-Based Nursing Practic
• ldquoCommunication--the human connection--is the key to pers
• Slide 3
• What is patient safety
• What is acute care
• What is Professional Communication
• Communication between medical professionals is not just a local
• PICO Question
• Definitions
• A Survey of the Impacts of Disruptive Behaviors and Communicat
• A Survey of the Impacts of Disruptive Behaviors and Communicat (2)
• Literature Review (Level One Evidence)
• Literature Review (Level Three Evidence)
• Literature Review (Level Four Evidence)
• Literature Review (Level Four Evidence continued)
• Literature Review (Level Six Evidence)
• Analysis of Evidence
• Slide 18
• Slide 19
• Article 1 ldquoConflict management training and nurse-physician
• Article 2 ldquoNine structures and leadership practices essentia
• Slide 22
• Article 3 ldquoThe effect of an educational programme on attitud
• Article 4 ldquoNurse-physician relationships in hospitals 2000
• Percentage of staff nurses responding affirmatively to nurse-ph
• Application of Evidence for oncology nursing practice (Lai Har
• Application of Evidence at the Cardiovascular Department (Marg
• Application of Evidence into the Surgical Setting (Gary Webste
• Slide 29
• Summary Statements
• References
• References (2)
• NURS 350 Evidence-Based Nursing Practice (Group paper plus Gr

Literature Review (Level Four Evidence)Research Articles

Research Studies

Theoretical Frameworks

Measurement Instruments

Samples Data AnalysesStudy Findings

Hendel Fish amp Berger (2007)

Cross-sectional Correlational study

Thomas-Kilman Model of Conflict Resolution

Conflict Mode Instrument (MODE)

75 physicians 54 charge nurses at 5 acute care hospitals in Israel

Non-probability sampling

charge nurses were more likely to use the ldquocollaboratingrdquo communication style when compared to physicians (P=0001) (Hendel et al p 249)

Karanikola et al (2012)

Descriptive Correlational study

Hamiltonrsquos Anxiety Scale

Stamprsquos Index of Work Satisfaction

2-stage random probability sampling

11 hospitals randomly selected in Greece then 229 nurses at intensive care units randomly selected

Satisfaction in physician communication was statistically significant and negatively associated with intensive care nursesrsquo anxiety level ldquocorrelation coefficient Kendall = -0160 P=0001rdquo and depressed mood ldquocorrelation coefficient = -0148 P=0005rdquo (p 41)

Limitations confounding variables of nursesrsquo personal psychiatric or psychological histories

Manojlovich amp DeCicco (2007)

Descriptive Cross-sectional Non-experimental

Concepts of workplace empowerment ICU Nurse-Physician QuestionnairePractice Environment Scale of the Nursing Work Index

462 nursesrsquo perceptions in 25 intensive care units from 8 Michigan hospitals

Non-probability sampling

statistical significance for the positive correlation of physician-nurse miscommunication to the perceived outcomes in medication errors (p 542)

Limitation not generalized findings not reflect cause-effect relationships

Literature Review (Level Four Evidence continued)

Research Articles

Research Studies

Theoretical Framework

Measurement Instruments

Samples Data AnalysesStudy Findings

Rosenstein amp ODaniel (2008)

Non-experimentalstudy quantitative and qualitative approach

Instrument ldquoNurse-Physician Impact of disruptive Behavior on Patient Carerdquo

Convenience samples 2846 nurses 944 physicians from 102 not-for-profit VHA member hospitals in the US from 2004 to 2007

physician-nurse disturbing behaviors are likely to reduce patient safety outcomes and nurse satisfaction Narrative data eg ldquoafraid to call Drrdquo ldquoget yelled atrdquo ldquopoor communication postoprdquo (Rosenstein amp OrsquoDaniel p 467)

67 respondents perceived that disruptive behaviors were associated with adverse patient outcomes (medical errors and patient mortality) (Rosenstein amp OrsquoDaniel p 464)

Limitation theoretical framework not specifically describedStrength large sample size

Rothsteinamp Hannum (2007)

Cross-sectional

Gender model (male physician dominance and nurse deference)

Professional model

self-reported close-ended questionnaire on nurse-physician relationship

125 advanced practice nursesAPN at a statewide professional conference

non-probability sampling

statistical significance for APNrsquo s positive attitudecommunication with female physicians (less than 50 years old) and male physicians (of all ages) male and female physicians are also likely to be positive and respectful about APNrsquos knowledge in patient care (2-tailed t test and one-way analysis of variance P value less than 005) (Rothstein amp Hannum p 238)

The gender model for the authoritative dominance of male physicians is not applicable to the female APNs who have at least a masterrsquos degree in nursing (p 235)

Limitation confounding variables not measured ldquotype and size of the work organization nurse and physician specialties and patient illness and social characteristicsrdquo (p 239)

Literature Review (Level Six Evidence)

Research

Article

Research Method

Theoretical Framework

Sample Study Findings

Gardezi Lingard Espin Whyte Orser amp Baker (2009)

Qualitative study

Ethnographic approach

Retrospective study

Critical Theory about silence in communication

observed physician-nurse communications over 700 surgeries at 3 acute care hospitals from 2005 to 2007 in Canada

Narrative and descriptive data about conflicts in physician-nurse communication styles at operating rooms due to nursesrsquo gap in knowledge about surgical procedures and surgeonsrsquo dominant authoritative power

Nursesrsquo passivesilent communication method had negative impacts on patient safety during surgeries (Gardezi et al p 1391)

Limitations evidence-based practice cannot be based on one qualitative study

Strengths explore the descriptive lived experiences about physician-nurse communication barriers over 2 years

Analysis of Evidence

The ability to critically analyze evidence presented in various research projects is necessary to evaluate the work for applicability and use in evidence based nursing practice ldquoTo use research evidence one must be able to evaluate this evidencerdquo (Nieswiadomy 2012 p 298)

bull STRENGTH OF EVIDENCEbull LEVEL 1 (HIGHEST)bull EXPERIMENTAL STUDY (RANDOMIZED CONTROLLED TRAIL OR RCT)bull bull Study participants (subjects) are randomly assigned to either a treatment (TX) or

controlbull (non-treatment) groupbull bull May bebull o Blind neither subject nor investigator knows which TX subject is receivingbull o Double-blind neither subject nor investigator knows which TX subject is receivingbull o Non-blind both subject and investigator know which TX subject is receiving usedbull when it is felt that the knowledge of treatment is unimportantbull META-ANALYSIS OF RCTSbull bull Quantitatively synthesizes and analyzes results of multiple primary studies addressing

abull similar research questionbull bull Statistically pools results from independent but combinable studiesbull bull Summary statistic (effect size) is expressed in terms of direction (positive negative

orbull zero) and magnitude (high medium small)

bull LEVEL 2bull QUASI-EXPERIMENTAL STUDYbull bull Always includes manipulation of an independent variablebull bull Lacks either random assignment or control groupbull bull Findings must be considered in light of threats to validity (particularly selection)

bull LEVEL 3bull NON-EXPERIMENTAL STUDYbull bull No manipulation of the independent variablebull bull Can be descriptive comparative or relationalbull bull Often uses secondary databull bull Findings must be considered in light of threats to validity (particularly selection lack

ofbull severity or co-morbidity adjustment)

bull QUALITATIVE STUDYbull 1048707 Explorative in nature such as interviews observations or focus groupsbull 1048707 Starting point for studies of questions for which little research currently existsbull 1048707 Sample sizes are usually small and study results are used to design stronger studies

thatbull are more objective and quantifiable

bull META-SYNTHESISbull 1048707 Research technique that critically analyzes and synthesizes findings from qualitativebull researchbull 1048707 Identifies key concepts and metaphors and determines their relationships to each

otherbull 1048707 Aim is not to produce a summary statistic but rather to interpret and

translate findings

JHNEBP Research Evidence Appraisal

The Johns Hopkins HospitalThe Johns Hopkins University

QUALITY RATING (SCIENTIFIC EVIDENCE)

A High quality consistent results sufficient sample size adequate control and

bull definitive conclusions consistent recommendations based on extensive literature

bull review that includes thoughtful reference to scientific evidence

B Good quality reasonably consistent results sufficient sample size some control

bull and fairly definitive conclusions reasonably consistent recommendations based

bull on fairly comprehensive literature review that includes some reference to

bull scientific evidence

C Low quality or major flaws little evidence with inconsistent results insufficient

bull sample size conclusions cannot be drawn

Article 1 ldquoConflict management training and nurse-physician collaborative behaviorsrdquo(Boone et al 2008)bull Quantitative quasi-experimental designbull The researchers are highly qualified and experiencedbull Convenience sample which closely approximates the real world experiencebull This study is ethically sound as a written explanation of the study was provided and

informed consent was obtainedbull The problem is clearly stated to examine a knowledge gap between a unit specific

intervention (conflict management training) and improved communication and collaboration between physicians and nurses

bull Theoretical framework Kilmann and Thomas conflict resolution theory (Boone et al 2008 p 168)

bull Findings reveal that the intervention was unsuccessful (The null hypothesis not rejected)

bull The importance of continued research for interventions that promote quality communication and collaboration is stressed

bull Creating a culture that values quality communication and collaboration forms the basis for developing a healthy work environment

bull Level of evidence varies by tool used but is evaluated as II or III Both levels are credible for utilization in evidence based care

bull Informed consent was obtained from all participants

Article 2 ldquoNine structures and leadership practices essential for a magnetic (healthy) work environmentrdquo (Kramer et al 2010)

bull This is a quantitative meta-analysis of thirty professional publications bull The problem is clearly stated to identify what structures and leadership

practices are necessary to support a healthy work environmentbull The researchers are experienced and well qualifiedbull The sample size was good Over 1300 interviews of expert nurses nurse

managers and physicians were compiled for comparison to findings from regulatory and professional organizations

bull The theoretical framework is based on the Donabedian model (httpwwwahrqgovqualmedteammedteamfig2htm) of patient safety

bull Healthy work environments lead to improved patient and nurse outcomesbull Creating a culture of interdisciplinary collaboration and teamwork through

shared power and administrative support were important themesbull This is a valid level I for evidence by all methods (course modules interview

with hospital research specialist and Johns Hopkins Nursing Research Evidence Appraisal) Level I is the highest level of evidence for utilization in evidence based practice

Structuresbest leadership practices essential for healthy work environments

Quality leadership at all levels in the organization

Availability of and support for education career performance and competence development

Administrative sanction for autonomous and collaborative practice

Evidence-based practice education and operational supports

Culture practice and opportunity to learn interdisciplinary collaboration

Empowered shared decision-making structures for control of the context of nursing practice

Generation and nurturance of a patient-centered culture

Staffing structures that take into account RN competence patient acuity and teamwork

Development and support of intradisciplinary teamwork

Article 3 ldquoThe effect of an educational programme on attitudes of nurses and medical residents towards the benefit of positive communication and collaborationrdquo(McCaffrey et al 2012)bull This is a quasi-experimental study based on a convenience sample of nurses and

medical residents bull The researchers are experienced and well qualifiedbull The research question is clearly statedbull Ethical research guidelines are carefully adhered tobull A pre and post-test design based on the Jefferson Scale of Attitudes towards

Physician-Nurse Collaboration and the Communication Collaboration and Critical Thinking for Quality Patient Outcomes tools Both tools are proven to be reliable and valid (the Cronbachrsquos alpha coefficient of 087-092)

bull A critical finding in this study is that ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Statistical findings reveal that the chosen intervention of an educational programme to improve physician-nurse communication and collaboration was beneficial

bull This study is evaluated as evidence level III due to lack of a control group by two methods (Ford 2012 C Bongiorno personal communication November 26 2012) Alternatively it is rated as level II on the Johns Hopkins scale (JHNEBP Research Evidence Appraisal nd)

Article 4 ldquoNurse-physician relationships in hospitals 20000 nurses tell their storyrdquo (Schmalenberg amp Kramer 2009)

bull This study is a quantitative synthesis of the findings of six research studies based on the Essentials of Magnetism

bull The researchers are experienced and highly qualifiedbull The purpose of the study is several fold 1) To discern what constitutes quality

communication and collaboration between physicians and nurses 2) Define types of nurse-physician relationships 3) Define organizational structures and leadership practices that help develop collaborative nurse-physician relationships and 4) Study differences in nurse-physician relationships between magnet and comparison hospitals

bull The sample size of 20616 staff nurses is excellentbull Thorough literature review is the foundation for this studybull It was consistently reported that nurses at magnet hospitals reported higher quality

relationships with physicians than the comparison hospitalsbull Structures that improve relationships and are supported by magnet institutions are

keep the patient first develop constructive conflict resolution techniques and have collaborative interdisciplinary patient rounds

bull Nurses can play an active role in bringing about these interventionsbull This is a double blinded peer review of six studies clearly making it evidence level I by

all methods

Percentage of staff nurses responding affirmatively to nurse-physician relationship types by magnet

and comparison hospitals and by period

Application of Evidence for oncology nursing practice (Lai Harper)

bull Utilize the Cochrane Database or the ldquoJHNEBP Research Evidence Appraisalrdquo as the research tools effectively communicate and collaborate with oncologists about the nursing perspective on evidence-based practice

bull Ongoing literature review for the most current credible and high-quality evidence-based practice for reducing oncology patientsrsquo physical psychological and emotional issues (such as pain nausea anxiety or depression)

bull Recommend the hospital nursing research committee to initiate a survey to explore possible physician-nurse communication barriers at an oncology unit

bull Recommend the implementation of the low-cost convenient computer-based training in physician-nurse communication skills

Application of Evidence at the Cardiovascular Department (Margaret Siler)

bull High quality communication and collaboration make a great difference in the cardiac catheterization laboratory (Boone King Gresham Wahl amp Suh 2008 p 168)

bull Experience and a broad knowledge base bring confidence to our daily work (Schmalenberg amp Kramer 2009 p 82)

bull All involved parties (patient nurse physician healthcare system) can reap the benefits of collaborative practice (Kramer et al 2012 p 7)

bull There are many educational opportunities available to improve interdisciplinary and interdepartmental communication Many are quite costly Some that may make the biggest difference are fairly inexpensive including Unit Action Council work and interdepartmental job shadowing (McCaffery et al 2012)

Application of Evidence into the Surgical Setting (Gary Webster)

Intra-operative settings place nurses and physicians in close collaborative work

settings The typical communication style is authoritarian Schmalenberg and

Kramer (2009) stated that physicians felt the nurse-physician relation to be more

collaborative than nurse did I can see that being true in my work environment

The Boone et al (2008) and McCaffrey (2011) articles combined are very

valuable Together the articles show a successful attempt to increase collaboration

and some pitfalls to avoid These can help direct any programs to support an

increase in collaboration

Application of Evidence (Jamie Ziemba)

bull Poor communication between nurses and physicians related to language and cultural barriers

bull Physiciansrsquo dysfunctional or authoritarian communication style (eg instruct nurses not to call at night unless it is a life-and-death emergency) is a major patient safety issue

bull As the patient advocate nurses have an important role of communicating with physicians to verify medication orders clinical procedures and improve patient outcomes

bull Hospital training programs in communication skills and cultural diversities are recommended for physicians and nurses with different culturalethnic backgrounds

Summary Statements

bull Meta-analytical review of evidence-based research articles support the clinical significance of effective communication styles

bull Authoritarian communication styles increase disruptive behaviors and negative hostile relationships at work environments

bull Healthy work environments have positive effects on nurses physicians patients and healthcare organizations

bull Inter-disciplinary collaboration is an essential aspect of healthy work environmentsbull Evidence-based studies have shown positive patient outcomes nursing job

satisfaction collaborative environments at Magnet hospitalsbull There is a need to address the barriers and incorporate educational programs to teach

effective communication and the need for collaboration Educational training should be re-enforced with weekly discussions ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Educate staff on the 5 types of nurse-physician relationships (collegial collaborative teacher-student friendly-stranger and hostileadversarial relationships)

bull Teach staff how to utilize positive relationships and change negative onesbull Training should avoid focusing on negative behaviorsbull Training should focus creating cooperative behaviors

ReferencesAgency for Healthcare Research and Quality (nd) Medical teamwork and patient safety The Donabedian model of patient safety Retrieved

from httpwwwahrqgovqualmedteammedteamfig2htm

American Nurses Association (1980) Nursing A social policy statement Washington DC American Nurses Association

Ballou K amp Landreneau K (2010) The authoritarian reign in American health care Policy Politics amp Nursing Practice 11(1) 71-79

doi1011771527154410372973

Boone B King M Gresham L Wahl P amp Suh E (2008) Conflict management training and nurse-physician collaborative behaviors

Journal For Nurses In Staff Development 24(4) 168-175 doi10109701NND00003206705641591

Burns N amp Grove S (2007) Understanding Nursing Research Building an Evidence Based Practice (4th Ed) St Louis Missouri Saunders

Elsevier Publishing

Ford L (2012) Week 8 amp 9 Critique of Research Retrieved from httpsfsulearnferriseduwebappsportalframesetjsp

tab_tab_group_id=_2_1ampurl=2Fwebapps2Fblackboard2Fexecute2Flauncher3Ftype3DCourseampid3D_2241_1ampurl3D

Gardezi F Lingard L Espin S Whyte S Orser B amp Baker G (2009) Silence power and communication in the operating room

Journal Of Advanced Nursing 65(7) 1390-1399 doi101111j1365-2648200904994x

Hendel T Fish M amp Berger O (2007) Nursephysician conflict management mode choices implications for improved collaborative

practice Nursing Administration Quarterly 31(3) 244-253

John Hopkins UniversityJohn Hopkins Hospital (nd) JHNEBP Research Evidence Appraisal Retrieved from

httpwwwnursingworldorgDocumentVaultNursingPracticeResearch-ToolkitJHNEBP-Research-Evidence-Appraisalpdf

Karanikola M Papathanassoglou E Kalafati M Stathopoulou H Mpouzika M amp Goutsikas C G (2012) Exploration of the

Association Between Professional Interactions and Emotional Distress of Intensive Care Unit Nursing Personnel Dimensions Of Critical

Care Nursing 31(1) 37-45 doi101097DCC0b013e31823a55b8

ReferencesKramer M Schmalenberg C amp Maguire P (2010) Nine structures and leadership practices essential for a magnetic (healthy)

work environment Nursing Administration Quarterly 34(1) 4-17 doi101097NAQ0b013e3181c95ef4

Manojlovich M amp DeCicco B (2007) Healthy work environments nurse-physician communication and patients outcome American Journal Of Critical Care 16(6) 536-543

McCaffrey R Hayes R Cassell A Miller-Reyes S Donaldson A amp Ferrell C (2012) The effect of an educational programme on attitudes of nurses and medical residents towards the benefits of positive communication and collaboration Journal Of Advanced Nursing 68(2) 293-301 doi101111j1365-2648201105736x

Nieswiadomy R M (2012) Foundations of Nursing Research (6th Ed) Upper Saddle River New Jersey Prentice Hall

Rosenstein A amp ODaniel M (2008) A survey of the impact of disruptive behaviors and communication defects on patient safety Joint Commission Journal On Quality amp Patient Safety 34(8) 464-471

Rothstein W amp Hannum S (2007) Profession and gender in relationships between advanced practice nurses and physicians Journal Of Professional Nursing 23(4) 235-240 doi101016jprofnurs200701008

Saxton R Hines T amp Enriquez M (2009) The negative impact of nurse-physician disruptive behavior on patient safety A review of the literature Journal of Patient Safety 5(3) 180-183

Stone P W (2002) Popping the PICO question in research and evidence-based practice Applied Nursing Research 16(2) 197-198

Schmalenberg C amp Kramer M (2009) Nurse-physician relationships in hospitals 20 000 nurses tell their story Critical Care Nurse 29(1) 74-83 doi104037ccn2009436

Zwarenstein M Goldman J amp Reeves S (2009) Interprofessional collaboration Effects of practice-based interventions on professional practice and healthcare outcomes Cochrane Database Of Systematic Reviews (3) 1-31 doi10100214651858CD000072

NURS 350 Evidence-Based Nursing Practice (Group paper plus Group Powerpoint presentation)

Total group grade 100Instructorrsquos comments Excellent paper I think your group

should consider submitting it for publication if you could flesh out the details on improving collaborative communication

• Ferris State University NURS 350 Evidence-Based Nursing Practic
• ldquoCommunication--the human connection--is the key to pers
• Slide 3
• What is patient safety
• What is acute care
• What is Professional Communication
• Communication between medical professionals is not just a local
• PICO Question
• Definitions
• A Survey of the Impacts of Disruptive Behaviors and Communicat
• A Survey of the Impacts of Disruptive Behaviors and Communicat (2)
• Literature Review (Level One Evidence)
• Literature Review (Level Three Evidence)
• Literature Review (Level Four Evidence)
• Literature Review (Level Four Evidence continued)
• Literature Review (Level Six Evidence)
• Analysis of Evidence
• Slide 18
• Slide 19
• Article 1 ldquoConflict management training and nurse-physician
• Article 2 ldquoNine structures and leadership practices essentia
• Slide 22
• Article 3 ldquoThe effect of an educational programme on attitud
• Article 4 ldquoNurse-physician relationships in hospitals 2000
• Percentage of staff nurses responding affirmatively to nurse-ph
• Application of Evidence for oncology nursing practice (Lai Har
• Application of Evidence at the Cardiovascular Department (Marg
• Application of Evidence into the Surgical Setting (Gary Webste
• Slide 29
• Summary Statements
• References
• References (2)
• NURS 350 Evidence-Based Nursing Practice (Group paper plus Gr

Literature Review (Level Four Evidence continued)

Research Articles

Research Studies

Theoretical Framework

Measurement Instruments

Samples Data AnalysesStudy Findings

Rosenstein amp ODaniel (2008)

Non-experimentalstudy quantitative and qualitative approach

Instrument ldquoNurse-Physician Impact of disruptive Behavior on Patient Carerdquo

Convenience samples 2846 nurses 944 physicians from 102 not-for-profit VHA member hospitals in the US from 2004 to 2007

physician-nurse disturbing behaviors are likely to reduce patient safety outcomes and nurse satisfaction Narrative data eg ldquoafraid to call Drrdquo ldquoget yelled atrdquo ldquopoor communication postoprdquo (Rosenstein amp OrsquoDaniel p 467)

67 respondents perceived that disruptive behaviors were associated with adverse patient outcomes (medical errors and patient mortality) (Rosenstein amp OrsquoDaniel p 464)

Limitation theoretical framework not specifically describedStrength large sample size

Rothsteinamp Hannum (2007)

Cross-sectional

Gender model (male physician dominance and nurse deference)

Professional model

self-reported close-ended questionnaire on nurse-physician relationship

125 advanced practice nursesAPN at a statewide professional conference

non-probability sampling

statistical significance for APNrsquo s positive attitudecommunication with female physicians (less than 50 years old) and male physicians (of all ages) male and female physicians are also likely to be positive and respectful about APNrsquos knowledge in patient care (2-tailed t test and one-way analysis of variance P value less than 005) (Rothstein amp Hannum p 238)

The gender model for the authoritative dominance of male physicians is not applicable to the female APNs who have at least a masterrsquos degree in nursing (p 235)

Limitation confounding variables not measured ldquotype and size of the work organization nurse and physician specialties and patient illness and social characteristicsrdquo (p 239)

Literature Review (Level Six Evidence)

Research

Article

Research Method

Theoretical Framework

Sample Study Findings

Gardezi Lingard Espin Whyte Orser amp Baker (2009)

Qualitative study

Ethnographic approach

Retrospective study

Critical Theory about silence in communication

observed physician-nurse communications over 700 surgeries at 3 acute care hospitals from 2005 to 2007 in Canada

Narrative and descriptive data about conflicts in physician-nurse communication styles at operating rooms due to nursesrsquo gap in knowledge about surgical procedures and surgeonsrsquo dominant authoritative power

Nursesrsquo passivesilent communication method had negative impacts on patient safety during surgeries (Gardezi et al p 1391)

Limitations evidence-based practice cannot be based on one qualitative study

Strengths explore the descriptive lived experiences about physician-nurse communication barriers over 2 years

Analysis of Evidence

The ability to critically analyze evidence presented in various research projects is necessary to evaluate the work for applicability and use in evidence based nursing practice ldquoTo use research evidence one must be able to evaluate this evidencerdquo (Nieswiadomy 2012 p 298)

bull STRENGTH OF EVIDENCEbull LEVEL 1 (HIGHEST)bull EXPERIMENTAL STUDY (RANDOMIZED CONTROLLED TRAIL OR RCT)bull bull Study participants (subjects) are randomly assigned to either a treatment (TX) or

controlbull (non-treatment) groupbull bull May bebull o Blind neither subject nor investigator knows which TX subject is receivingbull o Double-blind neither subject nor investigator knows which TX subject is receivingbull o Non-blind both subject and investigator know which TX subject is receiving usedbull when it is felt that the knowledge of treatment is unimportantbull META-ANALYSIS OF RCTSbull bull Quantitatively synthesizes and analyzes results of multiple primary studies addressing

abull similar research questionbull bull Statistically pools results from independent but combinable studiesbull bull Summary statistic (effect size) is expressed in terms of direction (positive negative

orbull zero) and magnitude (high medium small)

bull LEVEL 2bull QUASI-EXPERIMENTAL STUDYbull bull Always includes manipulation of an independent variablebull bull Lacks either random assignment or control groupbull bull Findings must be considered in light of threats to validity (particularly selection)

bull LEVEL 3bull NON-EXPERIMENTAL STUDYbull bull No manipulation of the independent variablebull bull Can be descriptive comparative or relationalbull bull Often uses secondary databull bull Findings must be considered in light of threats to validity (particularly selection lack

ofbull severity or co-morbidity adjustment)

bull QUALITATIVE STUDYbull 1048707 Explorative in nature such as interviews observations or focus groupsbull 1048707 Starting point for studies of questions for which little research currently existsbull 1048707 Sample sizes are usually small and study results are used to design stronger studies

thatbull are more objective and quantifiable

bull META-SYNTHESISbull 1048707 Research technique that critically analyzes and synthesizes findings from qualitativebull researchbull 1048707 Identifies key concepts and metaphors and determines their relationships to each

otherbull 1048707 Aim is not to produce a summary statistic but rather to interpret and

translate findings

JHNEBP Research Evidence Appraisal

The Johns Hopkins HospitalThe Johns Hopkins University

QUALITY RATING (SCIENTIFIC EVIDENCE)

A High quality consistent results sufficient sample size adequate control and

bull definitive conclusions consistent recommendations based on extensive literature

bull review that includes thoughtful reference to scientific evidence

B Good quality reasonably consistent results sufficient sample size some control

bull and fairly definitive conclusions reasonably consistent recommendations based

bull on fairly comprehensive literature review that includes some reference to

bull scientific evidence

C Low quality or major flaws little evidence with inconsistent results insufficient

bull sample size conclusions cannot be drawn

Article 1 ldquoConflict management training and nurse-physician collaborative behaviorsrdquo(Boone et al 2008)bull Quantitative quasi-experimental designbull The researchers are highly qualified and experiencedbull Convenience sample which closely approximates the real world experiencebull This study is ethically sound as a written explanation of the study was provided and

informed consent was obtainedbull The problem is clearly stated to examine a knowledge gap between a unit specific

intervention (conflict management training) and improved communication and collaboration between physicians and nurses

bull Theoretical framework Kilmann and Thomas conflict resolution theory (Boone et al 2008 p 168)

bull Findings reveal that the intervention was unsuccessful (The null hypothesis not rejected)

bull The importance of continued research for interventions that promote quality communication and collaboration is stressed

bull Creating a culture that values quality communication and collaboration forms the basis for developing a healthy work environment

bull Level of evidence varies by tool used but is evaluated as II or III Both levels are credible for utilization in evidence based care

bull Informed consent was obtained from all participants

Article 2 ldquoNine structures and leadership practices essential for a magnetic (healthy) work environmentrdquo (Kramer et al 2010)

bull This is a quantitative meta-analysis of thirty professional publications bull The problem is clearly stated to identify what structures and leadership

practices are necessary to support a healthy work environmentbull The researchers are experienced and well qualifiedbull The sample size was good Over 1300 interviews of expert nurses nurse

managers and physicians were compiled for comparison to findings from regulatory and professional organizations

bull The theoretical framework is based on the Donabedian model (httpwwwahrqgovqualmedteammedteamfig2htm) of patient safety

bull Healthy work environments lead to improved patient and nurse outcomesbull Creating a culture of interdisciplinary collaboration and teamwork through

shared power and administrative support were important themesbull This is a valid level I for evidence by all methods (course modules interview

with hospital research specialist and Johns Hopkins Nursing Research Evidence Appraisal) Level I is the highest level of evidence for utilization in evidence based practice

Structuresbest leadership practices essential for healthy work environments

Quality leadership at all levels in the organization

Availability of and support for education career performance and competence development

Administrative sanction for autonomous and collaborative practice

Evidence-based practice education and operational supports

Culture practice and opportunity to learn interdisciplinary collaboration

Empowered shared decision-making structures for control of the context of nursing practice

Generation and nurturance of a patient-centered culture

Staffing structures that take into account RN competence patient acuity and teamwork

Development and support of intradisciplinary teamwork

Article 3 ldquoThe effect of an educational programme on attitudes of nurses and medical residents towards the benefit of positive communication and collaborationrdquo(McCaffrey et al 2012)bull This is a quasi-experimental study based on a convenience sample of nurses and

medical residents bull The researchers are experienced and well qualifiedbull The research question is clearly statedbull Ethical research guidelines are carefully adhered tobull A pre and post-test design based on the Jefferson Scale of Attitudes towards

Physician-Nurse Collaboration and the Communication Collaboration and Critical Thinking for Quality Patient Outcomes tools Both tools are proven to be reliable and valid (the Cronbachrsquos alpha coefficient of 087-092)

bull A critical finding in this study is that ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Statistical findings reveal that the chosen intervention of an educational programme to improve physician-nurse communication and collaboration was beneficial

bull This study is evaluated as evidence level III due to lack of a control group by two methods (Ford 2012 C Bongiorno personal communication November 26 2012) Alternatively it is rated as level II on the Johns Hopkins scale (JHNEBP Research Evidence Appraisal nd)

Article 4 ldquoNurse-physician relationships in hospitals 20000 nurses tell their storyrdquo (Schmalenberg amp Kramer 2009)

bull This study is a quantitative synthesis of the findings of six research studies based on the Essentials of Magnetism

bull The researchers are experienced and highly qualifiedbull The purpose of the study is several fold 1) To discern what constitutes quality

communication and collaboration between physicians and nurses 2) Define types of nurse-physician relationships 3) Define organizational structures and leadership practices that help develop collaborative nurse-physician relationships and 4) Study differences in nurse-physician relationships between magnet and comparison hospitals

bull The sample size of 20616 staff nurses is excellentbull Thorough literature review is the foundation for this studybull It was consistently reported that nurses at magnet hospitals reported higher quality

relationships with physicians than the comparison hospitalsbull Structures that improve relationships and are supported by magnet institutions are

keep the patient first develop constructive conflict resolution techniques and have collaborative interdisciplinary patient rounds

bull Nurses can play an active role in bringing about these interventionsbull This is a double blinded peer review of six studies clearly making it evidence level I by

all methods

Percentage of staff nurses responding affirmatively to nurse-physician relationship types by magnet

and comparison hospitals and by period

Application of Evidence for oncology nursing practice (Lai Harper)

bull Utilize the Cochrane Database or the ldquoJHNEBP Research Evidence Appraisalrdquo as the research tools effectively communicate and collaborate with oncologists about the nursing perspective on evidence-based practice

bull Ongoing literature review for the most current credible and high-quality evidence-based practice for reducing oncology patientsrsquo physical psychological and emotional issues (such as pain nausea anxiety or depression)

bull Recommend the hospital nursing research committee to initiate a survey to explore possible physician-nurse communication barriers at an oncology unit

bull Recommend the implementation of the low-cost convenient computer-based training in physician-nurse communication skills

Application of Evidence at the Cardiovascular Department (Margaret Siler)

bull High quality communication and collaboration make a great difference in the cardiac catheterization laboratory (Boone King Gresham Wahl amp Suh 2008 p 168)

bull Experience and a broad knowledge base bring confidence to our daily work (Schmalenberg amp Kramer 2009 p 82)

bull All involved parties (patient nurse physician healthcare system) can reap the benefits of collaborative practice (Kramer et al 2012 p 7)

bull There are many educational opportunities available to improve interdisciplinary and interdepartmental communication Many are quite costly Some that may make the biggest difference are fairly inexpensive including Unit Action Council work and interdepartmental job shadowing (McCaffery et al 2012)

Application of Evidence into the Surgical Setting (Gary Webster)

Intra-operative settings place nurses and physicians in close collaborative work

settings The typical communication style is authoritarian Schmalenberg and

Kramer (2009) stated that physicians felt the nurse-physician relation to be more

collaborative than nurse did I can see that being true in my work environment

The Boone et al (2008) and McCaffrey (2011) articles combined are very

valuable Together the articles show a successful attempt to increase collaboration

and some pitfalls to avoid These can help direct any programs to support an

increase in collaboration

Application of Evidence (Jamie Ziemba)

bull Poor communication between nurses and physicians related to language and cultural barriers

bull Physiciansrsquo dysfunctional or authoritarian communication style (eg instruct nurses not to call at night unless it is a life-and-death emergency) is a major patient safety issue

bull As the patient advocate nurses have an important role of communicating with physicians to verify medication orders clinical procedures and improve patient outcomes

bull Hospital training programs in communication skills and cultural diversities are recommended for physicians and nurses with different culturalethnic backgrounds

Summary Statements

bull Meta-analytical review of evidence-based research articles support the clinical significance of effective communication styles

bull Authoritarian communication styles increase disruptive behaviors and negative hostile relationships at work environments

bull Healthy work environments have positive effects on nurses physicians patients and healthcare organizations

bull Inter-disciplinary collaboration is an essential aspect of healthy work environmentsbull Evidence-based studies have shown positive patient outcomes nursing job

satisfaction collaborative environments at Magnet hospitalsbull There is a need to address the barriers and incorporate educational programs to teach

effective communication and the need for collaboration Educational training should be re-enforced with weekly discussions ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Educate staff on the 5 types of nurse-physician relationships (collegial collaborative teacher-student friendly-stranger and hostileadversarial relationships)

bull Teach staff how to utilize positive relationships and change negative onesbull Training should avoid focusing on negative behaviorsbull Training should focus creating cooperative behaviors

ReferencesAgency for Healthcare Research and Quality (nd) Medical teamwork and patient safety The Donabedian model of patient safety Retrieved

from httpwwwahrqgovqualmedteammedteamfig2htm

American Nurses Association (1980) Nursing A social policy statement Washington DC American Nurses Association

Ballou K amp Landreneau K (2010) The authoritarian reign in American health care Policy Politics amp Nursing Practice 11(1) 71-79

doi1011771527154410372973

Boone B King M Gresham L Wahl P amp Suh E (2008) Conflict management training and nurse-physician collaborative behaviors

Journal For Nurses In Staff Development 24(4) 168-175 doi10109701NND00003206705641591

Burns N amp Grove S (2007) Understanding Nursing Research Building an Evidence Based Practice (4th Ed) St Louis Missouri Saunders

Elsevier Publishing

Ford L (2012) Week 8 amp 9 Critique of Research Retrieved from httpsfsulearnferriseduwebappsportalframesetjsp

tab_tab_group_id=_2_1ampurl=2Fwebapps2Fblackboard2Fexecute2Flauncher3Ftype3DCourseampid3D_2241_1ampurl3D

Gardezi F Lingard L Espin S Whyte S Orser B amp Baker G (2009) Silence power and communication in the operating room

Journal Of Advanced Nursing 65(7) 1390-1399 doi101111j1365-2648200904994x

Hendel T Fish M amp Berger O (2007) Nursephysician conflict management mode choices implications for improved collaborative

practice Nursing Administration Quarterly 31(3) 244-253

John Hopkins UniversityJohn Hopkins Hospital (nd) JHNEBP Research Evidence Appraisal Retrieved from

httpwwwnursingworldorgDocumentVaultNursingPracticeResearch-ToolkitJHNEBP-Research-Evidence-Appraisalpdf

Karanikola M Papathanassoglou E Kalafati M Stathopoulou H Mpouzika M amp Goutsikas C G (2012) Exploration of the

Association Between Professional Interactions and Emotional Distress of Intensive Care Unit Nursing Personnel Dimensions Of Critical

Care Nursing 31(1) 37-45 doi101097DCC0b013e31823a55b8

ReferencesKramer M Schmalenberg C amp Maguire P (2010) Nine structures and leadership practices essential for a magnetic (healthy)

work environment Nursing Administration Quarterly 34(1) 4-17 doi101097NAQ0b013e3181c95ef4

Manojlovich M amp DeCicco B (2007) Healthy work environments nurse-physician communication and patients outcome American Journal Of Critical Care 16(6) 536-543

McCaffrey R Hayes R Cassell A Miller-Reyes S Donaldson A amp Ferrell C (2012) The effect of an educational programme on attitudes of nurses and medical residents towards the benefits of positive communication and collaboration Journal Of Advanced Nursing 68(2) 293-301 doi101111j1365-2648201105736x

Nieswiadomy R M (2012) Foundations of Nursing Research (6th Ed) Upper Saddle River New Jersey Prentice Hall

Rosenstein A amp ODaniel M (2008) A survey of the impact of disruptive behaviors and communication defects on patient safety Joint Commission Journal On Quality amp Patient Safety 34(8) 464-471

Rothstein W amp Hannum S (2007) Profession and gender in relationships between advanced practice nurses and physicians Journal Of Professional Nursing 23(4) 235-240 doi101016jprofnurs200701008

Saxton R Hines T amp Enriquez M (2009) The negative impact of nurse-physician disruptive behavior on patient safety A review of the literature Journal of Patient Safety 5(3) 180-183

Stone P W (2002) Popping the PICO question in research and evidence-based practice Applied Nursing Research 16(2) 197-198

Schmalenberg C amp Kramer M (2009) Nurse-physician relationships in hospitals 20 000 nurses tell their story Critical Care Nurse 29(1) 74-83 doi104037ccn2009436

Zwarenstein M Goldman J amp Reeves S (2009) Interprofessional collaboration Effects of practice-based interventions on professional practice and healthcare outcomes Cochrane Database Of Systematic Reviews (3) 1-31 doi10100214651858CD000072

NURS 350 Evidence-Based Nursing Practice (Group paper plus Group Powerpoint presentation)

Total group grade 100Instructorrsquos comments Excellent paper I think your group

should consider submitting it for publication if you could flesh out the details on improving collaborative communication

• Ferris State University NURS 350 Evidence-Based Nursing Practic
• ldquoCommunication--the human connection--is the key to pers
• Slide 3
• What is patient safety
• What is acute care
• What is Professional Communication
• Communication between medical professionals is not just a local
• PICO Question
• Definitions
• A Survey of the Impacts of Disruptive Behaviors and Communicat
• A Survey of the Impacts of Disruptive Behaviors and Communicat (2)
• Literature Review (Level One Evidence)
• Literature Review (Level Three Evidence)
• Literature Review (Level Four Evidence)
• Literature Review (Level Four Evidence continued)
• Literature Review (Level Six Evidence)
• Analysis of Evidence
• Slide 18
• Slide 19
• Article 1 ldquoConflict management training and nurse-physician
• Article 2 ldquoNine structures and leadership practices essentia
• Slide 22
• Article 3 ldquoThe effect of an educational programme on attitud
• Article 4 ldquoNurse-physician relationships in hospitals 2000
• Percentage of staff nurses responding affirmatively to nurse-ph
• Application of Evidence for oncology nursing practice (Lai Har
• Application of Evidence at the Cardiovascular Department (Marg
• Application of Evidence into the Surgical Setting (Gary Webste
• Slide 29
• Summary Statements
• References
• References (2)
• NURS 350 Evidence-Based Nursing Practice (Group paper plus Gr

Literature Review (Level Six Evidence)

Research

Article

Research Method

Theoretical Framework

Sample Study Findings

Gardezi Lingard Espin Whyte Orser amp Baker (2009)

Qualitative study

Ethnographic approach

Retrospective study

Critical Theory about silence in communication

observed physician-nurse communications over 700 surgeries at 3 acute care hospitals from 2005 to 2007 in Canada

Narrative and descriptive data about conflicts in physician-nurse communication styles at operating rooms due to nursesrsquo gap in knowledge about surgical procedures and surgeonsrsquo dominant authoritative power

Nursesrsquo passivesilent communication method had negative impacts on patient safety during surgeries (Gardezi et al p 1391)

Limitations evidence-based practice cannot be based on one qualitative study

Strengths explore the descriptive lived experiences about physician-nurse communication barriers over 2 years

Analysis of Evidence

The ability to critically analyze evidence presented in various research projects is necessary to evaluate the work for applicability and use in evidence based nursing practice ldquoTo use research evidence one must be able to evaluate this evidencerdquo (Nieswiadomy 2012 p 298)

bull STRENGTH OF EVIDENCEbull LEVEL 1 (HIGHEST)bull EXPERIMENTAL STUDY (RANDOMIZED CONTROLLED TRAIL OR RCT)bull bull Study participants (subjects) are randomly assigned to either a treatment (TX) or

controlbull (non-treatment) groupbull bull May bebull o Blind neither subject nor investigator knows which TX subject is receivingbull o Double-blind neither subject nor investigator knows which TX subject is receivingbull o Non-blind both subject and investigator know which TX subject is receiving usedbull when it is felt that the knowledge of treatment is unimportantbull META-ANALYSIS OF RCTSbull bull Quantitatively synthesizes and analyzes results of multiple primary studies addressing

abull similar research questionbull bull Statistically pools results from independent but combinable studiesbull bull Summary statistic (effect size) is expressed in terms of direction (positive negative

orbull zero) and magnitude (high medium small)

bull LEVEL 2bull QUASI-EXPERIMENTAL STUDYbull bull Always includes manipulation of an independent variablebull bull Lacks either random assignment or control groupbull bull Findings must be considered in light of threats to validity (particularly selection)

bull LEVEL 3bull NON-EXPERIMENTAL STUDYbull bull No manipulation of the independent variablebull bull Can be descriptive comparative or relationalbull bull Often uses secondary databull bull Findings must be considered in light of threats to validity (particularly selection lack

ofbull severity or co-morbidity adjustment)

bull QUALITATIVE STUDYbull 1048707 Explorative in nature such as interviews observations or focus groupsbull 1048707 Starting point for studies of questions for which little research currently existsbull 1048707 Sample sizes are usually small and study results are used to design stronger studies

thatbull are more objective and quantifiable

bull META-SYNTHESISbull 1048707 Research technique that critically analyzes and synthesizes findings from qualitativebull researchbull 1048707 Identifies key concepts and metaphors and determines their relationships to each

otherbull 1048707 Aim is not to produce a summary statistic but rather to interpret and

translate findings

JHNEBP Research Evidence Appraisal

The Johns Hopkins HospitalThe Johns Hopkins University

QUALITY RATING (SCIENTIFIC EVIDENCE)

A High quality consistent results sufficient sample size adequate control and

bull definitive conclusions consistent recommendations based on extensive literature

bull review that includes thoughtful reference to scientific evidence

B Good quality reasonably consistent results sufficient sample size some control

bull and fairly definitive conclusions reasonably consistent recommendations based

bull on fairly comprehensive literature review that includes some reference to

bull scientific evidence

C Low quality or major flaws little evidence with inconsistent results insufficient

bull sample size conclusions cannot be drawn

Article 1 ldquoConflict management training and nurse-physician collaborative behaviorsrdquo(Boone et al 2008)bull Quantitative quasi-experimental designbull The researchers are highly qualified and experiencedbull Convenience sample which closely approximates the real world experiencebull This study is ethically sound as a written explanation of the study was provided and

informed consent was obtainedbull The problem is clearly stated to examine a knowledge gap between a unit specific

intervention (conflict management training) and improved communication and collaboration between physicians and nurses

bull Theoretical framework Kilmann and Thomas conflict resolution theory (Boone et al 2008 p 168)

bull Findings reveal that the intervention was unsuccessful (The null hypothesis not rejected)

bull The importance of continued research for interventions that promote quality communication and collaboration is stressed

bull Creating a culture that values quality communication and collaboration forms the basis for developing a healthy work environment

bull Level of evidence varies by tool used but is evaluated as II or III Both levels are credible for utilization in evidence based care

bull Informed consent was obtained from all participants

Article 2 ldquoNine structures and leadership practices essential for a magnetic (healthy) work environmentrdquo (Kramer et al 2010)

bull This is a quantitative meta-analysis of thirty professional publications bull The problem is clearly stated to identify what structures and leadership

practices are necessary to support a healthy work environmentbull The researchers are experienced and well qualifiedbull The sample size was good Over 1300 interviews of expert nurses nurse

managers and physicians were compiled for comparison to findings from regulatory and professional organizations

bull The theoretical framework is based on the Donabedian model (httpwwwahrqgovqualmedteammedteamfig2htm) of patient safety

bull Healthy work environments lead to improved patient and nurse outcomesbull Creating a culture of interdisciplinary collaboration and teamwork through

shared power and administrative support were important themesbull This is a valid level I for evidence by all methods (course modules interview

with hospital research specialist and Johns Hopkins Nursing Research Evidence Appraisal) Level I is the highest level of evidence for utilization in evidence based practice

Structuresbest leadership practices essential for healthy work environments

Quality leadership at all levels in the organization

Availability of and support for education career performance and competence development

Administrative sanction for autonomous and collaborative practice

Evidence-based practice education and operational supports

Culture practice and opportunity to learn interdisciplinary collaboration

Empowered shared decision-making structures for control of the context of nursing practice

Generation and nurturance of a patient-centered culture

Staffing structures that take into account RN competence patient acuity and teamwork

Development and support of intradisciplinary teamwork

Article 3 ldquoThe effect of an educational programme on attitudes of nurses and medical residents towards the benefit of positive communication and collaborationrdquo(McCaffrey et al 2012)bull This is a quasi-experimental study based on a convenience sample of nurses and

medical residents bull The researchers are experienced and well qualifiedbull The research question is clearly statedbull Ethical research guidelines are carefully adhered tobull A pre and post-test design based on the Jefferson Scale of Attitudes towards

Physician-Nurse Collaboration and the Communication Collaboration and Critical Thinking for Quality Patient Outcomes tools Both tools are proven to be reliable and valid (the Cronbachrsquos alpha coefficient of 087-092)

bull A critical finding in this study is that ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Statistical findings reveal that the chosen intervention of an educational programme to improve physician-nurse communication and collaboration was beneficial

bull This study is evaluated as evidence level III due to lack of a control group by two methods (Ford 2012 C Bongiorno personal communication November 26 2012) Alternatively it is rated as level II on the Johns Hopkins scale (JHNEBP Research Evidence Appraisal nd)

Article 4 ldquoNurse-physician relationships in hospitals 20000 nurses tell their storyrdquo (Schmalenberg amp Kramer 2009)

bull This study is a quantitative synthesis of the findings of six research studies based on the Essentials of Magnetism

bull The researchers are experienced and highly qualifiedbull The purpose of the study is several fold 1) To discern what constitutes quality

communication and collaboration between physicians and nurses 2) Define types of nurse-physician relationships 3) Define organizational structures and leadership practices that help develop collaborative nurse-physician relationships and 4) Study differences in nurse-physician relationships between magnet and comparison hospitals

bull The sample size of 20616 staff nurses is excellentbull Thorough literature review is the foundation for this studybull It was consistently reported that nurses at magnet hospitals reported higher quality

relationships with physicians than the comparison hospitalsbull Structures that improve relationships and are supported by magnet institutions are

keep the patient first develop constructive conflict resolution techniques and have collaborative interdisciplinary patient rounds

bull Nurses can play an active role in bringing about these interventionsbull This is a double blinded peer review of six studies clearly making it evidence level I by

all methods

Percentage of staff nurses responding affirmatively to nurse-physician relationship types by magnet

and comparison hospitals and by period

Application of Evidence for oncology nursing practice (Lai Harper)

bull Utilize the Cochrane Database or the ldquoJHNEBP Research Evidence Appraisalrdquo as the research tools effectively communicate and collaborate with oncologists about the nursing perspective on evidence-based practice

bull Ongoing literature review for the most current credible and high-quality evidence-based practice for reducing oncology patientsrsquo physical psychological and emotional issues (such as pain nausea anxiety or depression)

bull Recommend the hospital nursing research committee to initiate a survey to explore possible physician-nurse communication barriers at an oncology unit

bull Recommend the implementation of the low-cost convenient computer-based training in physician-nurse communication skills

Application of Evidence at the Cardiovascular Department (Margaret Siler)

bull High quality communication and collaboration make a great difference in the cardiac catheterization laboratory (Boone King Gresham Wahl amp Suh 2008 p 168)

bull Experience and a broad knowledge base bring confidence to our daily work (Schmalenberg amp Kramer 2009 p 82)

bull All involved parties (patient nurse physician healthcare system) can reap the benefits of collaborative practice (Kramer et al 2012 p 7)

bull There are many educational opportunities available to improve interdisciplinary and interdepartmental communication Many are quite costly Some that may make the biggest difference are fairly inexpensive including Unit Action Council work and interdepartmental job shadowing (McCaffery et al 2012)

Application of Evidence into the Surgical Setting (Gary Webster)

Intra-operative settings place nurses and physicians in close collaborative work

settings The typical communication style is authoritarian Schmalenberg and

Kramer (2009) stated that physicians felt the nurse-physician relation to be more

collaborative than nurse did I can see that being true in my work environment

The Boone et al (2008) and McCaffrey (2011) articles combined are very

valuable Together the articles show a successful attempt to increase collaboration

and some pitfalls to avoid These can help direct any programs to support an

increase in collaboration

Application of Evidence (Jamie Ziemba)

bull Poor communication between nurses and physicians related to language and cultural barriers

bull Physiciansrsquo dysfunctional or authoritarian communication style (eg instruct nurses not to call at night unless it is a life-and-death emergency) is a major patient safety issue

bull As the patient advocate nurses have an important role of communicating with physicians to verify medication orders clinical procedures and improve patient outcomes

bull Hospital training programs in communication skills and cultural diversities are recommended for physicians and nurses with different culturalethnic backgrounds

Summary Statements

bull Meta-analytical review of evidence-based research articles support the clinical significance of effective communication styles

bull Authoritarian communication styles increase disruptive behaviors and negative hostile relationships at work environments

bull Healthy work environments have positive effects on nurses physicians patients and healthcare organizations

bull Inter-disciplinary collaboration is an essential aspect of healthy work environmentsbull Evidence-based studies have shown positive patient outcomes nursing job

satisfaction collaborative environments at Magnet hospitalsbull There is a need to address the barriers and incorporate educational programs to teach

effective communication and the need for collaboration Educational training should be re-enforced with weekly discussions ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Educate staff on the 5 types of nurse-physician relationships (collegial collaborative teacher-student friendly-stranger and hostileadversarial relationships)

bull Teach staff how to utilize positive relationships and change negative onesbull Training should avoid focusing on negative behaviorsbull Training should focus creating cooperative behaviors

ReferencesAgency for Healthcare Research and Quality (nd) Medical teamwork and patient safety The Donabedian model of patient safety Retrieved

from httpwwwahrqgovqualmedteammedteamfig2htm

American Nurses Association (1980) Nursing A social policy statement Washington DC American Nurses Association

Ballou K amp Landreneau K (2010) The authoritarian reign in American health care Policy Politics amp Nursing Practice 11(1) 71-79

doi1011771527154410372973

Boone B King M Gresham L Wahl P amp Suh E (2008) Conflict management training and nurse-physician collaborative behaviors

Journal For Nurses In Staff Development 24(4) 168-175 doi10109701NND00003206705641591

Burns N amp Grove S (2007) Understanding Nursing Research Building an Evidence Based Practice (4th Ed) St Louis Missouri Saunders

Elsevier Publishing

Ford L (2012) Week 8 amp 9 Critique of Research Retrieved from httpsfsulearnferriseduwebappsportalframesetjsp

tab_tab_group_id=_2_1ampurl=2Fwebapps2Fblackboard2Fexecute2Flauncher3Ftype3DCourseampid3D_2241_1ampurl3D

Gardezi F Lingard L Espin S Whyte S Orser B amp Baker G (2009) Silence power and communication in the operating room

Journal Of Advanced Nursing 65(7) 1390-1399 doi101111j1365-2648200904994x

Hendel T Fish M amp Berger O (2007) Nursephysician conflict management mode choices implications for improved collaborative

practice Nursing Administration Quarterly 31(3) 244-253

John Hopkins UniversityJohn Hopkins Hospital (nd) JHNEBP Research Evidence Appraisal Retrieved from

httpwwwnursingworldorgDocumentVaultNursingPracticeResearch-ToolkitJHNEBP-Research-Evidence-Appraisalpdf

Karanikola M Papathanassoglou E Kalafati M Stathopoulou H Mpouzika M amp Goutsikas C G (2012) Exploration of the

Association Between Professional Interactions and Emotional Distress of Intensive Care Unit Nursing Personnel Dimensions Of Critical

Care Nursing 31(1) 37-45 doi101097DCC0b013e31823a55b8

ReferencesKramer M Schmalenberg C amp Maguire P (2010) Nine structures and leadership practices essential for a magnetic (healthy)

work environment Nursing Administration Quarterly 34(1) 4-17 doi101097NAQ0b013e3181c95ef4

Manojlovich M amp DeCicco B (2007) Healthy work environments nurse-physician communication and patients outcome American Journal Of Critical Care 16(6) 536-543

McCaffrey R Hayes R Cassell A Miller-Reyes S Donaldson A amp Ferrell C (2012) The effect of an educational programme on attitudes of nurses and medical residents towards the benefits of positive communication and collaboration Journal Of Advanced Nursing 68(2) 293-301 doi101111j1365-2648201105736x

Nieswiadomy R M (2012) Foundations of Nursing Research (6th Ed) Upper Saddle River New Jersey Prentice Hall

Rosenstein A amp ODaniel M (2008) A survey of the impact of disruptive behaviors and communication defects on patient safety Joint Commission Journal On Quality amp Patient Safety 34(8) 464-471

Rothstein W amp Hannum S (2007) Profession and gender in relationships between advanced practice nurses and physicians Journal Of Professional Nursing 23(4) 235-240 doi101016jprofnurs200701008

Saxton R Hines T amp Enriquez M (2009) The negative impact of nurse-physician disruptive behavior on patient safety A review of the literature Journal of Patient Safety 5(3) 180-183

Stone P W (2002) Popping the PICO question in research and evidence-based practice Applied Nursing Research 16(2) 197-198

Schmalenberg C amp Kramer M (2009) Nurse-physician relationships in hospitals 20 000 nurses tell their story Critical Care Nurse 29(1) 74-83 doi104037ccn2009436

Zwarenstein M Goldman J amp Reeves S (2009) Interprofessional collaboration Effects of practice-based interventions on professional practice and healthcare outcomes Cochrane Database Of Systematic Reviews (3) 1-31 doi10100214651858CD000072

NURS 350 Evidence-Based Nursing Practice (Group paper plus Group Powerpoint presentation)

Total group grade 100Instructorrsquos comments Excellent paper I think your group

should consider submitting it for publication if you could flesh out the details on improving collaborative communication

• Ferris State University NURS 350 Evidence-Based Nursing Practic
• ldquoCommunication--the human connection--is the key to pers
• Slide 3
• What is patient safety
• What is acute care
• What is Professional Communication
• Communication between medical professionals is not just a local
• PICO Question
• Definitions
• A Survey of the Impacts of Disruptive Behaviors and Communicat
• A Survey of the Impacts of Disruptive Behaviors and Communicat (2)
• Literature Review (Level One Evidence)
• Literature Review (Level Three Evidence)
• Literature Review (Level Four Evidence)
• Literature Review (Level Four Evidence continued)
• Literature Review (Level Six Evidence)
• Analysis of Evidence
• Slide 18
• Slide 19
• Article 1 ldquoConflict management training and nurse-physician
• Article 2 ldquoNine structures and leadership practices essentia
• Slide 22
• Article 3 ldquoThe effect of an educational programme on attitud
• Article 4 ldquoNurse-physician relationships in hospitals 2000
• Percentage of staff nurses responding affirmatively to nurse-ph
• Application of Evidence for oncology nursing practice (Lai Har
• Application of Evidence at the Cardiovascular Department (Marg
• Application of Evidence into the Surgical Setting (Gary Webste
• Slide 29
• Summary Statements
• References
• References (2)
• NURS 350 Evidence-Based Nursing Practice (Group paper plus Gr

Analysis of Evidence

The ability to critically analyze evidence presented in various research projects is necessary to evaluate the work for applicability and use in evidence based nursing practice ldquoTo use research evidence one must be able to evaluate this evidencerdquo (Nieswiadomy 2012 p 298)

bull STRENGTH OF EVIDENCEbull LEVEL 1 (HIGHEST)bull EXPERIMENTAL STUDY (RANDOMIZED CONTROLLED TRAIL OR RCT)bull bull Study participants (subjects) are randomly assigned to either a treatment (TX) or

controlbull (non-treatment) groupbull bull May bebull o Blind neither subject nor investigator knows which TX subject is receivingbull o Double-blind neither subject nor investigator knows which TX subject is receivingbull o Non-blind both subject and investigator know which TX subject is receiving usedbull when it is felt that the knowledge of treatment is unimportantbull META-ANALYSIS OF RCTSbull bull Quantitatively synthesizes and analyzes results of multiple primary studies addressing

abull similar research questionbull bull Statistically pools results from independent but combinable studiesbull bull Summary statistic (effect size) is expressed in terms of direction (positive negative

orbull zero) and magnitude (high medium small)

bull LEVEL 2bull QUASI-EXPERIMENTAL STUDYbull bull Always includes manipulation of an independent variablebull bull Lacks either random assignment or control groupbull bull Findings must be considered in light of threats to validity (particularly selection)

bull LEVEL 3bull NON-EXPERIMENTAL STUDYbull bull No manipulation of the independent variablebull bull Can be descriptive comparative or relationalbull bull Often uses secondary databull bull Findings must be considered in light of threats to validity (particularly selection lack

ofbull severity or co-morbidity adjustment)

bull QUALITATIVE STUDYbull 1048707 Explorative in nature such as interviews observations or focus groupsbull 1048707 Starting point for studies of questions for which little research currently existsbull 1048707 Sample sizes are usually small and study results are used to design stronger studies

thatbull are more objective and quantifiable

bull META-SYNTHESISbull 1048707 Research technique that critically analyzes and synthesizes findings from qualitativebull researchbull 1048707 Identifies key concepts and metaphors and determines their relationships to each

otherbull 1048707 Aim is not to produce a summary statistic but rather to interpret and

translate findings

JHNEBP Research Evidence Appraisal

The Johns Hopkins HospitalThe Johns Hopkins University

QUALITY RATING (SCIENTIFIC EVIDENCE)

A High quality consistent results sufficient sample size adequate control and

bull definitive conclusions consistent recommendations based on extensive literature

bull review that includes thoughtful reference to scientific evidence

B Good quality reasonably consistent results sufficient sample size some control

bull and fairly definitive conclusions reasonably consistent recommendations based

bull on fairly comprehensive literature review that includes some reference to

bull scientific evidence

C Low quality or major flaws little evidence with inconsistent results insufficient

bull sample size conclusions cannot be drawn

Article 1 ldquoConflict management training and nurse-physician collaborative behaviorsrdquo(Boone et al 2008)bull Quantitative quasi-experimental designbull The researchers are highly qualified and experiencedbull Convenience sample which closely approximates the real world experiencebull This study is ethically sound as a written explanation of the study was provided and

informed consent was obtainedbull The problem is clearly stated to examine a knowledge gap between a unit specific

intervention (conflict management training) and improved communication and collaboration between physicians and nurses

bull Theoretical framework Kilmann and Thomas conflict resolution theory (Boone et al 2008 p 168)

bull Findings reveal that the intervention was unsuccessful (The null hypothesis not rejected)

bull The importance of continued research for interventions that promote quality communication and collaboration is stressed

bull Creating a culture that values quality communication and collaboration forms the basis for developing a healthy work environment

bull Level of evidence varies by tool used but is evaluated as II or III Both levels are credible for utilization in evidence based care

bull Informed consent was obtained from all participants

Article 2 ldquoNine structures and leadership practices essential for a magnetic (healthy) work environmentrdquo (Kramer et al 2010)

bull This is a quantitative meta-analysis of thirty professional publications bull The problem is clearly stated to identify what structures and leadership

practices are necessary to support a healthy work environmentbull The researchers are experienced and well qualifiedbull The sample size was good Over 1300 interviews of expert nurses nurse

managers and physicians were compiled for comparison to findings from regulatory and professional organizations

bull The theoretical framework is based on the Donabedian model (httpwwwahrqgovqualmedteammedteamfig2htm) of patient safety

bull Healthy work environments lead to improved patient and nurse outcomesbull Creating a culture of interdisciplinary collaboration and teamwork through

shared power and administrative support were important themesbull This is a valid level I for evidence by all methods (course modules interview

with hospital research specialist and Johns Hopkins Nursing Research Evidence Appraisal) Level I is the highest level of evidence for utilization in evidence based practice

Structuresbest leadership practices essential for healthy work environments

Quality leadership at all levels in the organization

Availability of and support for education career performance and competence development

Administrative sanction for autonomous and collaborative practice

Evidence-based practice education and operational supports

Culture practice and opportunity to learn interdisciplinary collaboration

Empowered shared decision-making structures for control of the context of nursing practice

Generation and nurturance of a patient-centered culture

Staffing structures that take into account RN competence patient acuity and teamwork

Development and support of intradisciplinary teamwork

Article 3 ldquoThe effect of an educational programme on attitudes of nurses and medical residents towards the benefit of positive communication and collaborationrdquo(McCaffrey et al 2012)bull This is a quasi-experimental study based on a convenience sample of nurses and

medical residents bull The researchers are experienced and well qualifiedbull The research question is clearly statedbull Ethical research guidelines are carefully adhered tobull A pre and post-test design based on the Jefferson Scale of Attitudes towards

Physician-Nurse Collaboration and the Communication Collaboration and Critical Thinking for Quality Patient Outcomes tools Both tools are proven to be reliable and valid (the Cronbachrsquos alpha coefficient of 087-092)

bull A critical finding in this study is that ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Statistical findings reveal that the chosen intervention of an educational programme to improve physician-nurse communication and collaboration was beneficial

bull This study is evaluated as evidence level III due to lack of a control group by two methods (Ford 2012 C Bongiorno personal communication November 26 2012) Alternatively it is rated as level II on the Johns Hopkins scale (JHNEBP Research Evidence Appraisal nd)

Article 4 ldquoNurse-physician relationships in hospitals 20000 nurses tell their storyrdquo (Schmalenberg amp Kramer 2009)

bull This study is a quantitative synthesis of the findings of six research studies based on the Essentials of Magnetism

bull The researchers are experienced and highly qualifiedbull The purpose of the study is several fold 1) To discern what constitutes quality

communication and collaboration between physicians and nurses 2) Define types of nurse-physician relationships 3) Define organizational structures and leadership practices that help develop collaborative nurse-physician relationships and 4) Study differences in nurse-physician relationships between magnet and comparison hospitals

bull The sample size of 20616 staff nurses is excellentbull Thorough literature review is the foundation for this studybull It was consistently reported that nurses at magnet hospitals reported higher quality

relationships with physicians than the comparison hospitalsbull Structures that improve relationships and are supported by magnet institutions are

keep the patient first develop constructive conflict resolution techniques and have collaborative interdisciplinary patient rounds

bull Nurses can play an active role in bringing about these interventionsbull This is a double blinded peer review of six studies clearly making it evidence level I by

all methods

Percentage of staff nurses responding affirmatively to nurse-physician relationship types by magnet

and comparison hospitals and by period

Application of Evidence for oncology nursing practice (Lai Harper)

bull Utilize the Cochrane Database or the ldquoJHNEBP Research Evidence Appraisalrdquo as the research tools effectively communicate and collaborate with oncologists about the nursing perspective on evidence-based practice

bull Ongoing literature review for the most current credible and high-quality evidence-based practice for reducing oncology patientsrsquo physical psychological and emotional issues (such as pain nausea anxiety or depression)

bull Recommend the hospital nursing research committee to initiate a survey to explore possible physician-nurse communication barriers at an oncology unit

bull Recommend the implementation of the low-cost convenient computer-based training in physician-nurse communication skills

Application of Evidence at the Cardiovascular Department (Margaret Siler)

bull High quality communication and collaboration make a great difference in the cardiac catheterization laboratory (Boone King Gresham Wahl amp Suh 2008 p 168)

bull Experience and a broad knowledge base bring confidence to our daily work (Schmalenberg amp Kramer 2009 p 82)

bull All involved parties (patient nurse physician healthcare system) can reap the benefits of collaborative practice (Kramer et al 2012 p 7)

bull There are many educational opportunities available to improve interdisciplinary and interdepartmental communication Many are quite costly Some that may make the biggest difference are fairly inexpensive including Unit Action Council work and interdepartmental job shadowing (McCaffery et al 2012)

Application of Evidence into the Surgical Setting (Gary Webster)

Intra-operative settings place nurses and physicians in close collaborative work

settings The typical communication style is authoritarian Schmalenberg and

Kramer (2009) stated that physicians felt the nurse-physician relation to be more

collaborative than nurse did I can see that being true in my work environment

The Boone et al (2008) and McCaffrey (2011) articles combined are very

valuable Together the articles show a successful attempt to increase collaboration

and some pitfalls to avoid These can help direct any programs to support an

increase in collaboration

Application of Evidence (Jamie Ziemba)

bull Poor communication between nurses and physicians related to language and cultural barriers

bull Physiciansrsquo dysfunctional or authoritarian communication style (eg instruct nurses not to call at night unless it is a life-and-death emergency) is a major patient safety issue

bull As the patient advocate nurses have an important role of communicating with physicians to verify medication orders clinical procedures and improve patient outcomes

bull Hospital training programs in communication skills and cultural diversities are recommended for physicians and nurses with different culturalethnic backgrounds

Summary Statements

bull Meta-analytical review of evidence-based research articles support the clinical significance of effective communication styles

bull Authoritarian communication styles increase disruptive behaviors and negative hostile relationships at work environments

bull Healthy work environments have positive effects on nurses physicians patients and healthcare organizations

bull Inter-disciplinary collaboration is an essential aspect of healthy work environmentsbull Evidence-based studies have shown positive patient outcomes nursing job

satisfaction collaborative environments at Magnet hospitalsbull There is a need to address the barriers and incorporate educational programs to teach

effective communication and the need for collaboration Educational training should be re-enforced with weekly discussions ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Educate staff on the 5 types of nurse-physician relationships (collegial collaborative teacher-student friendly-stranger and hostileadversarial relationships)

bull Teach staff how to utilize positive relationships and change negative onesbull Training should avoid focusing on negative behaviorsbull Training should focus creating cooperative behaviors

ReferencesAgency for Healthcare Research and Quality (nd) Medical teamwork and patient safety The Donabedian model of patient safety Retrieved

from httpwwwahrqgovqualmedteammedteamfig2htm

American Nurses Association (1980) Nursing A social policy statement Washington DC American Nurses Association

Ballou K amp Landreneau K (2010) The authoritarian reign in American health care Policy Politics amp Nursing Practice 11(1) 71-79

doi1011771527154410372973

Boone B King M Gresham L Wahl P amp Suh E (2008) Conflict management training and nurse-physician collaborative behaviors

Journal For Nurses In Staff Development 24(4) 168-175 doi10109701NND00003206705641591

Burns N amp Grove S (2007) Understanding Nursing Research Building an Evidence Based Practice (4th Ed) St Louis Missouri Saunders

Elsevier Publishing

Ford L (2012) Week 8 amp 9 Critique of Research Retrieved from httpsfsulearnferriseduwebappsportalframesetjsp

tab_tab_group_id=_2_1ampurl=2Fwebapps2Fblackboard2Fexecute2Flauncher3Ftype3DCourseampid3D_2241_1ampurl3D

Gardezi F Lingard L Espin S Whyte S Orser B amp Baker G (2009) Silence power and communication in the operating room

Journal Of Advanced Nursing 65(7) 1390-1399 doi101111j1365-2648200904994x

Hendel T Fish M amp Berger O (2007) Nursephysician conflict management mode choices implications for improved collaborative

practice Nursing Administration Quarterly 31(3) 244-253

John Hopkins UniversityJohn Hopkins Hospital (nd) JHNEBP Research Evidence Appraisal Retrieved from

httpwwwnursingworldorgDocumentVaultNursingPracticeResearch-ToolkitJHNEBP-Research-Evidence-Appraisalpdf

Karanikola M Papathanassoglou E Kalafati M Stathopoulou H Mpouzika M amp Goutsikas C G (2012) Exploration of the

Association Between Professional Interactions and Emotional Distress of Intensive Care Unit Nursing Personnel Dimensions Of Critical

Care Nursing 31(1) 37-45 doi101097DCC0b013e31823a55b8

ReferencesKramer M Schmalenberg C amp Maguire P (2010) Nine structures and leadership practices essential for a magnetic (healthy)

work environment Nursing Administration Quarterly 34(1) 4-17 doi101097NAQ0b013e3181c95ef4

Manojlovich M amp DeCicco B (2007) Healthy work environments nurse-physician communication and patients outcome American Journal Of Critical Care 16(6) 536-543

McCaffrey R Hayes R Cassell A Miller-Reyes S Donaldson A amp Ferrell C (2012) The effect of an educational programme on attitudes of nurses and medical residents towards the benefits of positive communication and collaboration Journal Of Advanced Nursing 68(2) 293-301 doi101111j1365-2648201105736x

Nieswiadomy R M (2012) Foundations of Nursing Research (6th Ed) Upper Saddle River New Jersey Prentice Hall

Rosenstein A amp ODaniel M (2008) A survey of the impact of disruptive behaviors and communication defects on patient safety Joint Commission Journal On Quality amp Patient Safety 34(8) 464-471

Rothstein W amp Hannum S (2007) Profession and gender in relationships between advanced practice nurses and physicians Journal Of Professional Nursing 23(4) 235-240 doi101016jprofnurs200701008

Saxton R Hines T amp Enriquez M (2009) The negative impact of nurse-physician disruptive behavior on patient safety A review of the literature Journal of Patient Safety 5(3) 180-183

Stone P W (2002) Popping the PICO question in research and evidence-based practice Applied Nursing Research 16(2) 197-198

Schmalenberg C amp Kramer M (2009) Nurse-physician relationships in hospitals 20 000 nurses tell their story Critical Care Nurse 29(1) 74-83 doi104037ccn2009436

Zwarenstein M Goldman J amp Reeves S (2009) Interprofessional collaboration Effects of practice-based interventions on professional practice and healthcare outcomes Cochrane Database Of Systematic Reviews (3) 1-31 doi10100214651858CD000072

NURS 350 Evidence-Based Nursing Practice (Group paper plus Group Powerpoint presentation)

Total group grade 100Instructorrsquos comments Excellent paper I think your group

should consider submitting it for publication if you could flesh out the details on improving collaborative communication

• Ferris State University NURS 350 Evidence-Based Nursing Practic
• ldquoCommunication--the human connection--is the key to pers
• Slide 3
• What is patient safety
• What is acute care
• What is Professional Communication
• Communication between medical professionals is not just a local
• PICO Question
• Definitions
• A Survey of the Impacts of Disruptive Behaviors and Communicat
• A Survey of the Impacts of Disruptive Behaviors and Communicat (2)
• Literature Review (Level One Evidence)
• Literature Review (Level Three Evidence)
• Literature Review (Level Four Evidence)
• Literature Review (Level Four Evidence continued)
• Literature Review (Level Six Evidence)
• Analysis of Evidence
• Slide 18
• Slide 19
• Article 1 ldquoConflict management training and nurse-physician
• Article 2 ldquoNine structures and leadership practices essentia
• Slide 22
• Article 3 ldquoThe effect of an educational programme on attitud
• Article 4 ldquoNurse-physician relationships in hospitals 2000
• Percentage of staff nurses responding affirmatively to nurse-ph
• Application of Evidence for oncology nursing practice (Lai Har
• Application of Evidence at the Cardiovascular Department (Marg
• Application of Evidence into the Surgical Setting (Gary Webste
• Slide 29
• Summary Statements
• References
• References (2)
• NURS 350 Evidence-Based Nursing Practice (Group paper plus Gr

bull STRENGTH OF EVIDENCEbull LEVEL 1 (HIGHEST)bull EXPERIMENTAL STUDY (RANDOMIZED CONTROLLED TRAIL OR RCT)bull bull Study participants (subjects) are randomly assigned to either a treatment (TX) or

controlbull (non-treatment) groupbull bull May bebull o Blind neither subject nor investigator knows which TX subject is receivingbull o Double-blind neither subject nor investigator knows which TX subject is receivingbull o Non-blind both subject and investigator know which TX subject is receiving usedbull when it is felt that the knowledge of treatment is unimportantbull META-ANALYSIS OF RCTSbull bull Quantitatively synthesizes and analyzes results of multiple primary studies addressing

abull similar research questionbull bull Statistically pools results from independent but combinable studiesbull bull Summary statistic (effect size) is expressed in terms of direction (positive negative

orbull zero) and magnitude (high medium small)

bull LEVEL 2bull QUASI-EXPERIMENTAL STUDYbull bull Always includes manipulation of an independent variablebull bull Lacks either random assignment or control groupbull bull Findings must be considered in light of threats to validity (particularly selection)

bull LEVEL 3bull NON-EXPERIMENTAL STUDYbull bull No manipulation of the independent variablebull bull Can be descriptive comparative or relationalbull bull Often uses secondary databull bull Findings must be considered in light of threats to validity (particularly selection lack

ofbull severity or co-morbidity adjustment)

bull QUALITATIVE STUDYbull 1048707 Explorative in nature such as interviews observations or focus groupsbull 1048707 Starting point for studies of questions for which little research currently existsbull 1048707 Sample sizes are usually small and study results are used to design stronger studies

thatbull are more objective and quantifiable

bull META-SYNTHESISbull 1048707 Research technique that critically analyzes and synthesizes findings from qualitativebull researchbull 1048707 Identifies key concepts and metaphors and determines their relationships to each

otherbull 1048707 Aim is not to produce a summary statistic but rather to interpret and

translate findings

JHNEBP Research Evidence Appraisal

The Johns Hopkins HospitalThe Johns Hopkins University

QUALITY RATING (SCIENTIFIC EVIDENCE)

A High quality consistent results sufficient sample size adequate control and

bull definitive conclusions consistent recommendations based on extensive literature

bull review that includes thoughtful reference to scientific evidence

B Good quality reasonably consistent results sufficient sample size some control

bull and fairly definitive conclusions reasonably consistent recommendations based

bull on fairly comprehensive literature review that includes some reference to

bull scientific evidence

C Low quality or major flaws little evidence with inconsistent results insufficient

bull sample size conclusions cannot be drawn

Article 1 ldquoConflict management training and nurse-physician collaborative behaviorsrdquo(Boone et al 2008)bull Quantitative quasi-experimental designbull The researchers are highly qualified and experiencedbull Convenience sample which closely approximates the real world experiencebull This study is ethically sound as a written explanation of the study was provided and

informed consent was obtainedbull The problem is clearly stated to examine a knowledge gap between a unit specific

intervention (conflict management training) and improved communication and collaboration between physicians and nurses

bull Theoretical framework Kilmann and Thomas conflict resolution theory (Boone et al 2008 p 168)

bull Findings reveal that the intervention was unsuccessful (The null hypothesis not rejected)

bull The importance of continued research for interventions that promote quality communication and collaboration is stressed

bull Creating a culture that values quality communication and collaboration forms the basis for developing a healthy work environment

bull Level of evidence varies by tool used but is evaluated as II or III Both levels are credible for utilization in evidence based care

bull Informed consent was obtained from all participants

Article 2 ldquoNine structures and leadership practices essential for a magnetic (healthy) work environmentrdquo (Kramer et al 2010)

bull This is a quantitative meta-analysis of thirty professional publications bull The problem is clearly stated to identify what structures and leadership

practices are necessary to support a healthy work environmentbull The researchers are experienced and well qualifiedbull The sample size was good Over 1300 interviews of expert nurses nurse

managers and physicians were compiled for comparison to findings from regulatory and professional organizations

bull The theoretical framework is based on the Donabedian model (httpwwwahrqgovqualmedteammedteamfig2htm) of patient safety

bull Healthy work environments lead to improved patient and nurse outcomesbull Creating a culture of interdisciplinary collaboration and teamwork through

shared power and administrative support were important themesbull This is a valid level I for evidence by all methods (course modules interview

with hospital research specialist and Johns Hopkins Nursing Research Evidence Appraisal) Level I is the highest level of evidence for utilization in evidence based practice

Structuresbest leadership practices essential for healthy work environments

Quality leadership at all levels in the organization

Availability of and support for education career performance and competence development

Administrative sanction for autonomous and collaborative practice

Evidence-based practice education and operational supports

Culture practice and opportunity to learn interdisciplinary collaboration

Empowered shared decision-making structures for control of the context of nursing practice

Generation and nurturance of a patient-centered culture

Staffing structures that take into account RN competence patient acuity and teamwork

Development and support of intradisciplinary teamwork

Article 3 ldquoThe effect of an educational programme on attitudes of nurses and medical residents towards the benefit of positive communication and collaborationrdquo(McCaffrey et al 2012)bull This is a quasi-experimental study based on a convenience sample of nurses and

medical residents bull The researchers are experienced and well qualifiedbull The research question is clearly statedbull Ethical research guidelines are carefully adhered tobull A pre and post-test design based on the Jefferson Scale of Attitudes towards

Physician-Nurse Collaboration and the Communication Collaboration and Critical Thinking for Quality Patient Outcomes tools Both tools are proven to be reliable and valid (the Cronbachrsquos alpha coefficient of 087-092)

bull A critical finding in this study is that ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Statistical findings reveal that the chosen intervention of an educational programme to improve physician-nurse communication and collaboration was beneficial

bull This study is evaluated as evidence level III due to lack of a control group by two methods (Ford 2012 C Bongiorno personal communication November 26 2012) Alternatively it is rated as level II on the Johns Hopkins scale (JHNEBP Research Evidence Appraisal nd)

Article 4 ldquoNurse-physician relationships in hospitals 20000 nurses tell their storyrdquo (Schmalenberg amp Kramer 2009)

bull This study is a quantitative synthesis of the findings of six research studies based on the Essentials of Magnetism

bull The researchers are experienced and highly qualifiedbull The purpose of the study is several fold 1) To discern what constitutes quality

communication and collaboration between physicians and nurses 2) Define types of nurse-physician relationships 3) Define organizational structures and leadership practices that help develop collaborative nurse-physician relationships and 4) Study differences in nurse-physician relationships between magnet and comparison hospitals

bull The sample size of 20616 staff nurses is excellentbull Thorough literature review is the foundation for this studybull It was consistently reported that nurses at magnet hospitals reported higher quality

relationships with physicians than the comparison hospitalsbull Structures that improve relationships and are supported by magnet institutions are

keep the patient first develop constructive conflict resolution techniques and have collaborative interdisciplinary patient rounds

bull Nurses can play an active role in bringing about these interventionsbull This is a double blinded peer review of six studies clearly making it evidence level I by

all methods

Percentage of staff nurses responding affirmatively to nurse-physician relationship types by magnet

and comparison hospitals and by period

Application of Evidence for oncology nursing practice (Lai Harper)

bull Utilize the Cochrane Database or the ldquoJHNEBP Research Evidence Appraisalrdquo as the research tools effectively communicate and collaborate with oncologists about the nursing perspective on evidence-based practice

bull Ongoing literature review for the most current credible and high-quality evidence-based practice for reducing oncology patientsrsquo physical psychological and emotional issues (such as pain nausea anxiety or depression)

bull Recommend the hospital nursing research committee to initiate a survey to explore possible physician-nurse communication barriers at an oncology unit

bull Recommend the implementation of the low-cost convenient computer-based training in physician-nurse communication skills

Application of Evidence at the Cardiovascular Department (Margaret Siler)

bull High quality communication and collaboration make a great difference in the cardiac catheterization laboratory (Boone King Gresham Wahl amp Suh 2008 p 168)

bull Experience and a broad knowledge base bring confidence to our daily work (Schmalenberg amp Kramer 2009 p 82)

bull All involved parties (patient nurse physician healthcare system) can reap the benefits of collaborative practice (Kramer et al 2012 p 7)

bull There are many educational opportunities available to improve interdisciplinary and interdepartmental communication Many are quite costly Some that may make the biggest difference are fairly inexpensive including Unit Action Council work and interdepartmental job shadowing (McCaffery et al 2012)

Application of Evidence into the Surgical Setting (Gary Webster)

Intra-operative settings place nurses and physicians in close collaborative work

settings The typical communication style is authoritarian Schmalenberg and

Kramer (2009) stated that physicians felt the nurse-physician relation to be more

collaborative than nurse did I can see that being true in my work environment

The Boone et al (2008) and McCaffrey (2011) articles combined are very

valuable Together the articles show a successful attempt to increase collaboration

and some pitfalls to avoid These can help direct any programs to support an

increase in collaboration

Application of Evidence (Jamie Ziemba)

bull Poor communication between nurses and physicians related to language and cultural barriers

bull Physiciansrsquo dysfunctional or authoritarian communication style (eg instruct nurses not to call at night unless it is a life-and-death emergency) is a major patient safety issue

bull As the patient advocate nurses have an important role of communicating with physicians to verify medication orders clinical procedures and improve patient outcomes

bull Hospital training programs in communication skills and cultural diversities are recommended for physicians and nurses with different culturalethnic backgrounds

Summary Statements

bull Meta-analytical review of evidence-based research articles support the clinical significance of effective communication styles

bull Authoritarian communication styles increase disruptive behaviors and negative hostile relationships at work environments

bull Healthy work environments have positive effects on nurses physicians patients and healthcare organizations

bull Inter-disciplinary collaboration is an essential aspect of healthy work environmentsbull Evidence-based studies have shown positive patient outcomes nursing job

satisfaction collaborative environments at Magnet hospitalsbull There is a need to address the barriers and incorporate educational programs to teach

effective communication and the need for collaboration Educational training should be re-enforced with weekly discussions ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Educate staff on the 5 types of nurse-physician relationships (collegial collaborative teacher-student friendly-stranger and hostileadversarial relationships)

bull Teach staff how to utilize positive relationships and change negative onesbull Training should avoid focusing on negative behaviorsbull Training should focus creating cooperative behaviors

ReferencesAgency for Healthcare Research and Quality (nd) Medical teamwork and patient safety The Donabedian model of patient safety Retrieved

from httpwwwahrqgovqualmedteammedteamfig2htm

American Nurses Association (1980) Nursing A social policy statement Washington DC American Nurses Association

Ballou K amp Landreneau K (2010) The authoritarian reign in American health care Policy Politics amp Nursing Practice 11(1) 71-79

doi1011771527154410372973

Boone B King M Gresham L Wahl P amp Suh E (2008) Conflict management training and nurse-physician collaborative behaviors

Journal For Nurses In Staff Development 24(4) 168-175 doi10109701NND00003206705641591

Burns N amp Grove S (2007) Understanding Nursing Research Building an Evidence Based Practice (4th Ed) St Louis Missouri Saunders

Elsevier Publishing

Ford L (2012) Week 8 amp 9 Critique of Research Retrieved from httpsfsulearnferriseduwebappsportalframesetjsp

tab_tab_group_id=_2_1ampurl=2Fwebapps2Fblackboard2Fexecute2Flauncher3Ftype3DCourseampid3D_2241_1ampurl3D

Gardezi F Lingard L Espin S Whyte S Orser B amp Baker G (2009) Silence power and communication in the operating room

Journal Of Advanced Nursing 65(7) 1390-1399 doi101111j1365-2648200904994x

Hendel T Fish M amp Berger O (2007) Nursephysician conflict management mode choices implications for improved collaborative

practice Nursing Administration Quarterly 31(3) 244-253

John Hopkins UniversityJohn Hopkins Hospital (nd) JHNEBP Research Evidence Appraisal Retrieved from

httpwwwnursingworldorgDocumentVaultNursingPracticeResearch-ToolkitJHNEBP-Research-Evidence-Appraisalpdf

Karanikola M Papathanassoglou E Kalafati M Stathopoulou H Mpouzika M amp Goutsikas C G (2012) Exploration of the

Association Between Professional Interactions and Emotional Distress of Intensive Care Unit Nursing Personnel Dimensions Of Critical

Care Nursing 31(1) 37-45 doi101097DCC0b013e31823a55b8

ReferencesKramer M Schmalenberg C amp Maguire P (2010) Nine structures and leadership practices essential for a magnetic (healthy)

work environment Nursing Administration Quarterly 34(1) 4-17 doi101097NAQ0b013e3181c95ef4

Manojlovich M amp DeCicco B (2007) Healthy work environments nurse-physician communication and patients outcome American Journal Of Critical Care 16(6) 536-543

McCaffrey R Hayes R Cassell A Miller-Reyes S Donaldson A amp Ferrell C (2012) The effect of an educational programme on attitudes of nurses and medical residents towards the benefits of positive communication and collaboration Journal Of Advanced Nursing 68(2) 293-301 doi101111j1365-2648201105736x

Nieswiadomy R M (2012) Foundations of Nursing Research (6th Ed) Upper Saddle River New Jersey Prentice Hall

Rosenstein A amp ODaniel M (2008) A survey of the impact of disruptive behaviors and communication defects on patient safety Joint Commission Journal On Quality amp Patient Safety 34(8) 464-471

Rothstein W amp Hannum S (2007) Profession and gender in relationships between advanced practice nurses and physicians Journal Of Professional Nursing 23(4) 235-240 doi101016jprofnurs200701008

Saxton R Hines T amp Enriquez M (2009) The negative impact of nurse-physician disruptive behavior on patient safety A review of the literature Journal of Patient Safety 5(3) 180-183

Stone P W (2002) Popping the PICO question in research and evidence-based practice Applied Nursing Research 16(2) 197-198

Schmalenberg C amp Kramer M (2009) Nurse-physician relationships in hospitals 20 000 nurses tell their story Critical Care Nurse 29(1) 74-83 doi104037ccn2009436

Zwarenstein M Goldman J amp Reeves S (2009) Interprofessional collaboration Effects of practice-based interventions on professional practice and healthcare outcomes Cochrane Database Of Systematic Reviews (3) 1-31 doi10100214651858CD000072

NURS 350 Evidence-Based Nursing Practice (Group paper plus Group Powerpoint presentation)

Total group grade 100Instructorrsquos comments Excellent paper I think your group

should consider submitting it for publication if you could flesh out the details on improving collaborative communication

• Ferris State University NURS 350 Evidence-Based Nursing Practic
• ldquoCommunication--the human connection--is the key to pers
• Slide 3
• What is patient safety
• What is acute care
• What is Professional Communication
• Communication between medical professionals is not just a local
• PICO Question
• Definitions
• A Survey of the Impacts of Disruptive Behaviors and Communicat
• A Survey of the Impacts of Disruptive Behaviors and Communicat (2)
• Literature Review (Level One Evidence)
• Literature Review (Level Three Evidence)
• Literature Review (Level Four Evidence)
• Literature Review (Level Four Evidence continued)
• Literature Review (Level Six Evidence)
• Analysis of Evidence
• Slide 18
• Slide 19
• Article 1 ldquoConflict management training and nurse-physician
• Article 2 ldquoNine structures and leadership practices essentia
• Slide 22
• Article 3 ldquoThe effect of an educational programme on attitud
• Article 4 ldquoNurse-physician relationships in hospitals 2000
• Percentage of staff nurses responding affirmatively to nurse-ph
• Application of Evidence for oncology nursing practice (Lai Har
• Application of Evidence at the Cardiovascular Department (Marg
• Application of Evidence into the Surgical Setting (Gary Webste
• Slide 29
• Summary Statements
• References
• References (2)
• NURS 350 Evidence-Based Nursing Practice (Group paper plus Gr

Article 1 ldquoConflict management training and nurse-physician collaborative behaviorsrdquo(Boone et al 2008)bull Quantitative quasi-experimental designbull The researchers are highly qualified and experiencedbull Convenience sample which closely approximates the real world experiencebull This study is ethically sound as a written explanation of the study was provided and

informed consent was obtainedbull The problem is clearly stated to examine a knowledge gap between a unit specific

intervention (conflict management training) and improved communication and collaboration between physicians and nurses

bull Theoretical framework Kilmann and Thomas conflict resolution theory (Boone et al 2008 p 168)

bull Findings reveal that the intervention was unsuccessful (The null hypothesis not rejected)

bull The importance of continued research for interventions that promote quality communication and collaboration is stressed

bull Creating a culture that values quality communication and collaboration forms the basis for developing a healthy work environment

bull Level of evidence varies by tool used but is evaluated as II or III Both levels are credible for utilization in evidence based care

bull Informed consent was obtained from all participants

Article 2 ldquoNine structures and leadership practices essential for a magnetic (healthy) work environmentrdquo (Kramer et al 2010)

bull This is a quantitative meta-analysis of thirty professional publications bull The problem is clearly stated to identify what structures and leadership

practices are necessary to support a healthy work environmentbull The researchers are experienced and well qualifiedbull The sample size was good Over 1300 interviews of expert nurses nurse

managers and physicians were compiled for comparison to findings from regulatory and professional organizations

bull The theoretical framework is based on the Donabedian model (httpwwwahrqgovqualmedteammedteamfig2htm) of patient safety

bull Healthy work environments lead to improved patient and nurse outcomesbull Creating a culture of interdisciplinary collaboration and teamwork through

shared power and administrative support were important themesbull This is a valid level I for evidence by all methods (course modules interview

with hospital research specialist and Johns Hopkins Nursing Research Evidence Appraisal) Level I is the highest level of evidence for utilization in evidence based practice

Structuresbest leadership practices essential for healthy work environments

Quality leadership at all levels in the organization

Availability of and support for education career performance and competence development

Administrative sanction for autonomous and collaborative practice

Evidence-based practice education and operational supports

Culture practice and opportunity to learn interdisciplinary collaboration

Empowered shared decision-making structures for control of the context of nursing practice

Generation and nurturance of a patient-centered culture

Staffing structures that take into account RN competence patient acuity and teamwork

Development and support of intradisciplinary teamwork

Article 3 ldquoThe effect of an educational programme on attitudes of nurses and medical residents towards the benefit of positive communication and collaborationrdquo(McCaffrey et al 2012)bull This is a quasi-experimental study based on a convenience sample of nurses and

medical residents bull The researchers are experienced and well qualifiedbull The research question is clearly statedbull Ethical research guidelines are carefully adhered tobull A pre and post-test design based on the Jefferson Scale of Attitudes towards

Physician-Nurse Collaboration and the Communication Collaboration and Critical Thinking for Quality Patient Outcomes tools Both tools are proven to be reliable and valid (the Cronbachrsquos alpha coefficient of 087-092)

bull A critical finding in this study is that ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Statistical findings reveal that the chosen intervention of an educational programme to improve physician-nurse communication and collaboration was beneficial

bull This study is evaluated as evidence level III due to lack of a control group by two methods (Ford 2012 C Bongiorno personal communication November 26 2012) Alternatively it is rated as level II on the Johns Hopkins scale (JHNEBP Research Evidence Appraisal nd)

Article 4 ldquoNurse-physician relationships in hospitals 20000 nurses tell their storyrdquo (Schmalenberg amp Kramer 2009)

bull This study is a quantitative synthesis of the findings of six research studies based on the Essentials of Magnetism

bull The researchers are experienced and highly qualifiedbull The purpose of the study is several fold 1) To discern what constitutes quality

communication and collaboration between physicians and nurses 2) Define types of nurse-physician relationships 3) Define organizational structures and leadership practices that help develop collaborative nurse-physician relationships and 4) Study differences in nurse-physician relationships between magnet and comparison hospitals

bull The sample size of 20616 staff nurses is excellentbull Thorough literature review is the foundation for this studybull It was consistently reported that nurses at magnet hospitals reported higher quality

relationships with physicians than the comparison hospitalsbull Structures that improve relationships and are supported by magnet institutions are

keep the patient first develop constructive conflict resolution techniques and have collaborative interdisciplinary patient rounds

bull Nurses can play an active role in bringing about these interventionsbull This is a double blinded peer review of six studies clearly making it evidence level I by

all methods

Percentage of staff nurses responding affirmatively to nurse-physician relationship types by magnet

and comparison hospitals and by period

Application of Evidence for oncology nursing practice (Lai Harper)

bull Utilize the Cochrane Database or the ldquoJHNEBP Research Evidence Appraisalrdquo as the research tools effectively communicate and collaborate with oncologists about the nursing perspective on evidence-based practice

bull Ongoing literature review for the most current credible and high-quality evidence-based practice for reducing oncology patientsrsquo physical psychological and emotional issues (such as pain nausea anxiety or depression)

bull Recommend the hospital nursing research committee to initiate a survey to explore possible physician-nurse communication barriers at an oncology unit

bull Recommend the implementation of the low-cost convenient computer-based training in physician-nurse communication skills

Application of Evidence at the Cardiovascular Department (Margaret Siler)

bull High quality communication and collaboration make a great difference in the cardiac catheterization laboratory (Boone King Gresham Wahl amp Suh 2008 p 168)

bull Experience and a broad knowledge base bring confidence to our daily work (Schmalenberg amp Kramer 2009 p 82)

bull All involved parties (patient nurse physician healthcare system) can reap the benefits of collaborative practice (Kramer et al 2012 p 7)

bull There are many educational opportunities available to improve interdisciplinary and interdepartmental communication Many are quite costly Some that may make the biggest difference are fairly inexpensive including Unit Action Council work and interdepartmental job shadowing (McCaffery et al 2012)

Application of Evidence into the Surgical Setting (Gary Webster)

Intra-operative settings place nurses and physicians in close collaborative work

settings The typical communication style is authoritarian Schmalenberg and

Kramer (2009) stated that physicians felt the nurse-physician relation to be more

collaborative than nurse did I can see that being true in my work environment

The Boone et al (2008) and McCaffrey (2011) articles combined are very

valuable Together the articles show a successful attempt to increase collaboration

and some pitfalls to avoid These can help direct any programs to support an

increase in collaboration

Application of Evidence (Jamie Ziemba)

bull Poor communication between nurses and physicians related to language and cultural barriers

bull Physiciansrsquo dysfunctional or authoritarian communication style (eg instruct nurses not to call at night unless it is a life-and-death emergency) is a major patient safety issue

bull As the patient advocate nurses have an important role of communicating with physicians to verify medication orders clinical procedures and improve patient outcomes

bull Hospital training programs in communication skills and cultural diversities are recommended for physicians and nurses with different culturalethnic backgrounds

Summary Statements

bull Meta-analytical review of evidence-based research articles support the clinical significance of effective communication styles

bull Authoritarian communication styles increase disruptive behaviors and negative hostile relationships at work environments

bull Healthy work environments have positive effects on nurses physicians patients and healthcare organizations

bull Inter-disciplinary collaboration is an essential aspect of healthy work environmentsbull Evidence-based studies have shown positive patient outcomes nursing job

satisfaction collaborative environments at Magnet hospitalsbull There is a need to address the barriers and incorporate educational programs to teach

effective communication and the need for collaboration Educational training should be re-enforced with weekly discussions ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Educate staff on the 5 types of nurse-physician relationships (collegial collaborative teacher-student friendly-stranger and hostileadversarial relationships)

bull Teach staff how to utilize positive relationships and change negative onesbull Training should avoid focusing on negative behaviorsbull Training should focus creating cooperative behaviors

ReferencesAgency for Healthcare Research and Quality (nd) Medical teamwork and patient safety The Donabedian model of patient safety Retrieved

from httpwwwahrqgovqualmedteammedteamfig2htm

American Nurses Association (1980) Nursing A social policy statement Washington DC American Nurses Association

Ballou K amp Landreneau K (2010) The authoritarian reign in American health care Policy Politics amp Nursing Practice 11(1) 71-79

doi1011771527154410372973

Boone B King M Gresham L Wahl P amp Suh E (2008) Conflict management training and nurse-physician collaborative behaviors

Journal For Nurses In Staff Development 24(4) 168-175 doi10109701NND00003206705641591

Burns N amp Grove S (2007) Understanding Nursing Research Building an Evidence Based Practice (4th Ed) St Louis Missouri Saunders

Elsevier Publishing

Ford L (2012) Week 8 amp 9 Critique of Research Retrieved from httpsfsulearnferriseduwebappsportalframesetjsp

tab_tab_group_id=_2_1ampurl=2Fwebapps2Fblackboard2Fexecute2Flauncher3Ftype3DCourseampid3D_2241_1ampurl3D

Gardezi F Lingard L Espin S Whyte S Orser B amp Baker G (2009) Silence power and communication in the operating room

Journal Of Advanced Nursing 65(7) 1390-1399 doi101111j1365-2648200904994x

Hendel T Fish M amp Berger O (2007) Nursephysician conflict management mode choices implications for improved collaborative

practice Nursing Administration Quarterly 31(3) 244-253

John Hopkins UniversityJohn Hopkins Hospital (nd) JHNEBP Research Evidence Appraisal Retrieved from

httpwwwnursingworldorgDocumentVaultNursingPracticeResearch-ToolkitJHNEBP-Research-Evidence-Appraisalpdf

Karanikola M Papathanassoglou E Kalafati M Stathopoulou H Mpouzika M amp Goutsikas C G (2012) Exploration of the

Association Between Professional Interactions and Emotional Distress of Intensive Care Unit Nursing Personnel Dimensions Of Critical

Care Nursing 31(1) 37-45 doi101097DCC0b013e31823a55b8

ReferencesKramer M Schmalenberg C amp Maguire P (2010) Nine structures and leadership practices essential for a magnetic (healthy)

work environment Nursing Administration Quarterly 34(1) 4-17 doi101097NAQ0b013e3181c95ef4

Manojlovich M amp DeCicco B (2007) Healthy work environments nurse-physician communication and patients outcome American Journal Of Critical Care 16(6) 536-543

McCaffrey R Hayes R Cassell A Miller-Reyes S Donaldson A amp Ferrell C (2012) The effect of an educational programme on attitudes of nurses and medical residents towards the benefits of positive communication and collaboration Journal Of Advanced Nursing 68(2) 293-301 doi101111j1365-2648201105736x

Nieswiadomy R M (2012) Foundations of Nursing Research (6th Ed) Upper Saddle River New Jersey Prentice Hall

Rosenstein A amp ODaniel M (2008) A survey of the impact of disruptive behaviors and communication defects on patient safety Joint Commission Journal On Quality amp Patient Safety 34(8) 464-471

Rothstein W amp Hannum S (2007) Profession and gender in relationships between advanced practice nurses and physicians Journal Of Professional Nursing 23(4) 235-240 doi101016jprofnurs200701008

Saxton R Hines T amp Enriquez M (2009) The negative impact of nurse-physician disruptive behavior on patient safety A review of the literature Journal of Patient Safety 5(3) 180-183

Stone P W (2002) Popping the PICO question in research and evidence-based practice Applied Nursing Research 16(2) 197-198

Schmalenberg C amp Kramer M (2009) Nurse-physician relationships in hospitals 20 000 nurses tell their story Critical Care Nurse 29(1) 74-83 doi104037ccn2009436

Zwarenstein M Goldman J amp Reeves S (2009) Interprofessional collaboration Effects of practice-based interventions on professional practice and healthcare outcomes Cochrane Database Of Systematic Reviews (3) 1-31 doi10100214651858CD000072

NURS 350 Evidence-Based Nursing Practice (Group paper plus Group Powerpoint presentation)

Total group grade 100Instructorrsquos comments Excellent paper I think your group

should consider submitting it for publication if you could flesh out the details on improving collaborative communication

• Ferris State University NURS 350 Evidence-Based Nursing Practic
• ldquoCommunication--the human connection--is the key to pers
• Slide 3
• What is patient safety
• What is acute care
• What is Professional Communication
• Communication between medical professionals is not just a local
• PICO Question
• Definitions
• A Survey of the Impacts of Disruptive Behaviors and Communicat
• A Survey of the Impacts of Disruptive Behaviors and Communicat (2)
• Literature Review (Level One Evidence)
• Literature Review (Level Three Evidence)
• Literature Review (Level Four Evidence)
• Literature Review (Level Four Evidence continued)
• Literature Review (Level Six Evidence)
• Analysis of Evidence
• Slide 18
• Slide 19
• Article 1 ldquoConflict management training and nurse-physician
• Article 2 ldquoNine structures and leadership practices essentia
• Slide 22
• Article 3 ldquoThe effect of an educational programme on attitud
• Article 4 ldquoNurse-physician relationships in hospitals 2000
• Percentage of staff nurses responding affirmatively to nurse-ph
• Application of Evidence for oncology nursing practice (Lai Har
• Application of Evidence at the Cardiovascular Department (Marg
• Application of Evidence into the Surgical Setting (Gary Webste
• Slide 29
• Summary Statements
• References
• References (2)
• NURS 350 Evidence-Based Nursing Practice (Group paper plus Gr

Article 2 ldquoNine structures and leadership practices essential for a magnetic (healthy) work environmentrdquo (Kramer et al 2010)

bull This is a quantitative meta-analysis of thirty professional publications bull The problem is clearly stated to identify what structures and leadership

practices are necessary to support a healthy work environmentbull The researchers are experienced and well qualifiedbull The sample size was good Over 1300 interviews of expert nurses nurse

managers and physicians were compiled for comparison to findings from regulatory and professional organizations

bull The theoretical framework is based on the Donabedian model (httpwwwahrqgovqualmedteammedteamfig2htm) of patient safety

bull Healthy work environments lead to improved patient and nurse outcomesbull Creating a culture of interdisciplinary collaboration and teamwork through

shared power and administrative support were important themesbull This is a valid level I for evidence by all methods (course modules interview

with hospital research specialist and Johns Hopkins Nursing Research Evidence Appraisal) Level I is the highest level of evidence for utilization in evidence based practice

Structuresbest leadership practices essential for healthy work environments

Quality leadership at all levels in the organization

Availability of and support for education career performance and competence development

Administrative sanction for autonomous and collaborative practice

Evidence-based practice education and operational supports

Culture practice and opportunity to learn interdisciplinary collaboration

Empowered shared decision-making structures for control of the context of nursing practice

Generation and nurturance of a patient-centered culture

Staffing structures that take into account RN competence patient acuity and teamwork

Development and support of intradisciplinary teamwork

Article 3 ldquoThe effect of an educational programme on attitudes of nurses and medical residents towards the benefit of positive communication and collaborationrdquo(McCaffrey et al 2012)bull This is a quasi-experimental study based on a convenience sample of nurses and

medical residents bull The researchers are experienced and well qualifiedbull The research question is clearly statedbull Ethical research guidelines are carefully adhered tobull A pre and post-test design based on the Jefferson Scale of Attitudes towards

Physician-Nurse Collaboration and the Communication Collaboration and Critical Thinking for Quality Patient Outcomes tools Both tools are proven to be reliable and valid (the Cronbachrsquos alpha coefficient of 087-092)

bull A critical finding in this study is that ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Statistical findings reveal that the chosen intervention of an educational programme to improve physician-nurse communication and collaboration was beneficial

bull This study is evaluated as evidence level III due to lack of a control group by two methods (Ford 2012 C Bongiorno personal communication November 26 2012) Alternatively it is rated as level II on the Johns Hopkins scale (JHNEBP Research Evidence Appraisal nd)

Article 4 ldquoNurse-physician relationships in hospitals 20000 nurses tell their storyrdquo (Schmalenberg amp Kramer 2009)

bull This study is a quantitative synthesis of the findings of six research studies based on the Essentials of Magnetism

bull The researchers are experienced and highly qualifiedbull The purpose of the study is several fold 1) To discern what constitutes quality

communication and collaboration between physicians and nurses 2) Define types of nurse-physician relationships 3) Define organizational structures and leadership practices that help develop collaborative nurse-physician relationships and 4) Study differences in nurse-physician relationships between magnet and comparison hospitals

bull The sample size of 20616 staff nurses is excellentbull Thorough literature review is the foundation for this studybull It was consistently reported that nurses at magnet hospitals reported higher quality

relationships with physicians than the comparison hospitalsbull Structures that improve relationships and are supported by magnet institutions are

keep the patient first develop constructive conflict resolution techniques and have collaborative interdisciplinary patient rounds

bull Nurses can play an active role in bringing about these interventionsbull This is a double blinded peer review of six studies clearly making it evidence level I by

all methods

Percentage of staff nurses responding affirmatively to nurse-physician relationship types by magnet

and comparison hospitals and by period

Application of Evidence for oncology nursing practice (Lai Harper)

bull Utilize the Cochrane Database or the ldquoJHNEBP Research Evidence Appraisalrdquo as the research tools effectively communicate and collaborate with oncologists about the nursing perspective on evidence-based practice

bull Ongoing literature review for the most current credible and high-quality evidence-based practice for reducing oncology patientsrsquo physical psychological and emotional issues (such as pain nausea anxiety or depression)

bull Recommend the hospital nursing research committee to initiate a survey to explore possible physician-nurse communication barriers at an oncology unit

bull Recommend the implementation of the low-cost convenient computer-based training in physician-nurse communication skills

Application of Evidence at the Cardiovascular Department (Margaret Siler)

bull High quality communication and collaboration make a great difference in the cardiac catheterization laboratory (Boone King Gresham Wahl amp Suh 2008 p 168)

bull Experience and a broad knowledge base bring confidence to our daily work (Schmalenberg amp Kramer 2009 p 82)

bull All involved parties (patient nurse physician healthcare system) can reap the benefits of collaborative practice (Kramer et al 2012 p 7)

bull There are many educational opportunities available to improve interdisciplinary and interdepartmental communication Many are quite costly Some that may make the biggest difference are fairly inexpensive including Unit Action Council work and interdepartmental job shadowing (McCaffery et al 2012)

Application of Evidence into the Surgical Setting (Gary Webster)

Intra-operative settings place nurses and physicians in close collaborative work

settings The typical communication style is authoritarian Schmalenberg and

Kramer (2009) stated that physicians felt the nurse-physician relation to be more

collaborative than nurse did I can see that being true in my work environment

The Boone et al (2008) and McCaffrey (2011) articles combined are very

valuable Together the articles show a successful attempt to increase collaboration

and some pitfalls to avoid These can help direct any programs to support an

increase in collaboration

Application of Evidence (Jamie Ziemba)

bull Poor communication between nurses and physicians related to language and cultural barriers

bull Physiciansrsquo dysfunctional or authoritarian communication style (eg instruct nurses not to call at night unless it is a life-and-death emergency) is a major patient safety issue

bull As the patient advocate nurses have an important role of communicating with physicians to verify medication orders clinical procedures and improve patient outcomes

bull Hospital training programs in communication skills and cultural diversities are recommended for physicians and nurses with different culturalethnic backgrounds

Summary Statements

bull Meta-analytical review of evidence-based research articles support the clinical significance of effective communication styles

bull Authoritarian communication styles increase disruptive behaviors and negative hostile relationships at work environments

bull Healthy work environments have positive effects on nurses physicians patients and healthcare organizations

bull Inter-disciplinary collaboration is an essential aspect of healthy work environmentsbull Evidence-based studies have shown positive patient outcomes nursing job

satisfaction collaborative environments at Magnet hospitalsbull There is a need to address the barriers and incorporate educational programs to teach

effective communication and the need for collaboration Educational training should be re-enforced with weekly discussions ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Educate staff on the 5 types of nurse-physician relationships (collegial collaborative teacher-student friendly-stranger and hostileadversarial relationships)

bull Teach staff how to utilize positive relationships and change negative onesbull Training should avoid focusing on negative behaviorsbull Training should focus creating cooperative behaviors

ReferencesAgency for Healthcare Research and Quality (nd) Medical teamwork and patient safety The Donabedian model of patient safety Retrieved

from httpwwwahrqgovqualmedteammedteamfig2htm

American Nurses Association (1980) Nursing A social policy statement Washington DC American Nurses Association

Ballou K amp Landreneau K (2010) The authoritarian reign in American health care Policy Politics amp Nursing Practice 11(1) 71-79

doi1011771527154410372973

Boone B King M Gresham L Wahl P amp Suh E (2008) Conflict management training and nurse-physician collaborative behaviors

Journal For Nurses In Staff Development 24(4) 168-175 doi10109701NND00003206705641591

Burns N amp Grove S (2007) Understanding Nursing Research Building an Evidence Based Practice (4th Ed) St Louis Missouri Saunders

Elsevier Publishing

Ford L (2012) Week 8 amp 9 Critique of Research Retrieved from httpsfsulearnferriseduwebappsportalframesetjsp

tab_tab_group_id=_2_1ampurl=2Fwebapps2Fblackboard2Fexecute2Flauncher3Ftype3DCourseampid3D_2241_1ampurl3D

Gardezi F Lingard L Espin S Whyte S Orser B amp Baker G (2009) Silence power and communication in the operating room

Journal Of Advanced Nursing 65(7) 1390-1399 doi101111j1365-2648200904994x

Hendel T Fish M amp Berger O (2007) Nursephysician conflict management mode choices implications for improved collaborative

practice Nursing Administration Quarterly 31(3) 244-253

John Hopkins UniversityJohn Hopkins Hospital (nd) JHNEBP Research Evidence Appraisal Retrieved from

httpwwwnursingworldorgDocumentVaultNursingPracticeResearch-ToolkitJHNEBP-Research-Evidence-Appraisalpdf

Karanikola M Papathanassoglou E Kalafati M Stathopoulou H Mpouzika M amp Goutsikas C G (2012) Exploration of the

Association Between Professional Interactions and Emotional Distress of Intensive Care Unit Nursing Personnel Dimensions Of Critical

Care Nursing 31(1) 37-45 doi101097DCC0b013e31823a55b8

ReferencesKramer M Schmalenberg C amp Maguire P (2010) Nine structures and leadership practices essential for a magnetic (healthy)

work environment Nursing Administration Quarterly 34(1) 4-17 doi101097NAQ0b013e3181c95ef4

Manojlovich M amp DeCicco B (2007) Healthy work environments nurse-physician communication and patients outcome American Journal Of Critical Care 16(6) 536-543

McCaffrey R Hayes R Cassell A Miller-Reyes S Donaldson A amp Ferrell C (2012) The effect of an educational programme on attitudes of nurses and medical residents towards the benefits of positive communication and collaboration Journal Of Advanced Nursing 68(2) 293-301 doi101111j1365-2648201105736x

Nieswiadomy R M (2012) Foundations of Nursing Research (6th Ed) Upper Saddle River New Jersey Prentice Hall

Rosenstein A amp ODaniel M (2008) A survey of the impact of disruptive behaviors and communication defects on patient safety Joint Commission Journal On Quality amp Patient Safety 34(8) 464-471

Rothstein W amp Hannum S (2007) Profession and gender in relationships between advanced practice nurses and physicians Journal Of Professional Nursing 23(4) 235-240 doi101016jprofnurs200701008

Saxton R Hines T amp Enriquez M (2009) The negative impact of nurse-physician disruptive behavior on patient safety A review of the literature Journal of Patient Safety 5(3) 180-183

Stone P W (2002) Popping the PICO question in research and evidence-based practice Applied Nursing Research 16(2) 197-198

Schmalenberg C amp Kramer M (2009) Nurse-physician relationships in hospitals 20 000 nurses tell their story Critical Care Nurse 29(1) 74-83 doi104037ccn2009436

Zwarenstein M Goldman J amp Reeves S (2009) Interprofessional collaboration Effects of practice-based interventions on professional practice and healthcare outcomes Cochrane Database Of Systematic Reviews (3) 1-31 doi10100214651858CD000072

NURS 350 Evidence-Based Nursing Practice (Group paper plus Group Powerpoint presentation)

Total group grade 100Instructorrsquos comments Excellent paper I think your group

should consider submitting it for publication if you could flesh out the details on improving collaborative communication

• Ferris State University NURS 350 Evidence-Based Nursing Practic
• ldquoCommunication--the human connection--is the key to pers
• Slide 3
• What is patient safety
• What is acute care
• What is Professional Communication
• Communication between medical professionals is not just a local
• PICO Question
• Definitions
• A Survey of the Impacts of Disruptive Behaviors and Communicat
• A Survey of the Impacts of Disruptive Behaviors and Communicat (2)
• Literature Review (Level One Evidence)
• Literature Review (Level Three Evidence)
• Literature Review (Level Four Evidence)
• Literature Review (Level Four Evidence continued)
• Literature Review (Level Six Evidence)
• Analysis of Evidence
• Slide 18
• Slide 19
• Article 1 ldquoConflict management training and nurse-physician
• Article 2 ldquoNine structures and leadership practices essentia
• Slide 22
• Article 3 ldquoThe effect of an educational programme on attitud
• Article 4 ldquoNurse-physician relationships in hospitals 2000
• Percentage of staff nurses responding affirmatively to nurse-ph
• Application of Evidence for oncology nursing practice (Lai Har
• Application of Evidence at the Cardiovascular Department (Marg
• Application of Evidence into the Surgical Setting (Gary Webste
• Slide 29
• Summary Statements
• References
• References (2)
• NURS 350 Evidence-Based Nursing Practice (Group paper plus Gr

Structuresbest leadership practices essential for healthy work environments

Quality leadership at all levels in the organization

Availability of and support for education career performance and competence development

Administrative sanction for autonomous and collaborative practice

Evidence-based practice education and operational supports

Culture practice and opportunity to learn interdisciplinary collaboration

Empowered shared decision-making structures for control of the context of nursing practice

Generation and nurturance of a patient-centered culture

Staffing structures that take into account RN competence patient acuity and teamwork

Development and support of intradisciplinary teamwork

Article 3 ldquoThe effect of an educational programme on attitudes of nurses and medical residents towards the benefit of positive communication and collaborationrdquo(McCaffrey et al 2012)bull This is a quasi-experimental study based on a convenience sample of nurses and

medical residents bull The researchers are experienced and well qualifiedbull The research question is clearly statedbull Ethical research guidelines are carefully adhered tobull A pre and post-test design based on the Jefferson Scale of Attitudes towards

Physician-Nurse Collaboration and the Communication Collaboration and Critical Thinking for Quality Patient Outcomes tools Both tools are proven to be reliable and valid (the Cronbachrsquos alpha coefficient of 087-092)

bull A critical finding in this study is that ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Statistical findings reveal that the chosen intervention of an educational programme to improve physician-nurse communication and collaboration was beneficial

bull This study is evaluated as evidence level III due to lack of a control group by two methods (Ford 2012 C Bongiorno personal communication November 26 2012) Alternatively it is rated as level II on the Johns Hopkins scale (JHNEBP Research Evidence Appraisal nd)

Article 4 ldquoNurse-physician relationships in hospitals 20000 nurses tell their storyrdquo (Schmalenberg amp Kramer 2009)

bull This study is a quantitative synthesis of the findings of six research studies based on the Essentials of Magnetism

bull The researchers are experienced and highly qualifiedbull The purpose of the study is several fold 1) To discern what constitutes quality

communication and collaboration between physicians and nurses 2) Define types of nurse-physician relationships 3) Define organizational structures and leadership practices that help develop collaborative nurse-physician relationships and 4) Study differences in nurse-physician relationships between magnet and comparison hospitals

bull The sample size of 20616 staff nurses is excellentbull Thorough literature review is the foundation for this studybull It was consistently reported that nurses at magnet hospitals reported higher quality

relationships with physicians than the comparison hospitalsbull Structures that improve relationships and are supported by magnet institutions are

keep the patient first develop constructive conflict resolution techniques and have collaborative interdisciplinary patient rounds

bull Nurses can play an active role in bringing about these interventionsbull This is a double blinded peer review of six studies clearly making it evidence level I by

all methods

Percentage of staff nurses responding affirmatively to nurse-physician relationship types by magnet

and comparison hospitals and by period

Application of Evidence for oncology nursing practice (Lai Harper)

bull Utilize the Cochrane Database or the ldquoJHNEBP Research Evidence Appraisalrdquo as the research tools effectively communicate and collaborate with oncologists about the nursing perspective on evidence-based practice

bull Ongoing literature review for the most current credible and high-quality evidence-based practice for reducing oncology patientsrsquo physical psychological and emotional issues (such as pain nausea anxiety or depression)

bull Recommend the hospital nursing research committee to initiate a survey to explore possible physician-nurse communication barriers at an oncology unit

bull Recommend the implementation of the low-cost convenient computer-based training in physician-nurse communication skills

Application of Evidence at the Cardiovascular Department (Margaret Siler)

bull High quality communication and collaboration make a great difference in the cardiac catheterization laboratory (Boone King Gresham Wahl amp Suh 2008 p 168)

bull Experience and a broad knowledge base bring confidence to our daily work (Schmalenberg amp Kramer 2009 p 82)

bull All involved parties (patient nurse physician healthcare system) can reap the benefits of collaborative practice (Kramer et al 2012 p 7)

bull There are many educational opportunities available to improve interdisciplinary and interdepartmental communication Many are quite costly Some that may make the biggest difference are fairly inexpensive including Unit Action Council work and interdepartmental job shadowing (McCaffery et al 2012)

Application of Evidence into the Surgical Setting (Gary Webster)

Intra-operative settings place nurses and physicians in close collaborative work

settings The typical communication style is authoritarian Schmalenberg and

Kramer (2009) stated that physicians felt the nurse-physician relation to be more

collaborative than nurse did I can see that being true in my work environment

The Boone et al (2008) and McCaffrey (2011) articles combined are very

valuable Together the articles show a successful attempt to increase collaboration

and some pitfalls to avoid These can help direct any programs to support an

increase in collaboration

Application of Evidence (Jamie Ziemba)

bull Poor communication between nurses and physicians related to language and cultural barriers

bull Physiciansrsquo dysfunctional or authoritarian communication style (eg instruct nurses not to call at night unless it is a life-and-death emergency) is a major patient safety issue

bull As the patient advocate nurses have an important role of communicating with physicians to verify medication orders clinical procedures and improve patient outcomes

bull Hospital training programs in communication skills and cultural diversities are recommended for physicians and nurses with different culturalethnic backgrounds

Summary Statements

bull Meta-analytical review of evidence-based research articles support the clinical significance of effective communication styles

bull Authoritarian communication styles increase disruptive behaviors and negative hostile relationships at work environments

bull Healthy work environments have positive effects on nurses physicians patients and healthcare organizations

bull Inter-disciplinary collaboration is an essential aspect of healthy work environmentsbull Evidence-based studies have shown positive patient outcomes nursing job

satisfaction collaborative environments at Magnet hospitalsbull There is a need to address the barriers and incorporate educational programs to teach

effective communication and the need for collaboration Educational training should be re-enforced with weekly discussions ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Educate staff on the 5 types of nurse-physician relationships (collegial collaborative teacher-student friendly-stranger and hostileadversarial relationships)

bull Teach staff how to utilize positive relationships and change negative onesbull Training should avoid focusing on negative behaviorsbull Training should focus creating cooperative behaviors

ReferencesAgency for Healthcare Research and Quality (nd) Medical teamwork and patient safety The Donabedian model of patient safety Retrieved

from httpwwwahrqgovqualmedteammedteamfig2htm

American Nurses Association (1980) Nursing A social policy statement Washington DC American Nurses Association

Ballou K amp Landreneau K (2010) The authoritarian reign in American health care Policy Politics amp Nursing Practice 11(1) 71-79

doi1011771527154410372973

Boone B King M Gresham L Wahl P amp Suh E (2008) Conflict management training and nurse-physician collaborative behaviors

Journal For Nurses In Staff Development 24(4) 168-175 doi10109701NND00003206705641591

Burns N amp Grove S (2007) Understanding Nursing Research Building an Evidence Based Practice (4th Ed) St Louis Missouri Saunders

Elsevier Publishing

Ford L (2012) Week 8 amp 9 Critique of Research Retrieved from httpsfsulearnferriseduwebappsportalframesetjsp

tab_tab_group_id=_2_1ampurl=2Fwebapps2Fblackboard2Fexecute2Flauncher3Ftype3DCourseampid3D_2241_1ampurl3D

Gardezi F Lingard L Espin S Whyte S Orser B amp Baker G (2009) Silence power and communication in the operating room

Journal Of Advanced Nursing 65(7) 1390-1399 doi101111j1365-2648200904994x

Hendel T Fish M amp Berger O (2007) Nursephysician conflict management mode choices implications for improved collaborative

practice Nursing Administration Quarterly 31(3) 244-253

John Hopkins UniversityJohn Hopkins Hospital (nd) JHNEBP Research Evidence Appraisal Retrieved from

httpwwwnursingworldorgDocumentVaultNursingPracticeResearch-ToolkitJHNEBP-Research-Evidence-Appraisalpdf

Karanikola M Papathanassoglou E Kalafati M Stathopoulou H Mpouzika M amp Goutsikas C G (2012) Exploration of the

Association Between Professional Interactions and Emotional Distress of Intensive Care Unit Nursing Personnel Dimensions Of Critical

Care Nursing 31(1) 37-45 doi101097DCC0b013e31823a55b8

ReferencesKramer M Schmalenberg C amp Maguire P (2010) Nine structures and leadership practices essential for a magnetic (healthy)

work environment Nursing Administration Quarterly 34(1) 4-17 doi101097NAQ0b013e3181c95ef4

Manojlovich M amp DeCicco B (2007) Healthy work environments nurse-physician communication and patients outcome American Journal Of Critical Care 16(6) 536-543

McCaffrey R Hayes R Cassell A Miller-Reyes S Donaldson A amp Ferrell C (2012) The effect of an educational programme on attitudes of nurses and medical residents towards the benefits of positive communication and collaboration Journal Of Advanced Nursing 68(2) 293-301 doi101111j1365-2648201105736x

Nieswiadomy R M (2012) Foundations of Nursing Research (6th Ed) Upper Saddle River New Jersey Prentice Hall

Rosenstein A amp ODaniel M (2008) A survey of the impact of disruptive behaviors and communication defects on patient safety Joint Commission Journal On Quality amp Patient Safety 34(8) 464-471

Rothstein W amp Hannum S (2007) Profession and gender in relationships between advanced practice nurses and physicians Journal Of Professional Nursing 23(4) 235-240 doi101016jprofnurs200701008

Saxton R Hines T amp Enriquez M (2009) The negative impact of nurse-physician disruptive behavior on patient safety A review of the literature Journal of Patient Safety 5(3) 180-183

Stone P W (2002) Popping the PICO question in research and evidence-based practice Applied Nursing Research 16(2) 197-198

Schmalenberg C amp Kramer M (2009) Nurse-physician relationships in hospitals 20 000 nurses tell their story Critical Care Nurse 29(1) 74-83 doi104037ccn2009436

Zwarenstein M Goldman J amp Reeves S (2009) Interprofessional collaboration Effects of practice-based interventions on professional practice and healthcare outcomes Cochrane Database Of Systematic Reviews (3) 1-31 doi10100214651858CD000072

NURS 350 Evidence-Based Nursing Practice (Group paper plus Group Powerpoint presentation)

Total group grade 100Instructorrsquos comments Excellent paper I think your group

should consider submitting it for publication if you could flesh out the details on improving collaborative communication

• Ferris State University NURS 350 Evidence-Based Nursing Practic
• ldquoCommunication--the human connection--is the key to pers
• Slide 3
• What is patient safety
• What is acute care
• What is Professional Communication
• Communication between medical professionals is not just a local
• PICO Question
• Definitions
• A Survey of the Impacts of Disruptive Behaviors and Communicat
• A Survey of the Impacts of Disruptive Behaviors and Communicat (2)
• Literature Review (Level One Evidence)
• Literature Review (Level Three Evidence)
• Literature Review (Level Four Evidence)
• Literature Review (Level Four Evidence continued)
• Literature Review (Level Six Evidence)
• Analysis of Evidence
• Slide 18
• Slide 19
• Article 1 ldquoConflict management training and nurse-physician
• Article 2 ldquoNine structures and leadership practices essentia
• Slide 22
• Article 3 ldquoThe effect of an educational programme on attitud
• Article 4 ldquoNurse-physician relationships in hospitals 2000
• Percentage of staff nurses responding affirmatively to nurse-ph
• Application of Evidence for oncology nursing practice (Lai Har
• Application of Evidence at the Cardiovascular Department (Marg
• Application of Evidence into the Surgical Setting (Gary Webste
• Slide 29
• Summary Statements
• References
• References (2)
• NURS 350 Evidence-Based Nursing Practice (Group paper plus Gr

Article 3 ldquoThe effect of an educational programme on attitudes of nurses and medical residents towards the benefit of positive communication and collaborationrdquo(McCaffrey et al 2012)bull This is a quasi-experimental study based on a convenience sample of nurses and

medical residents bull The researchers are experienced and well qualifiedbull The research question is clearly statedbull Ethical research guidelines are carefully adhered tobull A pre and post-test design based on the Jefferson Scale of Attitudes towards

Physician-Nurse Collaboration and the Communication Collaboration and Critical Thinking for Quality Patient Outcomes tools Both tools are proven to be reliable and valid (the Cronbachrsquos alpha coefficient of 087-092)

bull A critical finding in this study is that ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Statistical findings reveal that the chosen intervention of an educational programme to improve physician-nurse communication and collaboration was beneficial

bull This study is evaluated as evidence level III due to lack of a control group by two methods (Ford 2012 C Bongiorno personal communication November 26 2012) Alternatively it is rated as level II on the Johns Hopkins scale (JHNEBP Research Evidence Appraisal nd)

Article 4 ldquoNurse-physician relationships in hospitals 20000 nurses tell their storyrdquo (Schmalenberg amp Kramer 2009)

bull This study is a quantitative synthesis of the findings of six research studies based on the Essentials of Magnetism

bull The researchers are experienced and highly qualifiedbull The purpose of the study is several fold 1) To discern what constitutes quality

communication and collaboration between physicians and nurses 2) Define types of nurse-physician relationships 3) Define organizational structures and leadership practices that help develop collaborative nurse-physician relationships and 4) Study differences in nurse-physician relationships between magnet and comparison hospitals

bull The sample size of 20616 staff nurses is excellentbull Thorough literature review is the foundation for this studybull It was consistently reported that nurses at magnet hospitals reported higher quality

relationships with physicians than the comparison hospitalsbull Structures that improve relationships and are supported by magnet institutions are

keep the patient first develop constructive conflict resolution techniques and have collaborative interdisciplinary patient rounds

bull Nurses can play an active role in bringing about these interventionsbull This is a double blinded peer review of six studies clearly making it evidence level I by

all methods

Percentage of staff nurses responding affirmatively to nurse-physician relationship types by magnet

and comparison hospitals and by period

Application of Evidence for oncology nursing practice (Lai Harper)

bull Utilize the Cochrane Database or the ldquoJHNEBP Research Evidence Appraisalrdquo as the research tools effectively communicate and collaborate with oncologists about the nursing perspective on evidence-based practice

bull Ongoing literature review for the most current credible and high-quality evidence-based practice for reducing oncology patientsrsquo physical psychological and emotional issues (such as pain nausea anxiety or depression)

bull Recommend the hospital nursing research committee to initiate a survey to explore possible physician-nurse communication barriers at an oncology unit

bull Recommend the implementation of the low-cost convenient computer-based training in physician-nurse communication skills

Application of Evidence at the Cardiovascular Department (Margaret Siler)

bull High quality communication and collaboration make a great difference in the cardiac catheterization laboratory (Boone King Gresham Wahl amp Suh 2008 p 168)

bull Experience and a broad knowledge base bring confidence to our daily work (Schmalenberg amp Kramer 2009 p 82)

bull All involved parties (patient nurse physician healthcare system) can reap the benefits of collaborative practice (Kramer et al 2012 p 7)

bull There are many educational opportunities available to improve interdisciplinary and interdepartmental communication Many are quite costly Some that may make the biggest difference are fairly inexpensive including Unit Action Council work and interdepartmental job shadowing (McCaffery et al 2012)

Application of Evidence into the Surgical Setting (Gary Webster)

Intra-operative settings place nurses and physicians in close collaborative work

settings The typical communication style is authoritarian Schmalenberg and

Kramer (2009) stated that physicians felt the nurse-physician relation to be more

collaborative than nurse did I can see that being true in my work environment

The Boone et al (2008) and McCaffrey (2011) articles combined are very

valuable Together the articles show a successful attempt to increase collaboration

and some pitfalls to avoid These can help direct any programs to support an

increase in collaboration

Application of Evidence (Jamie Ziemba)

bull Poor communication between nurses and physicians related to language and cultural barriers

bull Physiciansrsquo dysfunctional or authoritarian communication style (eg instruct nurses not to call at night unless it is a life-and-death emergency) is a major patient safety issue

bull As the patient advocate nurses have an important role of communicating with physicians to verify medication orders clinical procedures and improve patient outcomes

bull Hospital training programs in communication skills and cultural diversities are recommended for physicians and nurses with different culturalethnic backgrounds

Summary Statements

bull Meta-analytical review of evidence-based research articles support the clinical significance of effective communication styles

bull Authoritarian communication styles increase disruptive behaviors and negative hostile relationships at work environments

bull Healthy work environments have positive effects on nurses physicians patients and healthcare organizations

bull Inter-disciplinary collaboration is an essential aspect of healthy work environmentsbull Evidence-based studies have shown positive patient outcomes nursing job

satisfaction collaborative environments at Magnet hospitalsbull There is a need to address the barriers and incorporate educational programs to teach

effective communication and the need for collaboration Educational training should be re-enforced with weekly discussions ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Educate staff on the 5 types of nurse-physician relationships (collegial collaborative teacher-student friendly-stranger and hostileadversarial relationships)

bull Teach staff how to utilize positive relationships and change negative onesbull Training should avoid focusing on negative behaviorsbull Training should focus creating cooperative behaviors

ReferencesAgency for Healthcare Research and Quality (nd) Medical teamwork and patient safety The Donabedian model of patient safety Retrieved

from httpwwwahrqgovqualmedteammedteamfig2htm

American Nurses Association (1980) Nursing A social policy statement Washington DC American Nurses Association

Ballou K amp Landreneau K (2010) The authoritarian reign in American health care Policy Politics amp Nursing Practice 11(1) 71-79

doi1011771527154410372973

Boone B King M Gresham L Wahl P amp Suh E (2008) Conflict management training and nurse-physician collaborative behaviors

Journal For Nurses In Staff Development 24(4) 168-175 doi10109701NND00003206705641591

Burns N amp Grove S (2007) Understanding Nursing Research Building an Evidence Based Practice (4th Ed) St Louis Missouri Saunders

Elsevier Publishing

Ford L (2012) Week 8 amp 9 Critique of Research Retrieved from httpsfsulearnferriseduwebappsportalframesetjsp

tab_tab_group_id=_2_1ampurl=2Fwebapps2Fblackboard2Fexecute2Flauncher3Ftype3DCourseampid3D_2241_1ampurl3D

Gardezi F Lingard L Espin S Whyte S Orser B amp Baker G (2009) Silence power and communication in the operating room

Journal Of Advanced Nursing 65(7) 1390-1399 doi101111j1365-2648200904994x

Hendel T Fish M amp Berger O (2007) Nursephysician conflict management mode choices implications for improved collaborative

practice Nursing Administration Quarterly 31(3) 244-253

John Hopkins UniversityJohn Hopkins Hospital (nd) JHNEBP Research Evidence Appraisal Retrieved from

httpwwwnursingworldorgDocumentVaultNursingPracticeResearch-ToolkitJHNEBP-Research-Evidence-Appraisalpdf

Karanikola M Papathanassoglou E Kalafati M Stathopoulou H Mpouzika M amp Goutsikas C G (2012) Exploration of the

Association Between Professional Interactions and Emotional Distress of Intensive Care Unit Nursing Personnel Dimensions Of Critical

Care Nursing 31(1) 37-45 doi101097DCC0b013e31823a55b8

ReferencesKramer M Schmalenberg C amp Maguire P (2010) Nine structures and leadership practices essential for a magnetic (healthy)

work environment Nursing Administration Quarterly 34(1) 4-17 doi101097NAQ0b013e3181c95ef4

Manojlovich M amp DeCicco B (2007) Healthy work environments nurse-physician communication and patients outcome American Journal Of Critical Care 16(6) 536-543

McCaffrey R Hayes R Cassell A Miller-Reyes S Donaldson A amp Ferrell C (2012) The effect of an educational programme on attitudes of nurses and medical residents towards the benefits of positive communication and collaboration Journal Of Advanced Nursing 68(2) 293-301 doi101111j1365-2648201105736x

Nieswiadomy R M (2012) Foundations of Nursing Research (6th Ed) Upper Saddle River New Jersey Prentice Hall

Rosenstein A amp ODaniel M (2008) A survey of the impact of disruptive behaviors and communication defects on patient safety Joint Commission Journal On Quality amp Patient Safety 34(8) 464-471

Rothstein W amp Hannum S (2007) Profession and gender in relationships between advanced practice nurses and physicians Journal Of Professional Nursing 23(4) 235-240 doi101016jprofnurs200701008

Saxton R Hines T amp Enriquez M (2009) The negative impact of nurse-physician disruptive behavior on patient safety A review of the literature Journal of Patient Safety 5(3) 180-183

Stone P W (2002) Popping the PICO question in research and evidence-based practice Applied Nursing Research 16(2) 197-198

Schmalenberg C amp Kramer M (2009) Nurse-physician relationships in hospitals 20 000 nurses tell their story Critical Care Nurse 29(1) 74-83 doi104037ccn2009436

Zwarenstein M Goldman J amp Reeves S (2009) Interprofessional collaboration Effects of practice-based interventions on professional practice and healthcare outcomes Cochrane Database Of Systematic Reviews (3) 1-31 doi10100214651858CD000072

NURS 350 Evidence-Based Nursing Practice (Group paper plus Group Powerpoint presentation)

Total group grade 100Instructorrsquos comments Excellent paper I think your group

should consider submitting it for publication if you could flesh out the details on improving collaborative communication

• Ferris State University NURS 350 Evidence-Based Nursing Practic
• ldquoCommunication--the human connection--is the key to pers
• Slide 3
• What is patient safety
• What is acute care
• What is Professional Communication
• Communication between medical professionals is not just a local
• PICO Question
• Definitions
• A Survey of the Impacts of Disruptive Behaviors and Communicat
• A Survey of the Impacts of Disruptive Behaviors and Communicat (2)
• Literature Review (Level One Evidence)
• Literature Review (Level Three Evidence)
• Literature Review (Level Four Evidence)
• Literature Review (Level Four Evidence continued)
• Literature Review (Level Six Evidence)
• Analysis of Evidence
• Slide 18
• Slide 19
• Article 1 ldquoConflict management training and nurse-physician
• Article 2 ldquoNine structures and leadership practices essentia
• Slide 22
• Article 3 ldquoThe effect of an educational programme on attitud
• Article 4 ldquoNurse-physician relationships in hospitals 2000
• Percentage of staff nurses responding affirmatively to nurse-ph
• Application of Evidence for oncology nursing practice (Lai Har
• Application of Evidence at the Cardiovascular Department (Marg
• Application of Evidence into the Surgical Setting (Gary Webste
• Slide 29
• Summary Statements
• References
• References (2)
• NURS 350 Evidence-Based Nursing Practice (Group paper plus Gr

Article 4 ldquoNurse-physician relationships in hospitals 20000 nurses tell their storyrdquo (Schmalenberg amp Kramer 2009)

bull This study is a quantitative synthesis of the findings of six research studies based on the Essentials of Magnetism

bull The researchers are experienced and highly qualifiedbull The purpose of the study is several fold 1) To discern what constitutes quality

communication and collaboration between physicians and nurses 2) Define types of nurse-physician relationships 3) Define organizational structures and leadership practices that help develop collaborative nurse-physician relationships and 4) Study differences in nurse-physician relationships between magnet and comparison hospitals

bull The sample size of 20616 staff nurses is excellentbull Thorough literature review is the foundation for this studybull It was consistently reported that nurses at magnet hospitals reported higher quality

relationships with physicians than the comparison hospitalsbull Structures that improve relationships and are supported by magnet institutions are

keep the patient first develop constructive conflict resolution techniques and have collaborative interdisciplinary patient rounds

bull Nurses can play an active role in bringing about these interventionsbull This is a double blinded peer review of six studies clearly making it evidence level I by

all methods

Percentage of staff nurses responding affirmatively to nurse-physician relationship types by magnet

and comparison hospitals and by period

Application of Evidence for oncology nursing practice (Lai Harper)

bull Utilize the Cochrane Database or the ldquoJHNEBP Research Evidence Appraisalrdquo as the research tools effectively communicate and collaborate with oncologists about the nursing perspective on evidence-based practice

bull Ongoing literature review for the most current credible and high-quality evidence-based practice for reducing oncology patientsrsquo physical psychological and emotional issues (such as pain nausea anxiety or depression)

bull Recommend the hospital nursing research committee to initiate a survey to explore possible physician-nurse communication barriers at an oncology unit

bull Recommend the implementation of the low-cost convenient computer-based training in physician-nurse communication skills

Application of Evidence at the Cardiovascular Department (Margaret Siler)

bull High quality communication and collaboration make a great difference in the cardiac catheterization laboratory (Boone King Gresham Wahl amp Suh 2008 p 168)

bull Experience and a broad knowledge base bring confidence to our daily work (Schmalenberg amp Kramer 2009 p 82)

bull All involved parties (patient nurse physician healthcare system) can reap the benefits of collaborative practice (Kramer et al 2012 p 7)

bull There are many educational opportunities available to improve interdisciplinary and interdepartmental communication Many are quite costly Some that may make the biggest difference are fairly inexpensive including Unit Action Council work and interdepartmental job shadowing (McCaffery et al 2012)

Application of Evidence into the Surgical Setting (Gary Webster)

Intra-operative settings place nurses and physicians in close collaborative work

settings The typical communication style is authoritarian Schmalenberg and

Kramer (2009) stated that physicians felt the nurse-physician relation to be more

collaborative than nurse did I can see that being true in my work environment

The Boone et al (2008) and McCaffrey (2011) articles combined are very

valuable Together the articles show a successful attempt to increase collaboration

and some pitfalls to avoid These can help direct any programs to support an

increase in collaboration

Application of Evidence (Jamie Ziemba)

bull Poor communication between nurses and physicians related to language and cultural barriers

bull Physiciansrsquo dysfunctional or authoritarian communication style (eg instruct nurses not to call at night unless it is a life-and-death emergency) is a major patient safety issue

bull As the patient advocate nurses have an important role of communicating with physicians to verify medication orders clinical procedures and improve patient outcomes

bull Hospital training programs in communication skills and cultural diversities are recommended for physicians and nurses with different culturalethnic backgrounds

Summary Statements

bull Meta-analytical review of evidence-based research articles support the clinical significance of effective communication styles

bull Authoritarian communication styles increase disruptive behaviors and negative hostile relationships at work environments

bull Healthy work environments have positive effects on nurses physicians patients and healthcare organizations

bull Inter-disciplinary collaboration is an essential aspect of healthy work environmentsbull Evidence-based studies have shown positive patient outcomes nursing job

satisfaction collaborative environments at Magnet hospitalsbull There is a need to address the barriers and incorporate educational programs to teach

effective communication and the need for collaboration Educational training should be re-enforced with weekly discussions ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Educate staff on the 5 types of nurse-physician relationships (collegial collaborative teacher-student friendly-stranger and hostileadversarial relationships)

bull Teach staff how to utilize positive relationships and change negative onesbull Training should avoid focusing on negative behaviorsbull Training should focus creating cooperative behaviors

ReferencesAgency for Healthcare Research and Quality (nd) Medical teamwork and patient safety The Donabedian model of patient safety Retrieved

from httpwwwahrqgovqualmedteammedteamfig2htm

American Nurses Association (1980) Nursing A social policy statement Washington DC American Nurses Association

Ballou K amp Landreneau K (2010) The authoritarian reign in American health care Policy Politics amp Nursing Practice 11(1) 71-79

doi1011771527154410372973

Boone B King M Gresham L Wahl P amp Suh E (2008) Conflict management training and nurse-physician collaborative behaviors

Journal For Nurses In Staff Development 24(4) 168-175 doi10109701NND00003206705641591

Burns N amp Grove S (2007) Understanding Nursing Research Building an Evidence Based Practice (4th Ed) St Louis Missouri Saunders

Elsevier Publishing

Ford L (2012) Week 8 amp 9 Critique of Research Retrieved from httpsfsulearnferriseduwebappsportalframesetjsp

tab_tab_group_id=_2_1ampurl=2Fwebapps2Fblackboard2Fexecute2Flauncher3Ftype3DCourseampid3D_2241_1ampurl3D

Gardezi F Lingard L Espin S Whyte S Orser B amp Baker G (2009) Silence power and communication in the operating room

Journal Of Advanced Nursing 65(7) 1390-1399 doi101111j1365-2648200904994x

Hendel T Fish M amp Berger O (2007) Nursephysician conflict management mode choices implications for improved collaborative

practice Nursing Administration Quarterly 31(3) 244-253

John Hopkins UniversityJohn Hopkins Hospital (nd) JHNEBP Research Evidence Appraisal Retrieved from

httpwwwnursingworldorgDocumentVaultNursingPracticeResearch-ToolkitJHNEBP-Research-Evidence-Appraisalpdf

Karanikola M Papathanassoglou E Kalafati M Stathopoulou H Mpouzika M amp Goutsikas C G (2012) Exploration of the

Association Between Professional Interactions and Emotional Distress of Intensive Care Unit Nursing Personnel Dimensions Of Critical

Care Nursing 31(1) 37-45 doi101097DCC0b013e31823a55b8

ReferencesKramer M Schmalenberg C amp Maguire P (2010) Nine structures and leadership practices essential for a magnetic (healthy)

work environment Nursing Administration Quarterly 34(1) 4-17 doi101097NAQ0b013e3181c95ef4

Manojlovich M amp DeCicco B (2007) Healthy work environments nurse-physician communication and patients outcome American Journal Of Critical Care 16(6) 536-543

McCaffrey R Hayes R Cassell A Miller-Reyes S Donaldson A amp Ferrell C (2012) The effect of an educational programme on attitudes of nurses and medical residents towards the benefits of positive communication and collaboration Journal Of Advanced Nursing 68(2) 293-301 doi101111j1365-2648201105736x

Nieswiadomy R M (2012) Foundations of Nursing Research (6th Ed) Upper Saddle River New Jersey Prentice Hall

Rosenstein A amp ODaniel M (2008) A survey of the impact of disruptive behaviors and communication defects on patient safety Joint Commission Journal On Quality amp Patient Safety 34(8) 464-471

Rothstein W amp Hannum S (2007) Profession and gender in relationships between advanced practice nurses and physicians Journal Of Professional Nursing 23(4) 235-240 doi101016jprofnurs200701008

Saxton R Hines T amp Enriquez M (2009) The negative impact of nurse-physician disruptive behavior on patient safety A review of the literature Journal of Patient Safety 5(3) 180-183

Stone P W (2002) Popping the PICO question in research and evidence-based practice Applied Nursing Research 16(2) 197-198

Schmalenberg C amp Kramer M (2009) Nurse-physician relationships in hospitals 20 000 nurses tell their story Critical Care Nurse 29(1) 74-83 doi104037ccn2009436

Zwarenstein M Goldman J amp Reeves S (2009) Interprofessional collaboration Effects of practice-based interventions on professional practice and healthcare outcomes Cochrane Database Of Systematic Reviews (3) 1-31 doi10100214651858CD000072

NURS 350 Evidence-Based Nursing Practice (Group paper plus Group Powerpoint presentation)

Total group grade 100Instructorrsquos comments Excellent paper I think your group

should consider submitting it for publication if you could flesh out the details on improving collaborative communication

• Ferris State University NURS 350 Evidence-Based Nursing Practic
• ldquoCommunication--the human connection--is the key to pers
• Slide 3
• What is patient safety
• What is acute care
• What is Professional Communication
• Communication between medical professionals is not just a local
• PICO Question
• Definitions
• A Survey of the Impacts of Disruptive Behaviors and Communicat
• A Survey of the Impacts of Disruptive Behaviors and Communicat (2)
• Literature Review (Level One Evidence)
• Literature Review (Level Three Evidence)
• Literature Review (Level Four Evidence)
• Literature Review (Level Four Evidence continued)
• Literature Review (Level Six Evidence)
• Analysis of Evidence
• Slide 18
• Slide 19
• Article 1 ldquoConflict management training and nurse-physician
• Article 2 ldquoNine structures and leadership practices essentia
• Slide 22
• Article 3 ldquoThe effect of an educational programme on attitud
• Article 4 ldquoNurse-physician relationships in hospitals 2000
• Percentage of staff nurses responding affirmatively to nurse-ph
• Application of Evidence for oncology nursing practice (Lai Har
• Application of Evidence at the Cardiovascular Department (Marg
• Application of Evidence into the Surgical Setting (Gary Webste
• Slide 29
• Summary Statements
• References
• References (2)
• NURS 350 Evidence-Based Nursing Practice (Group paper plus Gr

Percentage of staff nurses responding affirmatively to nurse-physician relationship types by magnet

and comparison hospitals and by period

Application of Evidence for oncology nursing practice (Lai Harper)

bull Utilize the Cochrane Database or the ldquoJHNEBP Research Evidence Appraisalrdquo as the research tools effectively communicate and collaborate with oncologists about the nursing perspective on evidence-based practice

bull Ongoing literature review for the most current credible and high-quality evidence-based practice for reducing oncology patientsrsquo physical psychological and emotional issues (such as pain nausea anxiety or depression)

bull Recommend the hospital nursing research committee to initiate a survey to explore possible physician-nurse communication barriers at an oncology unit

bull Recommend the implementation of the low-cost convenient computer-based training in physician-nurse communication skills

Application of Evidence at the Cardiovascular Department (Margaret Siler)

bull High quality communication and collaboration make a great difference in the cardiac catheterization laboratory (Boone King Gresham Wahl amp Suh 2008 p 168)

bull Experience and a broad knowledge base bring confidence to our daily work (Schmalenberg amp Kramer 2009 p 82)

bull All involved parties (patient nurse physician healthcare system) can reap the benefits of collaborative practice (Kramer et al 2012 p 7)

bull There are many educational opportunities available to improve interdisciplinary and interdepartmental communication Many are quite costly Some that may make the biggest difference are fairly inexpensive including Unit Action Council work and interdepartmental job shadowing (McCaffery et al 2012)

Application of Evidence into the Surgical Setting (Gary Webster)

Intra-operative settings place nurses and physicians in close collaborative work

settings The typical communication style is authoritarian Schmalenberg and

Kramer (2009) stated that physicians felt the nurse-physician relation to be more

collaborative than nurse did I can see that being true in my work environment

The Boone et al (2008) and McCaffrey (2011) articles combined are very

valuable Together the articles show a successful attempt to increase collaboration

and some pitfalls to avoid These can help direct any programs to support an

increase in collaboration

Application of Evidence (Jamie Ziemba)

bull Poor communication between nurses and physicians related to language and cultural barriers

bull Physiciansrsquo dysfunctional or authoritarian communication style (eg instruct nurses not to call at night unless it is a life-and-death emergency) is a major patient safety issue

bull As the patient advocate nurses have an important role of communicating with physicians to verify medication orders clinical procedures and improve patient outcomes

bull Hospital training programs in communication skills and cultural diversities are recommended for physicians and nurses with different culturalethnic backgrounds

Summary Statements

bull Meta-analytical review of evidence-based research articles support the clinical significance of effective communication styles

bull Authoritarian communication styles increase disruptive behaviors and negative hostile relationships at work environments

bull Healthy work environments have positive effects on nurses physicians patients and healthcare organizations

bull Inter-disciplinary collaboration is an essential aspect of healthy work environmentsbull Evidence-based studies have shown positive patient outcomes nursing job

satisfaction collaborative environments at Magnet hospitalsbull There is a need to address the barriers and incorporate educational programs to teach

effective communication and the need for collaboration Educational training should be re-enforced with weekly discussions ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Educate staff on the 5 types of nurse-physician relationships (collegial collaborative teacher-student friendly-stranger and hostileadversarial relationships)

bull Teach staff how to utilize positive relationships and change negative onesbull Training should avoid focusing on negative behaviorsbull Training should focus creating cooperative behaviors

ReferencesAgency for Healthcare Research and Quality (nd) Medical teamwork and patient safety The Donabedian model of patient safety Retrieved

from httpwwwahrqgovqualmedteammedteamfig2htm

American Nurses Association (1980) Nursing A social policy statement Washington DC American Nurses Association

Ballou K amp Landreneau K (2010) The authoritarian reign in American health care Policy Politics amp Nursing Practice 11(1) 71-79

doi1011771527154410372973

Boone B King M Gresham L Wahl P amp Suh E (2008) Conflict management training and nurse-physician collaborative behaviors

Journal For Nurses In Staff Development 24(4) 168-175 doi10109701NND00003206705641591

Burns N amp Grove S (2007) Understanding Nursing Research Building an Evidence Based Practice (4th Ed) St Louis Missouri Saunders

Elsevier Publishing

Ford L (2012) Week 8 amp 9 Critique of Research Retrieved from httpsfsulearnferriseduwebappsportalframesetjsp

tab_tab_group_id=_2_1ampurl=2Fwebapps2Fblackboard2Fexecute2Flauncher3Ftype3DCourseampid3D_2241_1ampurl3D

Gardezi F Lingard L Espin S Whyte S Orser B amp Baker G (2009) Silence power and communication in the operating room

Journal Of Advanced Nursing 65(7) 1390-1399 doi101111j1365-2648200904994x

Hendel T Fish M amp Berger O (2007) Nursephysician conflict management mode choices implications for improved collaborative

practice Nursing Administration Quarterly 31(3) 244-253

John Hopkins UniversityJohn Hopkins Hospital (nd) JHNEBP Research Evidence Appraisal Retrieved from

httpwwwnursingworldorgDocumentVaultNursingPracticeResearch-ToolkitJHNEBP-Research-Evidence-Appraisalpdf

Karanikola M Papathanassoglou E Kalafati M Stathopoulou H Mpouzika M amp Goutsikas C G (2012) Exploration of the

Association Between Professional Interactions and Emotional Distress of Intensive Care Unit Nursing Personnel Dimensions Of Critical

Care Nursing 31(1) 37-45 doi101097DCC0b013e31823a55b8

ReferencesKramer M Schmalenberg C amp Maguire P (2010) Nine structures and leadership practices essential for a magnetic (healthy)

work environment Nursing Administration Quarterly 34(1) 4-17 doi101097NAQ0b013e3181c95ef4

Manojlovich M amp DeCicco B (2007) Healthy work environments nurse-physician communication and patients outcome American Journal Of Critical Care 16(6) 536-543

McCaffrey R Hayes R Cassell A Miller-Reyes S Donaldson A amp Ferrell C (2012) The effect of an educational programme on attitudes of nurses and medical residents towards the benefits of positive communication and collaboration Journal Of Advanced Nursing 68(2) 293-301 doi101111j1365-2648201105736x

Nieswiadomy R M (2012) Foundations of Nursing Research (6th Ed) Upper Saddle River New Jersey Prentice Hall

Rosenstein A amp ODaniel M (2008) A survey of the impact of disruptive behaviors and communication defects on patient safety Joint Commission Journal On Quality amp Patient Safety 34(8) 464-471

Rothstein W amp Hannum S (2007) Profession and gender in relationships between advanced practice nurses and physicians Journal Of Professional Nursing 23(4) 235-240 doi101016jprofnurs200701008

Saxton R Hines T amp Enriquez M (2009) The negative impact of nurse-physician disruptive behavior on patient safety A review of the literature Journal of Patient Safety 5(3) 180-183

Stone P W (2002) Popping the PICO question in research and evidence-based practice Applied Nursing Research 16(2) 197-198

Schmalenberg C amp Kramer M (2009) Nurse-physician relationships in hospitals 20 000 nurses tell their story Critical Care Nurse 29(1) 74-83 doi104037ccn2009436

Zwarenstein M Goldman J amp Reeves S (2009) Interprofessional collaboration Effects of practice-based interventions on professional practice and healthcare outcomes Cochrane Database Of Systematic Reviews (3) 1-31 doi10100214651858CD000072

NURS 350 Evidence-Based Nursing Practice (Group paper plus Group Powerpoint presentation)

Total group grade 100Instructorrsquos comments Excellent paper I think your group

should consider submitting it for publication if you could flesh out the details on improving collaborative communication

• Ferris State University NURS 350 Evidence-Based Nursing Practic
• ldquoCommunication--the human connection--is the key to pers
• Slide 3
• What is patient safety
• What is acute care
• What is Professional Communication
• Communication between medical professionals is not just a local
• PICO Question
• Definitions
• A Survey of the Impacts of Disruptive Behaviors and Communicat
• A Survey of the Impacts of Disruptive Behaviors and Communicat (2)
• Literature Review (Level One Evidence)
• Literature Review (Level Three Evidence)
• Literature Review (Level Four Evidence)
• Literature Review (Level Four Evidence continued)
• Literature Review (Level Six Evidence)
• Analysis of Evidence
• Slide 18
• Slide 19
• Article 1 ldquoConflict management training and nurse-physician
• Article 2 ldquoNine structures and leadership practices essentia
• Slide 22
• Article 3 ldquoThe effect of an educational programme on attitud
• Article 4 ldquoNurse-physician relationships in hospitals 2000
• Percentage of staff nurses responding affirmatively to nurse-ph
• Application of Evidence for oncology nursing practice (Lai Har
• Application of Evidence at the Cardiovascular Department (Marg
• Application of Evidence into the Surgical Setting (Gary Webste
• Slide 29
• Summary Statements
• References
• References (2)
• NURS 350 Evidence-Based Nursing Practice (Group paper plus Gr

Application of Evidence for oncology nursing practice (Lai Harper)

bull Utilize the Cochrane Database or the ldquoJHNEBP Research Evidence Appraisalrdquo as the research tools effectively communicate and collaborate with oncologists about the nursing perspective on evidence-based practice

bull Ongoing literature review for the most current credible and high-quality evidence-based practice for reducing oncology patientsrsquo physical psychological and emotional issues (such as pain nausea anxiety or depression)

bull Recommend the hospital nursing research committee to initiate a survey to explore possible physician-nurse communication barriers at an oncology unit

bull Recommend the implementation of the low-cost convenient computer-based training in physician-nurse communication skills

Application of Evidence at the Cardiovascular Department (Margaret Siler)

bull High quality communication and collaboration make a great difference in the cardiac catheterization laboratory (Boone King Gresham Wahl amp Suh 2008 p 168)

bull Experience and a broad knowledge base bring confidence to our daily work (Schmalenberg amp Kramer 2009 p 82)

bull All involved parties (patient nurse physician healthcare system) can reap the benefits of collaborative practice (Kramer et al 2012 p 7)

bull There are many educational opportunities available to improve interdisciplinary and interdepartmental communication Many are quite costly Some that may make the biggest difference are fairly inexpensive including Unit Action Council work and interdepartmental job shadowing (McCaffery et al 2012)

Application of Evidence into the Surgical Setting (Gary Webster)

Intra-operative settings place nurses and physicians in close collaborative work

settings The typical communication style is authoritarian Schmalenberg and

Kramer (2009) stated that physicians felt the nurse-physician relation to be more

collaborative than nurse did I can see that being true in my work environment

The Boone et al (2008) and McCaffrey (2011) articles combined are very

valuable Together the articles show a successful attempt to increase collaboration

and some pitfalls to avoid These can help direct any programs to support an

increase in collaboration

Application of Evidence (Jamie Ziemba)

bull Poor communication between nurses and physicians related to language and cultural barriers

bull Physiciansrsquo dysfunctional or authoritarian communication style (eg instruct nurses not to call at night unless it is a life-and-death emergency) is a major patient safety issue

bull As the patient advocate nurses have an important role of communicating with physicians to verify medication orders clinical procedures and improve patient outcomes

bull Hospital training programs in communication skills and cultural diversities are recommended for physicians and nurses with different culturalethnic backgrounds

Summary Statements

bull Meta-analytical review of evidence-based research articles support the clinical significance of effective communication styles

bull Authoritarian communication styles increase disruptive behaviors and negative hostile relationships at work environments

bull Healthy work environments have positive effects on nurses physicians patients and healthcare organizations

bull Inter-disciplinary collaboration is an essential aspect of healthy work environmentsbull Evidence-based studies have shown positive patient outcomes nursing job

satisfaction collaborative environments at Magnet hospitalsbull There is a need to address the barriers and incorporate educational programs to teach

effective communication and the need for collaboration Educational training should be re-enforced with weekly discussions ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Educate staff on the 5 types of nurse-physician relationships (collegial collaborative teacher-student friendly-stranger and hostileadversarial relationships)

bull Teach staff how to utilize positive relationships and change negative onesbull Training should avoid focusing on negative behaviorsbull Training should focus creating cooperative behaviors

ReferencesAgency for Healthcare Research and Quality (nd) Medical teamwork and patient safety The Donabedian model of patient safety Retrieved

from httpwwwahrqgovqualmedteammedteamfig2htm

American Nurses Association (1980) Nursing A social policy statement Washington DC American Nurses Association

Ballou K amp Landreneau K (2010) The authoritarian reign in American health care Policy Politics amp Nursing Practice 11(1) 71-79

doi1011771527154410372973

Boone B King M Gresham L Wahl P amp Suh E (2008) Conflict management training and nurse-physician collaborative behaviors

Journal For Nurses In Staff Development 24(4) 168-175 doi10109701NND00003206705641591

Burns N amp Grove S (2007) Understanding Nursing Research Building an Evidence Based Practice (4th Ed) St Louis Missouri Saunders

Elsevier Publishing

Ford L (2012) Week 8 amp 9 Critique of Research Retrieved from httpsfsulearnferriseduwebappsportalframesetjsp

tab_tab_group_id=_2_1ampurl=2Fwebapps2Fblackboard2Fexecute2Flauncher3Ftype3DCourseampid3D_2241_1ampurl3D

Gardezi F Lingard L Espin S Whyte S Orser B amp Baker G (2009) Silence power and communication in the operating room

Journal Of Advanced Nursing 65(7) 1390-1399 doi101111j1365-2648200904994x

Hendel T Fish M amp Berger O (2007) Nursephysician conflict management mode choices implications for improved collaborative

practice Nursing Administration Quarterly 31(3) 244-253

John Hopkins UniversityJohn Hopkins Hospital (nd) JHNEBP Research Evidence Appraisal Retrieved from

httpwwwnursingworldorgDocumentVaultNursingPracticeResearch-ToolkitJHNEBP-Research-Evidence-Appraisalpdf

Karanikola M Papathanassoglou E Kalafati M Stathopoulou H Mpouzika M amp Goutsikas C G (2012) Exploration of the

Association Between Professional Interactions and Emotional Distress of Intensive Care Unit Nursing Personnel Dimensions Of Critical

Care Nursing 31(1) 37-45 doi101097DCC0b013e31823a55b8

ReferencesKramer M Schmalenberg C amp Maguire P (2010) Nine structures and leadership practices essential for a magnetic (healthy)

work environment Nursing Administration Quarterly 34(1) 4-17 doi101097NAQ0b013e3181c95ef4

Manojlovich M amp DeCicco B (2007) Healthy work environments nurse-physician communication and patients outcome American Journal Of Critical Care 16(6) 536-543

McCaffrey R Hayes R Cassell A Miller-Reyes S Donaldson A amp Ferrell C (2012) The effect of an educational programme on attitudes of nurses and medical residents towards the benefits of positive communication and collaboration Journal Of Advanced Nursing 68(2) 293-301 doi101111j1365-2648201105736x

Nieswiadomy R M (2012) Foundations of Nursing Research (6th Ed) Upper Saddle River New Jersey Prentice Hall

Rosenstein A amp ODaniel M (2008) A survey of the impact of disruptive behaviors and communication defects on patient safety Joint Commission Journal On Quality amp Patient Safety 34(8) 464-471

Rothstein W amp Hannum S (2007) Profession and gender in relationships between advanced practice nurses and physicians Journal Of Professional Nursing 23(4) 235-240 doi101016jprofnurs200701008

Saxton R Hines T amp Enriquez M (2009) The negative impact of nurse-physician disruptive behavior on patient safety A review of the literature Journal of Patient Safety 5(3) 180-183

Stone P W (2002) Popping the PICO question in research and evidence-based practice Applied Nursing Research 16(2) 197-198

Schmalenberg C amp Kramer M (2009) Nurse-physician relationships in hospitals 20 000 nurses tell their story Critical Care Nurse 29(1) 74-83 doi104037ccn2009436

Zwarenstein M Goldman J amp Reeves S (2009) Interprofessional collaboration Effects of practice-based interventions on professional practice and healthcare outcomes Cochrane Database Of Systematic Reviews (3) 1-31 doi10100214651858CD000072

NURS 350 Evidence-Based Nursing Practice (Group paper plus Group Powerpoint presentation)

Total group grade 100Instructorrsquos comments Excellent paper I think your group

should consider submitting it for publication if you could flesh out the details on improving collaborative communication

• Ferris State University NURS 350 Evidence-Based Nursing Practic
• ldquoCommunication--the human connection--is the key to pers
• Slide 3
• What is patient safety
• What is acute care
• What is Professional Communication
• Communication between medical professionals is not just a local
• PICO Question
• Definitions
• A Survey of the Impacts of Disruptive Behaviors and Communicat
• A Survey of the Impacts of Disruptive Behaviors and Communicat (2)
• Literature Review (Level One Evidence)
• Literature Review (Level Three Evidence)
• Literature Review (Level Four Evidence)
• Literature Review (Level Four Evidence continued)
• Literature Review (Level Six Evidence)
• Analysis of Evidence
• Slide 18
• Slide 19
• Article 1 ldquoConflict management training and nurse-physician
• Article 2 ldquoNine structures and leadership practices essentia
• Slide 22
• Article 3 ldquoThe effect of an educational programme on attitud
• Article 4 ldquoNurse-physician relationships in hospitals 2000
• Percentage of staff nurses responding affirmatively to nurse-ph
• Application of Evidence for oncology nursing practice (Lai Har
• Application of Evidence at the Cardiovascular Department (Marg
• Application of Evidence into the Surgical Setting (Gary Webste
• Slide 29
• Summary Statements
• References
• References (2)
• NURS 350 Evidence-Based Nursing Practice (Group paper plus Gr

Application of Evidence at the Cardiovascular Department (Margaret Siler)

bull High quality communication and collaboration make a great difference in the cardiac catheterization laboratory (Boone King Gresham Wahl amp Suh 2008 p 168)

bull Experience and a broad knowledge base bring confidence to our daily work (Schmalenberg amp Kramer 2009 p 82)

bull All involved parties (patient nurse physician healthcare system) can reap the benefits of collaborative practice (Kramer et al 2012 p 7)

bull There are many educational opportunities available to improve interdisciplinary and interdepartmental communication Many are quite costly Some that may make the biggest difference are fairly inexpensive including Unit Action Council work and interdepartmental job shadowing (McCaffery et al 2012)

Application of Evidence into the Surgical Setting (Gary Webster)

Intra-operative settings place nurses and physicians in close collaborative work

settings The typical communication style is authoritarian Schmalenberg and

Kramer (2009) stated that physicians felt the nurse-physician relation to be more

collaborative than nurse did I can see that being true in my work environment

The Boone et al (2008) and McCaffrey (2011) articles combined are very

valuable Together the articles show a successful attempt to increase collaboration

and some pitfalls to avoid These can help direct any programs to support an

increase in collaboration

Application of Evidence (Jamie Ziemba)

bull Poor communication between nurses and physicians related to language and cultural barriers

bull Physiciansrsquo dysfunctional or authoritarian communication style (eg instruct nurses not to call at night unless it is a life-and-death emergency) is a major patient safety issue

bull As the patient advocate nurses have an important role of communicating with physicians to verify medication orders clinical procedures and improve patient outcomes

bull Hospital training programs in communication skills and cultural diversities are recommended for physicians and nurses with different culturalethnic backgrounds

Summary Statements

bull Meta-analytical review of evidence-based research articles support the clinical significance of effective communication styles

bull Authoritarian communication styles increase disruptive behaviors and negative hostile relationships at work environments

bull Healthy work environments have positive effects on nurses physicians patients and healthcare organizations

bull Inter-disciplinary collaboration is an essential aspect of healthy work environmentsbull Evidence-based studies have shown positive patient outcomes nursing job

satisfaction collaborative environments at Magnet hospitalsbull There is a need to address the barriers and incorporate educational programs to teach

effective communication and the need for collaboration Educational training should be re-enforced with weekly discussions ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Educate staff on the 5 types of nurse-physician relationships (collegial collaborative teacher-student friendly-stranger and hostileadversarial relationships)

bull Teach staff how to utilize positive relationships and change negative onesbull Training should avoid focusing on negative behaviorsbull Training should focus creating cooperative behaviors

ReferencesAgency for Healthcare Research and Quality (nd) Medical teamwork and patient safety The Donabedian model of patient safety Retrieved

from httpwwwahrqgovqualmedteammedteamfig2htm

American Nurses Association (1980) Nursing A social policy statement Washington DC American Nurses Association

Ballou K amp Landreneau K (2010) The authoritarian reign in American health care Policy Politics amp Nursing Practice 11(1) 71-79

doi1011771527154410372973

Boone B King M Gresham L Wahl P amp Suh E (2008) Conflict management training and nurse-physician collaborative behaviors

Journal For Nurses In Staff Development 24(4) 168-175 doi10109701NND00003206705641591

Burns N amp Grove S (2007) Understanding Nursing Research Building an Evidence Based Practice (4th Ed) St Louis Missouri Saunders

Elsevier Publishing

Ford L (2012) Week 8 amp 9 Critique of Research Retrieved from httpsfsulearnferriseduwebappsportalframesetjsp

tab_tab_group_id=_2_1ampurl=2Fwebapps2Fblackboard2Fexecute2Flauncher3Ftype3DCourseampid3D_2241_1ampurl3D

Gardezi F Lingard L Espin S Whyte S Orser B amp Baker G (2009) Silence power and communication in the operating room

Journal Of Advanced Nursing 65(7) 1390-1399 doi101111j1365-2648200904994x

Hendel T Fish M amp Berger O (2007) Nursephysician conflict management mode choices implications for improved collaborative

practice Nursing Administration Quarterly 31(3) 244-253

John Hopkins UniversityJohn Hopkins Hospital (nd) JHNEBP Research Evidence Appraisal Retrieved from

httpwwwnursingworldorgDocumentVaultNursingPracticeResearch-ToolkitJHNEBP-Research-Evidence-Appraisalpdf

Karanikola M Papathanassoglou E Kalafati M Stathopoulou H Mpouzika M amp Goutsikas C G (2012) Exploration of the

Association Between Professional Interactions and Emotional Distress of Intensive Care Unit Nursing Personnel Dimensions Of Critical

Care Nursing 31(1) 37-45 doi101097DCC0b013e31823a55b8

ReferencesKramer M Schmalenberg C amp Maguire P (2010) Nine structures and leadership practices essential for a magnetic (healthy)

work environment Nursing Administration Quarterly 34(1) 4-17 doi101097NAQ0b013e3181c95ef4

Manojlovich M amp DeCicco B (2007) Healthy work environments nurse-physician communication and patients outcome American Journal Of Critical Care 16(6) 536-543

McCaffrey R Hayes R Cassell A Miller-Reyes S Donaldson A amp Ferrell C (2012) The effect of an educational programme on attitudes of nurses and medical residents towards the benefits of positive communication and collaboration Journal Of Advanced Nursing 68(2) 293-301 doi101111j1365-2648201105736x

Nieswiadomy R M (2012) Foundations of Nursing Research (6th Ed) Upper Saddle River New Jersey Prentice Hall

Rosenstein A amp ODaniel M (2008) A survey of the impact of disruptive behaviors and communication defects on patient safety Joint Commission Journal On Quality amp Patient Safety 34(8) 464-471

Rothstein W amp Hannum S (2007) Profession and gender in relationships between advanced practice nurses and physicians Journal Of Professional Nursing 23(4) 235-240 doi101016jprofnurs200701008

Saxton R Hines T amp Enriquez M (2009) The negative impact of nurse-physician disruptive behavior on patient safety A review of the literature Journal of Patient Safety 5(3) 180-183

Stone P W (2002) Popping the PICO question in research and evidence-based practice Applied Nursing Research 16(2) 197-198

Schmalenberg C amp Kramer M (2009) Nurse-physician relationships in hospitals 20 000 nurses tell their story Critical Care Nurse 29(1) 74-83 doi104037ccn2009436

Zwarenstein M Goldman J amp Reeves S (2009) Interprofessional collaboration Effects of practice-based interventions on professional practice and healthcare outcomes Cochrane Database Of Systematic Reviews (3) 1-31 doi10100214651858CD000072

NURS 350 Evidence-Based Nursing Practice (Group paper plus Group Powerpoint presentation)

Total group grade 100Instructorrsquos comments Excellent paper I think your group

should consider submitting it for publication if you could flesh out the details on improving collaborative communication

• Ferris State University NURS 350 Evidence-Based Nursing Practic
• ldquoCommunication--the human connection--is the key to pers
• Slide 3
• What is patient safety
• What is acute care
• What is Professional Communication
• Communication between medical professionals is not just a local
• PICO Question
• Definitions
• A Survey of the Impacts of Disruptive Behaviors and Communicat
• A Survey of the Impacts of Disruptive Behaviors and Communicat (2)
• Literature Review (Level One Evidence)
• Literature Review (Level Three Evidence)
• Literature Review (Level Four Evidence)
• Literature Review (Level Four Evidence continued)
• Literature Review (Level Six Evidence)
• Analysis of Evidence
• Slide 18
• Slide 19
• Article 1 ldquoConflict management training and nurse-physician
• Article 2 ldquoNine structures and leadership practices essentia
• Slide 22
• Article 3 ldquoThe effect of an educational programme on attitud
• Article 4 ldquoNurse-physician relationships in hospitals 2000
• Percentage of staff nurses responding affirmatively to nurse-ph
• Application of Evidence for oncology nursing practice (Lai Har
• Application of Evidence at the Cardiovascular Department (Marg
• Application of Evidence into the Surgical Setting (Gary Webste
• Slide 29
• Summary Statements
• References
• References (2)
• NURS 350 Evidence-Based Nursing Practice (Group paper plus Gr

Application of Evidence into the Surgical Setting (Gary Webster)

Intra-operative settings place nurses and physicians in close collaborative work

settings The typical communication style is authoritarian Schmalenberg and

Kramer (2009) stated that physicians felt the nurse-physician relation to be more

collaborative than nurse did I can see that being true in my work environment

The Boone et al (2008) and McCaffrey (2011) articles combined are very

valuable Together the articles show a successful attempt to increase collaboration

and some pitfalls to avoid These can help direct any programs to support an

increase in collaboration

Application of Evidence (Jamie Ziemba)

bull Poor communication between nurses and physicians related to language and cultural barriers

bull Physiciansrsquo dysfunctional or authoritarian communication style (eg instruct nurses not to call at night unless it is a life-and-death emergency) is a major patient safety issue

bull As the patient advocate nurses have an important role of communicating with physicians to verify medication orders clinical procedures and improve patient outcomes

bull Hospital training programs in communication skills and cultural diversities are recommended for physicians and nurses with different culturalethnic backgrounds

Summary Statements

bull Meta-analytical review of evidence-based research articles support the clinical significance of effective communication styles

bull Authoritarian communication styles increase disruptive behaviors and negative hostile relationships at work environments

bull Healthy work environments have positive effects on nurses physicians patients and healthcare organizations

bull Inter-disciplinary collaboration is an essential aspect of healthy work environmentsbull Evidence-based studies have shown positive patient outcomes nursing job

satisfaction collaborative environments at Magnet hospitalsbull There is a need to address the barriers and incorporate educational programs to teach

effective communication and the need for collaboration Educational training should be re-enforced with weekly discussions ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Educate staff on the 5 types of nurse-physician relationships (collegial collaborative teacher-student friendly-stranger and hostileadversarial relationships)

bull Teach staff how to utilize positive relationships and change negative onesbull Training should avoid focusing on negative behaviorsbull Training should focus creating cooperative behaviors

ReferencesAgency for Healthcare Research and Quality (nd) Medical teamwork and patient safety The Donabedian model of patient safety Retrieved

from httpwwwahrqgovqualmedteammedteamfig2htm

American Nurses Association (1980) Nursing A social policy statement Washington DC American Nurses Association

Ballou K amp Landreneau K (2010) The authoritarian reign in American health care Policy Politics amp Nursing Practice 11(1) 71-79

doi1011771527154410372973

Boone B King M Gresham L Wahl P amp Suh E (2008) Conflict management training and nurse-physician collaborative behaviors

Journal For Nurses In Staff Development 24(4) 168-175 doi10109701NND00003206705641591

Burns N amp Grove S (2007) Understanding Nursing Research Building an Evidence Based Practice (4th Ed) St Louis Missouri Saunders

Elsevier Publishing

Ford L (2012) Week 8 amp 9 Critique of Research Retrieved from httpsfsulearnferriseduwebappsportalframesetjsp

tab_tab_group_id=_2_1ampurl=2Fwebapps2Fblackboard2Fexecute2Flauncher3Ftype3DCourseampid3D_2241_1ampurl3D

Gardezi F Lingard L Espin S Whyte S Orser B amp Baker G (2009) Silence power and communication in the operating room

Journal Of Advanced Nursing 65(7) 1390-1399 doi101111j1365-2648200904994x

Hendel T Fish M amp Berger O (2007) Nursephysician conflict management mode choices implications for improved collaborative

practice Nursing Administration Quarterly 31(3) 244-253

John Hopkins UniversityJohn Hopkins Hospital (nd) JHNEBP Research Evidence Appraisal Retrieved from

httpwwwnursingworldorgDocumentVaultNursingPracticeResearch-ToolkitJHNEBP-Research-Evidence-Appraisalpdf

Karanikola M Papathanassoglou E Kalafati M Stathopoulou H Mpouzika M amp Goutsikas C G (2012) Exploration of the

Association Between Professional Interactions and Emotional Distress of Intensive Care Unit Nursing Personnel Dimensions Of Critical

Care Nursing 31(1) 37-45 doi101097DCC0b013e31823a55b8

ReferencesKramer M Schmalenberg C amp Maguire P (2010) Nine structures and leadership practices essential for a magnetic (healthy)

work environment Nursing Administration Quarterly 34(1) 4-17 doi101097NAQ0b013e3181c95ef4

Manojlovich M amp DeCicco B (2007) Healthy work environments nurse-physician communication and patients outcome American Journal Of Critical Care 16(6) 536-543

McCaffrey R Hayes R Cassell A Miller-Reyes S Donaldson A amp Ferrell C (2012) The effect of an educational programme on attitudes of nurses and medical residents towards the benefits of positive communication and collaboration Journal Of Advanced Nursing 68(2) 293-301 doi101111j1365-2648201105736x

Nieswiadomy R M (2012) Foundations of Nursing Research (6th Ed) Upper Saddle River New Jersey Prentice Hall

Rosenstein A amp ODaniel M (2008) A survey of the impact of disruptive behaviors and communication defects on patient safety Joint Commission Journal On Quality amp Patient Safety 34(8) 464-471

Rothstein W amp Hannum S (2007) Profession and gender in relationships between advanced practice nurses and physicians Journal Of Professional Nursing 23(4) 235-240 doi101016jprofnurs200701008

Saxton R Hines T amp Enriquez M (2009) The negative impact of nurse-physician disruptive behavior on patient safety A review of the literature Journal of Patient Safety 5(3) 180-183

Stone P W (2002) Popping the PICO question in research and evidence-based practice Applied Nursing Research 16(2) 197-198

Schmalenberg C amp Kramer M (2009) Nurse-physician relationships in hospitals 20 000 nurses tell their story Critical Care Nurse 29(1) 74-83 doi104037ccn2009436

Zwarenstein M Goldman J amp Reeves S (2009) Interprofessional collaboration Effects of practice-based interventions on professional practice and healthcare outcomes Cochrane Database Of Systematic Reviews (3) 1-31 doi10100214651858CD000072

NURS 350 Evidence-Based Nursing Practice (Group paper plus Group Powerpoint presentation)

Total group grade 100Instructorrsquos comments Excellent paper I think your group

should consider submitting it for publication if you could flesh out the details on improving collaborative communication

• Ferris State University NURS 350 Evidence-Based Nursing Practic
• ldquoCommunication--the human connection--is the key to pers
• Slide 3
• What is patient safety
• What is acute care
• What is Professional Communication
• Communication between medical professionals is not just a local
• PICO Question
• Definitions
• A Survey of the Impacts of Disruptive Behaviors and Communicat
• A Survey of the Impacts of Disruptive Behaviors and Communicat (2)
• Literature Review (Level One Evidence)
• Literature Review (Level Three Evidence)
• Literature Review (Level Four Evidence)
• Literature Review (Level Four Evidence continued)
• Literature Review (Level Six Evidence)
• Analysis of Evidence
• Slide 18
• Slide 19
• Article 1 ldquoConflict management training and nurse-physician
• Article 2 ldquoNine structures and leadership practices essentia
• Slide 22
• Article 3 ldquoThe effect of an educational programme on attitud
• Article 4 ldquoNurse-physician relationships in hospitals 2000
• Percentage of staff nurses responding affirmatively to nurse-ph
• Application of Evidence for oncology nursing practice (Lai Har
• Application of Evidence at the Cardiovascular Department (Marg
• Application of Evidence into the Surgical Setting (Gary Webste
• Slide 29
• Summary Statements
• References
• References (2)
• NURS 350 Evidence-Based Nursing Practice (Group paper plus Gr

Application of Evidence (Jamie Ziemba)

bull Poor communication between nurses and physicians related to language and cultural barriers

bull Physiciansrsquo dysfunctional or authoritarian communication style (eg instruct nurses not to call at night unless it is a life-and-death emergency) is a major patient safety issue

bull As the patient advocate nurses have an important role of communicating with physicians to verify medication orders clinical procedures and improve patient outcomes

bull Hospital training programs in communication skills and cultural diversities are recommended for physicians and nurses with different culturalethnic backgrounds

Summary Statements

bull Meta-analytical review of evidence-based research articles support the clinical significance of effective communication styles

bull Authoritarian communication styles increase disruptive behaviors and negative hostile relationships at work environments

bull Healthy work environments have positive effects on nurses physicians patients and healthcare organizations

bull Inter-disciplinary collaboration is an essential aspect of healthy work environmentsbull Evidence-based studies have shown positive patient outcomes nursing job

satisfaction collaborative environments at Magnet hospitalsbull There is a need to address the barriers and incorporate educational programs to teach

effective communication and the need for collaboration Educational training should be re-enforced with weekly discussions ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Educate staff on the 5 types of nurse-physician relationships (collegial collaborative teacher-student friendly-stranger and hostileadversarial relationships)

bull Teach staff how to utilize positive relationships and change negative onesbull Training should avoid focusing on negative behaviorsbull Training should focus creating cooperative behaviors

ReferencesAgency for Healthcare Research and Quality (nd) Medical teamwork and patient safety The Donabedian model of patient safety Retrieved

from httpwwwahrqgovqualmedteammedteamfig2htm

American Nurses Association (1980) Nursing A social policy statement Washington DC American Nurses Association

Ballou K amp Landreneau K (2010) The authoritarian reign in American health care Policy Politics amp Nursing Practice 11(1) 71-79

doi1011771527154410372973

Boone B King M Gresham L Wahl P amp Suh E (2008) Conflict management training and nurse-physician collaborative behaviors

Journal For Nurses In Staff Development 24(4) 168-175 doi10109701NND00003206705641591

Burns N amp Grove S (2007) Understanding Nursing Research Building an Evidence Based Practice (4th Ed) St Louis Missouri Saunders

Elsevier Publishing

Ford L (2012) Week 8 amp 9 Critique of Research Retrieved from httpsfsulearnferriseduwebappsportalframesetjsp

tab_tab_group_id=_2_1ampurl=2Fwebapps2Fblackboard2Fexecute2Flauncher3Ftype3DCourseampid3D_2241_1ampurl3D

Gardezi F Lingard L Espin S Whyte S Orser B amp Baker G (2009) Silence power and communication in the operating room

Journal Of Advanced Nursing 65(7) 1390-1399 doi101111j1365-2648200904994x

Hendel T Fish M amp Berger O (2007) Nursephysician conflict management mode choices implications for improved collaborative

practice Nursing Administration Quarterly 31(3) 244-253

John Hopkins UniversityJohn Hopkins Hospital (nd) JHNEBP Research Evidence Appraisal Retrieved from

httpwwwnursingworldorgDocumentVaultNursingPracticeResearch-ToolkitJHNEBP-Research-Evidence-Appraisalpdf

Karanikola M Papathanassoglou E Kalafati M Stathopoulou H Mpouzika M amp Goutsikas C G (2012) Exploration of the

Association Between Professional Interactions and Emotional Distress of Intensive Care Unit Nursing Personnel Dimensions Of Critical

Care Nursing 31(1) 37-45 doi101097DCC0b013e31823a55b8

ReferencesKramer M Schmalenberg C amp Maguire P (2010) Nine structures and leadership practices essential for a magnetic (healthy)

work environment Nursing Administration Quarterly 34(1) 4-17 doi101097NAQ0b013e3181c95ef4

Manojlovich M amp DeCicco B (2007) Healthy work environments nurse-physician communication and patients outcome American Journal Of Critical Care 16(6) 536-543

McCaffrey R Hayes R Cassell A Miller-Reyes S Donaldson A amp Ferrell C (2012) The effect of an educational programme on attitudes of nurses and medical residents towards the benefits of positive communication and collaboration Journal Of Advanced Nursing 68(2) 293-301 doi101111j1365-2648201105736x

Nieswiadomy R M (2012) Foundations of Nursing Research (6th Ed) Upper Saddle River New Jersey Prentice Hall

Rosenstein A amp ODaniel M (2008) A survey of the impact of disruptive behaviors and communication defects on patient safety Joint Commission Journal On Quality amp Patient Safety 34(8) 464-471

Rothstein W amp Hannum S (2007) Profession and gender in relationships between advanced practice nurses and physicians Journal Of Professional Nursing 23(4) 235-240 doi101016jprofnurs200701008

Saxton R Hines T amp Enriquez M (2009) The negative impact of nurse-physician disruptive behavior on patient safety A review of the literature Journal of Patient Safety 5(3) 180-183

Stone P W (2002) Popping the PICO question in research and evidence-based practice Applied Nursing Research 16(2) 197-198

Schmalenberg C amp Kramer M (2009) Nurse-physician relationships in hospitals 20 000 nurses tell their story Critical Care Nurse 29(1) 74-83 doi104037ccn2009436

Zwarenstein M Goldman J amp Reeves S (2009) Interprofessional collaboration Effects of practice-based interventions on professional practice and healthcare outcomes Cochrane Database Of Systematic Reviews (3) 1-31 doi10100214651858CD000072

NURS 350 Evidence-Based Nursing Practice (Group paper plus Group Powerpoint presentation)

Total group grade 100Instructorrsquos comments Excellent paper I think your group

should consider submitting it for publication if you could flesh out the details on improving collaborative communication

• Ferris State University NURS 350 Evidence-Based Nursing Practic
• ldquoCommunication--the human connection--is the key to pers
• Slide 3
• What is patient safety
• What is acute care
• What is Professional Communication
• Communication between medical professionals is not just a local
• PICO Question
• Definitions
• A Survey of the Impacts of Disruptive Behaviors and Communicat
• A Survey of the Impacts of Disruptive Behaviors and Communicat (2)
• Literature Review (Level One Evidence)
• Literature Review (Level Three Evidence)
• Literature Review (Level Four Evidence)
• Literature Review (Level Four Evidence continued)
• Literature Review (Level Six Evidence)
• Analysis of Evidence
• Slide 18
• Slide 19
• Article 1 ldquoConflict management training and nurse-physician
• Article 2 ldquoNine structures and leadership practices essentia
• Slide 22
• Article 3 ldquoThe effect of an educational programme on attitud
• Article 4 ldquoNurse-physician relationships in hospitals 2000
• Percentage of staff nurses responding affirmatively to nurse-ph
• Application of Evidence for oncology nursing practice (Lai Har
• Application of Evidence at the Cardiovascular Department (Marg
• Application of Evidence into the Surgical Setting (Gary Webste
• Slide 29
• Summary Statements
• References
• References (2)
• NURS 350 Evidence-Based Nursing Practice (Group paper plus Gr

Summary Statements

bull Meta-analytical review of evidence-based research articles support the clinical significance of effective communication styles

bull Authoritarian communication styles increase disruptive behaviors and negative hostile relationships at work environments

bull Healthy work environments have positive effects on nurses physicians patients and healthcare organizations

bull Inter-disciplinary collaboration is an essential aspect of healthy work environmentsbull Evidence-based studies have shown positive patient outcomes nursing job

satisfaction collaborative environments at Magnet hospitalsbull There is a need to address the barriers and incorporate educational programs to teach

effective communication and the need for collaboration Educational training should be re-enforced with weekly discussions ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et al 2012 p 294)

bull Educate staff on the 5 types of nurse-physician relationships (collegial collaborative teacher-student friendly-stranger and hostileadversarial relationships)

bull Teach staff how to utilize positive relationships and change negative onesbull Training should avoid focusing on negative behaviorsbull Training should focus creating cooperative behaviors

ReferencesAgency for Healthcare Research and Quality (nd) Medical teamwork and patient safety The Donabedian model of patient safety Retrieved

from httpwwwahrqgovqualmedteammedteamfig2htm

American Nurses Association (1980) Nursing A social policy statement Washington DC American Nurses Association

Ballou K amp Landreneau K (2010) The authoritarian reign in American health care Policy Politics amp Nursing Practice 11(1) 71-79

doi1011771527154410372973

Boone B King M Gresham L Wahl P amp Suh E (2008) Conflict management training and nurse-physician collaborative behaviors

Journal For Nurses In Staff Development 24(4) 168-175 doi10109701NND00003206705641591

Burns N amp Grove S (2007) Understanding Nursing Research Building an Evidence Based Practice (4th Ed) St Louis Missouri Saunders

Elsevier Publishing

Ford L (2012) Week 8 amp 9 Critique of Research Retrieved from httpsfsulearnferriseduwebappsportalframesetjsp

tab_tab_group_id=_2_1ampurl=2Fwebapps2Fblackboard2Fexecute2Flauncher3Ftype3DCourseampid3D_2241_1ampurl3D

Gardezi F Lingard L Espin S Whyte S Orser B amp Baker G (2009) Silence power and communication in the operating room

Journal Of Advanced Nursing 65(7) 1390-1399 doi101111j1365-2648200904994x

Hendel T Fish M amp Berger O (2007) Nursephysician conflict management mode choices implications for improved collaborative

practice Nursing Administration Quarterly 31(3) 244-253

John Hopkins UniversityJohn Hopkins Hospital (nd) JHNEBP Research Evidence Appraisal Retrieved from

httpwwwnursingworldorgDocumentVaultNursingPracticeResearch-ToolkitJHNEBP-Research-Evidence-Appraisalpdf

Karanikola M Papathanassoglou E Kalafati M Stathopoulou H Mpouzika M amp Goutsikas C G (2012) Exploration of the

Association Between Professional Interactions and Emotional Distress of Intensive Care Unit Nursing Personnel Dimensions Of Critical

Care Nursing 31(1) 37-45 doi101097DCC0b013e31823a55b8

ReferencesKramer M Schmalenberg C amp Maguire P (2010) Nine structures and leadership practices essential for a magnetic (healthy)

work environment Nursing Administration Quarterly 34(1) 4-17 doi101097NAQ0b013e3181c95ef4

Manojlovich M amp DeCicco B (2007) Healthy work environments nurse-physician communication and patients outcome American Journal Of Critical Care 16(6) 536-543

McCaffrey R Hayes R Cassell A Miller-Reyes S Donaldson A amp Ferrell C (2012) The effect of an educational programme on attitudes of nurses and medical residents towards the benefits of positive communication and collaboration Journal Of Advanced Nursing 68(2) 293-301 doi101111j1365-2648201105736x

Nieswiadomy R M (2012) Foundations of Nursing Research (6th Ed) Upper Saddle River New Jersey Prentice Hall

Rosenstein A amp ODaniel M (2008) A survey of the impact of disruptive behaviors and communication defects on patient safety Joint Commission Journal On Quality amp Patient Safety 34(8) 464-471

Rothstein W amp Hannum S (2007) Profession and gender in relationships between advanced practice nurses and physicians Journal Of Professional Nursing 23(4) 235-240 doi101016jprofnurs200701008

Saxton R Hines T amp Enriquez M (2009) The negative impact of nurse-physician disruptive behavior on patient safety A review of the literature Journal of Patient Safety 5(3) 180-183

Stone P W (2002) Popping the PICO question in research and evidence-based practice Applied Nursing Research 16(2) 197-198

Schmalenberg C amp Kramer M (2009) Nurse-physician relationships in hospitals 20 000 nurses tell their story Critical Care Nurse 29(1) 74-83 doi104037ccn2009436

Zwarenstein M Goldman J amp Reeves S (2009) Interprofessional collaboration Effects of practice-based interventions on professional practice and healthcare outcomes Cochrane Database Of Systematic Reviews (3) 1-31 doi10100214651858CD000072

NURS 350 Evidence-Based Nursing Practice (Group paper plus Group Powerpoint presentation)

Total group grade 100Instructorrsquos comments Excellent paper I think your group

should consider submitting it for publication if you could flesh out the details on improving collaborative communication

• Ferris State University NURS 350 Evidence-Based Nursing Practic
• ldquoCommunication--the human connection--is the key to pers
• Slide 3
• What is patient safety
• What is acute care
• What is Professional Communication
• Communication between medical professionals is not just a local
• PICO Question
• Definitions
• A Survey of the Impacts of Disruptive Behaviors and Communicat
• A Survey of the Impacts of Disruptive Behaviors and Communicat (2)
• Literature Review (Level One Evidence)
• Literature Review (Level Three Evidence)
• Literature Review (Level Four Evidence)
• Literature Review (Level Four Evidence continued)
• Literature Review (Level Six Evidence)
• Analysis of Evidence
• Slide 18
• Slide 19
• Article 1 ldquoConflict management training and nurse-physician
• Article 2 ldquoNine structures and leadership practices essentia
• Slide 22
• Article 3 ldquoThe effect of an educational programme on attitud
• Article 4 ldquoNurse-physician relationships in hospitals 2000
• Percentage of staff nurses responding affirmatively to nurse-ph
• Application of Evidence for oncology nursing practice (Lai Har
• Application of Evidence at the Cardiovascular Department (Marg
• Application of Evidence into the Surgical Setting (Gary Webste
• Slide 29
• Summary Statements
• References
• References (2)
• NURS 350 Evidence-Based Nursing Practice (Group paper plus Gr

ReferencesAgency for Healthcare Research and Quality (nd) Medical teamwork and patient safety The Donabedian model of patient safety Retrieved

from httpwwwahrqgovqualmedteammedteamfig2htm

American Nurses Association (1980) Nursing A social policy statement Washington DC American Nurses Association

Ballou K amp Landreneau K (2010) The authoritarian reign in American health care Policy Politics amp Nursing Practice 11(1) 71-79

doi1011771527154410372973

Boone B King M Gresham L Wahl P amp Suh E (2008) Conflict management training and nurse-physician collaborative behaviors

Journal For Nurses In Staff Development 24(4) 168-175 doi10109701NND00003206705641591

Burns N amp Grove S (2007) Understanding Nursing Research Building an Evidence Based Practice (4th Ed) St Louis Missouri Saunders

Elsevier Publishing

Ford L (2012) Week 8 amp 9 Critique of Research Retrieved from httpsfsulearnferriseduwebappsportalframesetjsp

tab_tab_group_id=_2_1ampurl=2Fwebapps2Fblackboard2Fexecute2Flauncher3Ftype3DCourseampid3D_2241_1ampurl3D

Gardezi F Lingard L Espin S Whyte S Orser B amp Baker G (2009) Silence power and communication in the operating room

Journal Of Advanced Nursing 65(7) 1390-1399 doi101111j1365-2648200904994x

Hendel T Fish M amp Berger O (2007) Nursephysician conflict management mode choices implications for improved collaborative

practice Nursing Administration Quarterly 31(3) 244-253

John Hopkins UniversityJohn Hopkins Hospital (nd) JHNEBP Research Evidence Appraisal Retrieved from

httpwwwnursingworldorgDocumentVaultNursingPracticeResearch-ToolkitJHNEBP-Research-Evidence-Appraisalpdf

Karanikola M Papathanassoglou E Kalafati M Stathopoulou H Mpouzika M amp Goutsikas C G (2012) Exploration of the

Association Between Professional Interactions and Emotional Distress of Intensive Care Unit Nursing Personnel Dimensions Of Critical

Care Nursing 31(1) 37-45 doi101097DCC0b013e31823a55b8

ReferencesKramer M Schmalenberg C amp Maguire P (2010) Nine structures and leadership practices essential for a magnetic (healthy)

work environment Nursing Administration Quarterly 34(1) 4-17 doi101097NAQ0b013e3181c95ef4

Manojlovich M amp DeCicco B (2007) Healthy work environments nurse-physician communication and patients outcome American Journal Of Critical Care 16(6) 536-543

McCaffrey R Hayes R Cassell A Miller-Reyes S Donaldson A amp Ferrell C (2012) The effect of an educational programme on attitudes of nurses and medical residents towards the benefits of positive communication and collaboration Journal Of Advanced Nursing 68(2) 293-301 doi101111j1365-2648201105736x

Nieswiadomy R M (2012) Foundations of Nursing Research (6th Ed) Upper Saddle River New Jersey Prentice Hall

Rosenstein A amp ODaniel M (2008) A survey of the impact of disruptive behaviors and communication defects on patient safety Joint Commission Journal On Quality amp Patient Safety 34(8) 464-471

Rothstein W amp Hannum S (2007) Profession and gender in relationships between advanced practice nurses and physicians Journal Of Professional Nursing 23(4) 235-240 doi101016jprofnurs200701008

Saxton R Hines T amp Enriquez M (2009) The negative impact of nurse-physician disruptive behavior on patient safety A review of the literature Journal of Patient Safety 5(3) 180-183

Stone P W (2002) Popping the PICO question in research and evidence-based practice Applied Nursing Research 16(2) 197-198

Schmalenberg C amp Kramer M (2009) Nurse-physician relationships in hospitals 20 000 nurses tell their story Critical Care Nurse 29(1) 74-83 doi104037ccn2009436

Zwarenstein M Goldman J amp Reeves S (2009) Interprofessional collaboration Effects of practice-based interventions on professional practice and healthcare outcomes Cochrane Database Of Systematic Reviews (3) 1-31 doi10100214651858CD000072

NURS 350 Evidence-Based Nursing Practice (Group paper plus Group Powerpoint presentation)

Total group grade 100Instructorrsquos comments Excellent paper I think your group

should consider submitting it for publication if you could flesh out the details on improving collaborative communication

• Ferris State University NURS 350 Evidence-Based Nursing Practic
• ldquoCommunication--the human connection--is the key to pers
• Slide 3
• What is patient safety
• What is acute care
• What is Professional Communication
• Communication between medical professionals is not just a local
• PICO Question
• Definitions
• A Survey of the Impacts of Disruptive Behaviors and Communicat
• A Survey of the Impacts of Disruptive Behaviors and Communicat (2)
• Literature Review (Level One Evidence)
• Literature Review (Level Three Evidence)
• Literature Review (Level Four Evidence)
• Literature Review (Level Four Evidence continued)
• Literature Review (Level Six Evidence)
• Analysis of Evidence
• Slide 18
• Slide 19
• Article 1 ldquoConflict management training and nurse-physician
• Article 2 ldquoNine structures and leadership practices essentia
• Slide 22
• Article 3 ldquoThe effect of an educational programme on attitud
• Article 4 ldquoNurse-physician relationships in hospitals 2000
• Percentage of staff nurses responding affirmatively to nurse-ph
• Application of Evidence for oncology nursing practice (Lai Har
• Application of Evidence at the Cardiovascular Department (Marg
• Application of Evidence into the Surgical Setting (Gary Webste
• Slide 29
• Summary Statements
• References
• References (2)
• NURS 350 Evidence-Based Nursing Practice (Group paper plus Gr

ReferencesKramer M Schmalenberg C amp Maguire P (2010) Nine structures and leadership practices essential for a magnetic (healthy)

work environment Nursing Administration Quarterly 34(1) 4-17 doi101097NAQ0b013e3181c95ef4

Manojlovich M amp DeCicco B (2007) Healthy work environments nurse-physician communication and patients outcome American Journal Of Critical Care 16(6) 536-543

McCaffrey R Hayes R Cassell A Miller-Reyes S Donaldson A amp Ferrell C (2012) The effect of an educational programme on attitudes of nurses and medical residents towards the benefits of positive communication and collaboration Journal Of Advanced Nursing 68(2) 293-301 doi101111j1365-2648201105736x

Nieswiadomy R M (2012) Foundations of Nursing Research (6th Ed) Upper Saddle River New Jersey Prentice Hall

Rosenstein A amp ODaniel M (2008) A survey of the impact of disruptive behaviors and communication defects on patient safety Joint Commission Journal On Quality amp Patient Safety 34(8) 464-471

Rothstein W amp Hannum S (2007) Profession and gender in relationships between advanced practice nurses and physicians Journal Of Professional Nursing 23(4) 235-240 doi101016jprofnurs200701008

Saxton R Hines T amp Enriquez M (2009) The negative impact of nurse-physician disruptive behavior on patient safety A review of the literature Journal of Patient Safety 5(3) 180-183

Stone P W (2002) Popping the PICO question in research and evidence-based practice Applied Nursing Research 16(2) 197-198

Schmalenberg C amp Kramer M (2009) Nurse-physician relationships in hospitals 20 000 nurses tell their story Critical Care Nurse 29(1) 74-83 doi104037ccn2009436

Zwarenstein M Goldman J amp Reeves S (2009) Interprofessional collaboration Effects of practice-based interventions on professional practice and healthcare outcomes Cochrane Database Of Systematic Reviews (3) 1-31 doi10100214651858CD000072

NURS 350 Evidence-Based Nursing Practice (Group paper plus Group Powerpoint presentation)

Total group grade 100Instructorrsquos comments Excellent paper I think your group

should consider submitting it for publication if you could flesh out the details on improving collaborative communication

• Ferris State University NURS 350 Evidence-Based Nursing Practic
• ldquoCommunication--the human connection--is the key to pers
• Slide 3
• What is patient safety
• What is acute care
• What is Professional Communication
• Communication between medical professionals is not just a local
• PICO Question
• Definitions
• A Survey of the Impacts of Disruptive Behaviors and Communicat
• A Survey of the Impacts of Disruptive Behaviors and Communicat (2)
• Literature Review (Level One Evidence)
• Literature Review (Level Three Evidence)
• Literature Review (Level Four Evidence)
• Literature Review (Level Four Evidence continued)
• Literature Review (Level Six Evidence)
• Analysis of Evidence
• Slide 18
• Slide 19
• Article 1 ldquoConflict management training and nurse-physician
• Article 2 ldquoNine structures and leadership practices essentia
• Slide 22
• Article 3 ldquoThe effect of an educational programme on attitud
• Article 4 ldquoNurse-physician relationships in hospitals 2000
• Percentage of staff nurses responding affirmatively to nurse-ph
• Application of Evidence for oncology nursing practice (Lai Har
• Application of Evidence at the Cardiovascular Department (Marg
• Application of Evidence into the Surgical Setting (Gary Webste
• Slide 29
• Summary Statements
• References
• References (2)
• NURS 350 Evidence-Based Nursing Practice (Group paper plus Gr

NURS 350 Evidence-Based Nursing Practice (Group paper plus Group Powerpoint presentation)

Total group grade 100Instructorrsquos comments Excellent paper I think your group

should consider submitting it for publication if you could flesh out the details on improving collaborative communication

• Ferris State University NURS 350 Evidence-Based Nursing Practic
• ldquoCommunication--the human connection--is the key to pers
• Slide 3
• What is patient safety
• What is acute care
• What is Professional Communication
• Communication between medical professionals is not just a local
• PICO Question
• Definitions
• A Survey of the Impacts of Disruptive Behaviors and Communicat
• A Survey of the Impacts of Disruptive Behaviors and Communicat (2)
• Literature Review (Level One Evidence)
• Literature Review (Level Three Evidence)
• Literature Review (Level Four Evidence)
• Literature Review (Level Four Evidence continued)
• Literature Review (Level Six Evidence)
• Analysis of Evidence
• Slide 18
• Slide 19
• Article 1 ldquoConflict management training and nurse-physician
• Article 2 ldquoNine structures and leadership practices essentia
• Slide 22
• Article 3 ldquoThe effect of an educational programme on attitud
• Article 4 ldquoNurse-physician relationships in hospitals 2000
• Percentage of staff nurses responding affirmatively to nurse-ph
• Application of Evidence for oncology nursing practice (Lai Har
• Application of Evidence at the Cardiovascular Department (Marg
• Application of Evidence into the Surgical Setting (Gary Webste
• Slide 29
• Summary Statements
• References
• References (2)
• NURS 350 Evidence-Based Nursing Practice (Group paper plus Gr