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34 AJN M July 2009 M Vol. 109, No. 7 ajnonline.com

How to improve the nurse–physician relationshipis a frequent topic in nursing journals. But de-spite the interest in this issue among nurses andpatient-safety advocates, most literature is still,as Sweet and Normal described in a 1995 review,

either “prescriptive or anecdotal.” Some work on this topic

also has the limitation of focusing on nurses’ reports orexperiences and not taking into account physicians’ expe-riences. Further, nurses and physicians may have a differentunderstanding of what it means to work together effec-tively. Physicians have historically embraced a hierarchicalmodel of giving orders that nurses carry out, whereas nurseshave increasingly come to desire a more egalitarian, collab-orative interaction.

The ‘doctor–nurse game.’ In 1967 the psychiatristLeonard Stein described a “game” in which nurses makerecommendations in such a way that their suggestionsappear to be initiated by physicians; thus they participatein decision making while still preserving their subordinateplace in the hierarchy.1 In 1990 Stein and colleagues sug-gested that the move away from hospital-based diplomaprograms to academic education, in the form of associ-ate’s and bachelor’s degrees, was a “principal vehicle”behind a shift in nurse–physician relations: “Instead of being told to defer to physicians, [nursing] students aretold that nurses are equal to other health care providers,in a relationship that is collegial, not subservient, andthat nurses are professionals and thus obligated tomake decisions and take responsibility.”2 The shift innurse–physician relations likely reflected broader socialinfluences as well, including the dramatic changes in

women’s social status that allowed greater opportunitiesfor their participation in the workforce. But these social

‘It Depends’: Medical Residents’Perspectives on Working with Nurses

A QUALITATIVE STUDY SHOWS THAT RESIDENTS DON’T NECESSARILYVIEW NURSES AS COLLEAGUES AND COLLABORATORS.

BY DAN A B. WEINBERG, PHD, DIANNE COONEY MINER, PHD, RN, CNRN, AN D LEETAL RIVLIN, MA

Continuing Education2.9 HOURS

ORIGINAL RESEARCH

ABSTRACTObjective: Using the theory of relational coordination, which

holds that in high-pressure settings such as hospitals, high-quality

communication and strong relationships are necessary for coordi-

nated action, we soughtto determinethequality of thenurse–physician

relationship by examining the communication and interaction

between nurses and residents from the residents’ perspective.

Methods: A sample of 20 medical and surgical residents,

selected by a snowball sampling technique, were interviewed about

the quality of their communication and relationships with nurses

in the workplace.

Results: Residents’ responses were influenced by their percep-

tions of nurses’ cooperativeness and competence,and their impressions

of nurses’ professional preparation and demeanor varied widely.

Although 19 of 20 residents reported instances of poor communica-

tion or problematic relationships with nurses, most believed that this

posed no significant threat to patient care because the nurses’ role,

as they saw it, was one of simply following orders.

Conclusions: Given the strong doubts someresidents expressed

about nurses’ cooperativeness and competence, the nursing profes-

sion should consider strengthening nursing education and clearly

delineating nurses’ roles and competencies.

Key words: Nurse–physician relations, interdisciplinary com-

munication, relational coordination.

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changes have hardly changed nurses’ structural posi-tion in health care, which is often subordinate tophysicians and to administrative bureaucracies. Fornurses, therefore, attempts at collaboration may bealienating rather than empowering.

A study by Kramer and Schmalenberg suggeststhat nurses believe “nurse autonomy and controlover nursing practice” to be an important contrib-utor to a “good” nurse–physician relationship andto the quality of care.3 In their study, the highestrelationship rating given by nurses was “differentbut equal.” Positive nurse–physician collaborationhas been associated with good patient outcomesin ICUs.4-8 In other settings, problems with nurse–physician collaboration or communication have beenassociated with medication errors,9 patient safetyissues,10 and patient deaths.11

In order to see how physicians themselves viewthe nurse–physician relationship, we performed aqualitative study of nurse–physician interactions fromthe perspective of medical and surgical residents.

OBJECTIVEWe set out to examine the nurse–physician relation-ship through the lens of relational coordination, a

theory that holds that work is successfully accom-plished when high-quality relationships and com-

munication exist among participants in the workprocess. The theory of relational coordination wasfirst developed and validated in the context of com-mercial airline flight departures12 and then wasshown to have significant effects on quality and effi-ciency outcomes in a number of health care con-texts.13-15 Gittell’s theory of relational coordinationsuggests that coordinated action is based on factorsrelated to

• frequent, high-quality communication (which istimely, accurate, and problem solving).

• high-quality relationships (in which shared goals,shared knowledge, and mutual respect are pres-ent).

Relational forms of coordination are important inacute care, where tasks are often interdependent,uncertain, time constrained, and performed underconditions of great complexity.

We focus here on nurses’ relationships withresidents for several reasons. We anticipated that res-idents, who are still in training and are thereforelower in the health care hierarchy than physicians,might be more open to collaborating with nursesand including them in decision making. On theother hand, inexperienced residents may find their

judgments and decisions scrutinized by nurses andmay perceive a lack of respect or even hostility from

[email protected] AJN M July 2009 M Vol. 109, No. 7 35

A P P

h o t o / R i c h P e d r o n c e l l i

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nurses who question their competence. Residentsmay also have more frequent interactions withnurses because there are more of them than thereare attending physicians. Finally, whether inclusiveand collaborative or hostile and disrespectful, resi-dents’ interactions with nurses may contribute totheir future attitudes toward working with nurses.

METHODSThe data for this analysis came from a larger studyof medical and surgical residents’ duty hours andhandoffs. The larger study examined residents’ workhours; workload and work intensity; and com-munication with and support from other residentsandattending physicians, nurses, and other care providersin the hospital. This article presents the findingsrelated to the general relationship and communica-tion between nurses and residents.

The Queens College (Flushing, New York) insti-tutional review board approved this project. Usinga snowball sampling technique, we asked our con-tacts and interviewees to provide names of residentswho might be willing to talk with us about theirdaily work experiences. We conducted telephoneinterviews with 20 medical and surgical residents(11 men and nine women) in academic health cen-ters and community hospitals in New York, Califor-nia, Ohio, Massachusetts, and Michigan. Fourteenwere in medical specialties, and six were in surgicalspecialties. Interviews followed a structured, open-ended questionnaire protocol and lasted 45 minutes

on average. With few exceptions, interviews wereconducted over the telephone, recorded, and tran-scribed. The questions on communication andrelationships with nurses, which are the focus of this analysis, were one of seven sections in the inter-view protocol. As shown in Table 1, these questionscorrelate with the seven dimensions of relational

coordination:

• frequency• timeliness• accuracy• problem solving• mutual respect• shared knowledge• shared goals

Our questions were open ended rather than multi-ple choice because we wanted to understand howoften high levels of relational coordination occurredand what, in the residents’ view, accounted for it.These seven dimensions of relational coordinationprovide the concepts used in the initial coding of the data. Two independent raters examined eachrespondent’s statements, looking for the presence of a “highly positive” response, one that indicated thatthe dimension in question occurred “all of the time,”

“always,” “frequently,” “usually,” “often,” or “mostof the time.” We then categorized other types of

Dimension of Relational

Coordination

Relational Coordination

Survey Item

Interview Question

Frequent communication How frequently do youcommunicate with peoplein each of these groupsabout [specific workprocess or client]?

How much interac-tion do you havewith nurses?How often do youtalk to nurses aboutyour patients?

Timely communication Do people in these groupscommunicate with you ina timely way regarding[specific work process or

client]?

Do nurses tell youwhat you need orwould like to knowabout your patients

when you need toknow it?

Accurate communication Do people in these groupscommunicate with youaccurately about [spe-cific work process orclient]?

How much do youtrust what nurses tellyou about patients?

Problem-solvingcommunication

When a problem occurswith [specific workprocess or client], do thepeople in these groupswork with you to solvethe problem?

When there is a prob-lem with a patient,do nurses try to helpyou solve the prob-lem? Can you give anexample?

Mutual respect How much do people inthese groups respect thework you do with [spe-cific work process orclient]?

How would youdescribe the nursesyou work with?Do they respect you?What makes youthink so?

Shared knowledge How much do people ineach of these groups

know about the workyou do with [specificwork process or client]?

What is the nurses’role?

How well do theyunderstand what youdo?What type of informa-tion do you give them?What do they do withthat information?

Shared Goals How much do people inthese groups share yourgoals regarding [specificwork process or client]?

What do you needfrom nurses to doyour job?

TABLE 1. Mapping Interview Questions on Residents’

Communication and Relationships with Nurses

Gittell JH. Relational coordination: guidelines for theory, measurement and analysis .2009. [Unpublished book manuscript].

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responses as “negative” or “weak” (occurring“rarely” or “never”) or “contingent” (identified byphrases like “it depends” or “sometimes”). Therewas extremely high interrater reliability, with nodisagreements about typology.

Next, we analyzed the residents’ statements accom-panying these typologies, in particular their descrip-

tions of interactions with nurses and the concepts orthemes that emerged from these descriptions. Weconducted this analysis first within each dimensionand then across dimensions. As we describe below,several prominent themes related to competence,cooperation, and roles emerged.

RESULTSThe most common response to our questions onaspects of relational coordination was a variant of “itdepends.” What it depended on, according to resi-dents, was whether nurses had these two qualities:

• cooperativeness

• competenceAs one resident summed up, “It all depends. Someare very nice. Some are not very nice. Some are verysmart and knowledgeable, and some are not.”Cooperativeness referred to how congenial andhardworking residents perceived the nurses to be.Competence referred to how smart or experiencedthe residents perceived the nurses to be. Most resi-dents associated experience with competence, as inthe following observation: “You have more oldernurses that know how the system runs; they knowwhat to do with a patient.” But experience wasnot synonymous with competence; many residentspointed to the importance of education, either onits own or combined with experience. For exam-ple, one resident said, “The day-shift nurses, someof them have a lot of experience and have actu-ally been working for 20 years and, you know,[have] been educating themselves the whole timeand getting better and learning from their experi-ence, and then others have been doing the samethings incorrectly for 20 years.” These themes werecentral in every interview. No systematic, observablerelationship appeared to exist between residents’views on nurses’ cooperativeness and competence

and residents’ sex, specialty, region, or hospitaltype.

Frequent, high-quality communication was thefirst of the two aspects of relational coordinationwe explored; it encompasses four of the seven dimen-sions.

Frequency. When asked, “How often do youtalk to nurses about your patients?” most residentsanswered “quite a bit” or “a lot.” Only five resi-

dents described communication with nurses as rare.But whether regular or rare, the frequency of com-munication was not perceived as an important issueby residents, one of whom said, “Whenever I needthem or I want to go over something with them,I find whoever it is. It’s not really an issue.” Thekey concern for residents seemed to be frequencyrelative to need. For example, one resident said thatshe didn’t have much interaction with nurses becauseof her limited need to exchange information withthem: “I tell them tests that I need, but I don’t givethem much information. They’re not making deci-sions about treatment or anything.”

Most residents sought or initiated contact withnurses to tell them which orders to fill or to giveinstructions related to patient care. But not all inter-actions between residents and nurses were aboutpatient care. Some were purely relational, like chit-chat or exchanges of niceties. Yet residents describedthis type of interaction as also having an instru-mental purpose. As one explained, such interactionskeep the nurses happy, and they will work harderfor you, and they’ll do a better job.”

Only two residents said that frequent communi-cation was important because of what the nurse hadto say. One said, “Nurses’ feedback is essential andimportant. Very, very important. Many times wemay miss out on things and patients’ condition[s]that the nurse may pick up and bring to our atten-tion. . . . Without a smooth communication andgood rapport it wouldn’t be possible for us to pickit up or treat that.” Working in the same locationand going on rounds together also contributed tothe frequency of residents’ and nurses’ interactions.

Timeliness. About half of the residents saidnurses gave them the information they needed in atimely way “most of the time,” but only three hadunqualified responses. Other respondents were more

tentative and—in general—presented one of twotypes of complaints:

‘I tell them tests that I need, but I don’t give them

much information. They’re not making decisions

about treatment or anything.’

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• Nurses did not give them enough information.• Nurses gave them too much trivial and unneces-

sary information.For example, one said, “Sometimes you wish theywould have told you, but you find out when you’rein with the patient.” Another said, “Some might tellyou way too much, and it’s like there is no process-

ing of it first . . . and others know exactly what tosay and only call you when they really need you.”In the residents’ view, whether they received theinformation they needed when they needed itdepended on the nurses’ ability to discern whatconstituted crucial information as well as on thenurses’ willingness to communicate with them—what residents referred to as “personality.” Forexample: “Some nurses don’t talk, some do. It’spersonality,” or, “It is part of their personality.They like to talk about the patients longer, they giveme more information than I care to have at a cer-tain time, or they want to talk longer than I might

have time for.”Accuracy. Whether residents trusted patient

information from nurses was strongly related totheir perceptions of the nurses’ competence. Onlyone resident stated outright that she didn’t trustnurses (“I look into whatever they tell me just toknow what’s the truth”); the majority of residentsgave qualified answers. For some, trust dependedon which nurse gave the information: “It totallydepends who it is. Some of them are very good, andthen some of them are not.”

Being trustworthy or “good” depended on thenurses’ ability to discern the important facts andmake a case with them. For example, “There aresome nurses who I felt I could trust more of whatthey say. You know, ‘This patient has been exhibit-ing X, Y, and Z . . . and I’m concerned about thesethings because of it.’ And this is a really sharp nursewho . . . in the past has been right on.” In contrast,other nurses “were not as good at reading patientsand reporting appropriate things. They would bereporting things that are minor and making it intoa bigger deal than it was. Or the reverse.” Anotherresident connected the nurses’ reporting withtheir education: “It depends on the academic level,

I mean, whether whatever information they giveis . . . right or not.”

Residents felt that nurses’ clinical judgment andability to distinguish crucial from trivial informa-tion was related to their experience and training.Said one, “I think it just depends on the nurse andtheir experience. Some of them are really good atthis kind of picking up something that doesn’t lookright or doesn’t smell right. Then some of them call

you every five minutes, so you never trust them. . . .Those types of nurses . . . start losing their credibil-ity.” Residents distinguished nurses’ presentation of facts about a patient from their assessment of thepatient. One said, “I trust factual things they tellme. . . . I trust less, you know, their opinions ortheir interpretations of what’s happening.” Anotheremphasized the need to “see for yourself and makeyour own judgment. . . . I don’t feel like that’s theirjob, to diagnose what’s wrong with the patient orwhat this acute situation is all about. I’m happy if they recognize one and just tell me.” Residents’ esti-mation of the accuracy of information provided by

nurses reflected their opinion of the nurses’ clinicaljudgment. This suggests that residents perceived vari-ation in nurses’ abilities and didn’t take competenceas a given.

Problem solving. Fifteen residents recalled situ-ations in which nurses helped them solve problems.Nine of these felt that nurses made a positive con-tribution to problem solving. One said, “They usuallyhave ideas [about] what they think is going on, andthey are good about being open about that so thatwe are sure that we don’t miss anything.” Two of six residents who gave qualified answers took issuewith the idea that nurses helped them solve prob-lems. Said one, “Many times I think it’s the re-verse. . . . They already have a plan of action in theirmind and would get very upset if you didn’t goalong with it.” Some residents noted that nurseswere more likely to help out in acute situations.One said, “Usually nurses help me solve problems,especially the better nurses, and always when acuteattention is required.”

Residents’ examples of how nurses helped themsolve problems underscored a division of laborbetween nurses and physicians in which nurses hadtheir own distinct responsibilities. In most cases, the

problems nurses solved pertained to communica-tion with the patient and the patient’s family or to

‘If there’s really an acute problem, the nurse is probably

going to be the one to catch it first. Then us. That’s why

you do have to take what they say seriously.’

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coordination with other hospital functions, as inthis example: “They’re very good about settingthings up and communicating with other depart-ments in the hospital and orchestrating transfers,[computed tomographic] scans, studies, anythingthat we need to get done.”

Residents were more positive about problemsolving than about other aspects of their commu-nication with nurses. Throughout the interviews,residents emphasized that successful communica-tion was contingent upon the nurse (competent orincompetent, able or unable to communicate impor-tant information), the situation (acute or nonacute),and the type of information communicated (factualor subjective). In terms of the quality of the commu-nication, only four of the 20 residents experiencedhigh-quality communication with nurses.

High-quality relationships was the second of the

two aspects of relational coordination we explored.If residents’ communication with nurses couldn’t becharacterized as “high quality,” what about theirrelationships? The other three dimensions of rela-tional coordination relate to this aspect.

Mutual respect. Residents’ descriptions of nurseswere indicative of whether they respected thenurses and of the qualities that garnered their respect.Generally, residents couldn’t say whether the nursesthey worked with had diplomas, associate’s degrees,or bachelor’s degrees, although they tended to sin-gle out as exceptional those with master’s degrees,such as advanced practice nurses (APNs). They

didn’t otherwise differentiate RNs from unlicensedassistive personnel or from LPNs, all of whom theycalled “nurses.” One resident noted the confusioninherent in the term: “Of course, there’s always thegood apples and the bad apples. There are some thatare wonderful, that I know are RNs, and there aresome that are LPNs or patient care technicians. . . .They don’t seem to be highly educated people. Ithink most of them have an associate’s degree ormaybe a bachelor’s degree.” Residents consideredthemselves “lucky” to work with exceptional nurses,and didn’t take them for granted: “In our case,we’re very lucky because our floor nurses, they’revery well trained. They know exactly how peopleneed to be taken care of. They know our routineprocedures and follow-up care that’s mandated,

and they’re very good at it.” Said another, “They’rewonderful. . . . We have really good nurses here, butI’ve heard horror stories from the other clinic onthe service.”

Residents understood that respect is “a two-waystreet”—“You don’t treat them like crap, and theyrespect the fact that you don’t treat them like that.”They also noticed that their colleagues didn’t alwaysshow proper respect for nurses. About half the res-idents said they felt respected by the nurses, espe-cially when the nurses were cooperative—when, inother words, nurses observed the medical hierarchy.One said, “I feel like they do respect me. They cometo me when they need to, and they don’t argue withmy decisions.”

But residents recognized that just as their opinionof nurses depended on which nurse they were work-ing with, so nurses’ respect for them was dependent

on the resident in question. “They usually have anidea of which residents to trust.” Residents told usthey had to prove their competence to the nursingstaff and that respect from nurses was not alwaysforthcoming. “You earn that respect. You don’texpect them to follow your orders as a first-weekintern. They obviously know a lot more of clinicalmedicine than you do.” Residents noted that somenurses even abused or hazed interns or new resi-dents. One said: “Just the way that they speak toyou. . . . Most of the time it’s very disrespectful. . . .It’s like an initiation type of thing. I think that theytry to see how far they can push you sometimes,

especially if you’re new.”Shared knowledge, in our study, pertains to how

well residents understood the interdependence of residents’ and nurses’ roles. Residents repeatedlycharacterized this interdependence as a pattern inwhich residents gave orders that nurses carried out:“We make the decisions; they follow the orders,essentially.” Most residents emphasized the one-wayflow of information, in which they communicatedtreatment plans and orders to nurses. Some resi-dents recognized that nurses did more than carryout orders, but their descriptions of nurses’ rolesdidn’t place nurses at the center of the care processor consider them full partners in care. One residentcharacterized nurses as handling “ancillary miscel-laneous aspects of health care” like obtaining “the

‘I trust factual things they tell me. . . .

I trust less, you know, their opinions or

their interpretation of what’s happening.’

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social work intervention or the special intervention.”Another described nurses as handmaidens: “Thenurses take the patients to the rooms and do bloodpressure and vitals. They pull the charts and get every-thing ready for us. They also do blood draws andthe tests we request. . . . They’re good about gettingeverything ready and getting us what we need.”

But some residents did recognize the importantrole nurses play in promoting patient safety: “Thenurses are seeing them more often. . . . So if there’sreally an acute problem, the nurse is probably goingto be the one to catch it first. Then us. That’s whyyou do have to take what they say seriously.”

Overall, the residents’ comments suggest a per-vasive tendency to treat nurses as if they don’t needto understand what’s happening with patientsbecause they merely follow orders. But four resi-dents said that communication with nurses shouldconsist of more than giving orders. They saw anadvantage in sharing with nurses their thoughts

or decision-making processes, either for theirown convenience or the patients’ benefit. One said,“I want to explain to the nurse what’s happen-ing to the patient and not just give orders andgo. . . . Because if she understands what’s going on. . . there’s a better chance the next time the patientdevelops something that she has some idea whatmight’ve been the case. And then she may notbother you. Also . . . she might be able to help thepatient more because she knows what’s going on. . . .And then, I mean, you know, all said and done,they have education too; so they should not betreated like they don’t know what’s going on.”These residents are aware that nurses who receivean explanation are more likely to follow ordersand “not bother” them, that if they demonstrate tonurses the accuracy and trustworthiness of theirtreatment decisions, they will gain the nurses’ coop-eration, and that, in some cases, nurses can makeuseful contributions to developing care plans. Thisminority in our sample recognized that buildingup or drawing upon nurses’ training can benefitpatients.

But even if sharing information with nurses canimprove trust and care, a key concern for residents

was time. For some, whether to spend time explain-ing treatment plans or decisions to nurses depended

on their impression of the nurses’ competence: “It’sindividual. If you have a very competent nurse whois very knowledgeable, who is professional enoughto understand the situation, she knows what I amdoing and carrying out, that’s fine. Then again, onan average, the nurses are competent, but then youhave those nurses who may not be up to the task,

[with] whom you will have to spend more time,you know, explaining what you are planning to dofor the patient.”

Sharing information with “less competent”nurses might require more time than a residentthinks is worthwhile. One resident who advocatedhaving extensive discussions with nurses aboutpathophysiology and treatment also noted that heworked with nine APNs “and all of them have atleast a master’s degree. They have all worked withneurosurgeons . . . anywhere from one to 20 years.A lot of them have taken medical school classes inneuroanatomy, and a lot of them have at least par-

tial and some extensive critical care training.” Heexplained that these APNs “play a huge role in help-ing us comanage our routine floor issues, . . . and area good, good, good bridge between us and the nurs-ing staff while we’re in the operating room.” Theeducation and qualifications of the nursing staff may underlie this resident’s views about the value of discussing patient care with nurses. This residentwas the only one in the sample who described ahigh-quality relationship with nurses.

Shared goals. For the most part, residents didn’tfeel that nurses shared their goals. In particular,they felt frustrated that they lacked the power tocompel nurses to cooperate. One emphasized theshift-worker mentality of some nurses, observingthat some are “intelligent” and “would give yousuggestions themselves,” but others “just are therefor the hours, and they don’t really, you know, carewhat the patient gets or what, you know, what hap-pens to the patient. They’re just doing their hoursand doing their duty and getting out of there.”Another noted, “Sometimes they get kinda surlyand roll their eyes at us . . . they’re usually prettygood, unless it’s 4:30. They like to leave on time.They get a little testy when it’s near the end of the

shift and you need something from them. . . . Youbetter only request tests that you really need when

‘Some might tell you way too much, and it’s like there is

no processing of it first . . . and others know exactly what

to say and only call you when they really need you.’

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it’s 4:30.” These examples point to the potentialdifferences between residents and nurses in theirorientation to work, as well as to residents’ inabil-ity to compel nurses to pass information on toother nurses or to complete tasks, even when theseare in the best interests of patients.

Many comments concerned time, and residentswere aware that sometimes their priorities were atodds with those of nurses. Residents, for example,spoke of nurses “abusing” residents by off-loadingtasks or failing to alert residents of new admis-sions. A resident explained, “Your time is valuable,and why should you be here till eight o’clock atnight? . . . You know, when their shift ends, they’reout the door. And they didn’t seem to value yourtime.” Another resident noted that nurses mightplace their priorities ahead of residents’ and “beworking on a trivial matter when this important

issue has to be addressed.” A surgical resident com-plained, “They’ll page you 10 times for a Tylenolorder and nothing for a temperature or . . . some-thing else that needs to be communicated. And it’sall written out, too, in the orders. . . . I don’t wantto be running up there if the patient’s like, ‘Oh,I’m just in pain.’” These statements point to thefact that nurses and residents have some incongru-ent goals.

Residents didn’t feel that nurses valued residents’time or made an effort to minimize requests—particularly for things that could have waited orshould have been automatic—when residents were

exhausted or overburdened. But residents’ exam-ples also illustrate the differences in how residentsand nurses value priorities related to patient com-fort. Although pain control and food were low onthe residents’ lists of priorities or reasons for pagesor emergency floor visits, these issues are veryimportant to patients and nurses.

DISCUSSIONThe interviews point to a number of positive aspectsof communication and productive relationshipsbetween residents and nurses. Residents prized nurseswho were knowledgeable and collaborative, focus-ing specifically on nurses’

• depth of understanding of patients’ health andsocial issues.

• ability to anticipate and respond to patients’medical needs.

• partnership in identifying problems and coursesof treatment.

• help in getting work done.Although most of the 20 residents interviewed saidthat they’d had positive interactions with nursesand valued them, only one resident had frequent,high-quality communication and high-quality rela-tionships with nurses. Are high levels of relationalcoordination among nurses and physicians theexception rather than the rule?

Our findings also point to the critical importanceof physicians’ and nurses’ willingness to cooperateand to their ability to shape positive communica-tion and relationships. Residents’ descriptions of their attitude toward nurses are consistent with nurs-es’ frequent complaints that physicians tend to see

nurses as implements or tools16

and to have a “Wedecide; you carry it out” approach to collaboration.17

Although residents’ medical training may be partlyto blame for their disparaging view of nurses, theircomments suggest that obstacles to nurse–physiciancollaboration are related to

• residents’ and nurses’ styles of communicationand availability to communicate.

• the lack of standardization in nursing education.• residents and nurses not sharing goals or under-

standing each other’s roles.These findings raise questions about the ability of nurses to overcome obstacles to good communi-

cation and relationships on their own. Althoughan individual nurse may be able to handle herself professionally, her efforts may be undermined byother nurses’ behavior and by the nursing profes-sion’s shortcomings. Residents judged nurses not juston prior interactions with them but on their expe-riences with other nurses. The oft-repeated answer“it depends” and the references to “bad apples”and “horror stories” point to negative experiencesthat made residents wary of trusting nurses or of expecting their cooperation.

Our study’s limitations include its qualitativedesign and small sample size. Our findings can’ttherefore be generalized to other physicians or resi-dents. At the same time, the internal consistencyamong our interviews warrants some attention,

‘You earn that respect. You don’t expect them to follow

your orders as a first-week intern. They obviously know

a lot more of clinical medicine than you do.’

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given the diversity of residents’ specialties and hos-pital and clinical settings.

Residents’ general impressions of nurses under-scored the variability in the education level anddemeanor of nurses and fell short of an endorse-ment of the average nurse’s potential role in care—a role that most nurses would argue should extendbeyond following orders and arranging for ancil-lary services. At the same time, by underestimating

or overlooking nurses’ contributions to patientcare, residents could consider breakdowns in com-munication and relationship as mere annoyances;as long as nurses carried out their orders, there wasno threat to patient care. Two authors, includingone of us (DBW), have pointed out that even highlyeducated nurses have failed to articulate the criticalrole nurses play, to the detriment of nurses’ statusin hospitals and patient care.16, 18 The ubiquitousconfusion about nurses’ roles that also emerged inthese interviews identifies a far-reaching problemfor nurses in explaining what they actually do andin making their contributions visible.

Residents were often unaware of the educationof the nurses with whom they worked—unless theyhad master’s degrees, which overtly changed anurse’s role. Some residents couldn’t differentiatethe unlicensed assistive personnel in hospitals fromLPNs or RNs, although they differentiated the APNsand described them as “excellent.”

Nurses’ interest in having an egalitarian relation-ship with physicians seems at odds with nurses’ sta-tus as the least educated group of licensed healthcare professionals in the country. While other pro-fessions such as pharmacy, physical therapy, andoccupational therapy are moving toward requiringdoctoral degrees for entry-level jobs, nurses stillhave primarily associate’s degrees, and debate aboutwhether to mandate the baccalaureate (specifically,the bachelor of science in nursing [BSN]) for entry-level nursing or for maintaining licensure is ongo-ing. Our finding that residents regarded even nurseswith baccalaureates as “not highly educated” raisesquestions about whether an associate’s degree or aBSN would make a more egalitarian collaborationpossible—or whether such a collaboration wouldrequire nurses with a master’s-level or even highereducation. At the same time, residents’ perceptions

that better-educated nurses are better communica-tors as well as more competent nurses, seem consis-

tent with the observed relationship between greaterproportions of nurses with BSNs and lower patientmortality rates.19-22 It may be that physicians havecloser relationships and communicate better withnurses in hospitals that favor higher educationalpreparation for nurses, and that the resultant bene-fit to relational coordination promotes better patientoutcomes.

Our findings highlight some of the problems

between nurses and physicians that need to be solvedbefore relational coordination, let alone collabora-tion, can occur with any consistency. Though qual-itative, these findings are further evidence of the riftbetween nurses and physicians over the importanceof collaboration. Although residents’ concerns aboutnurses’ cooperativeness and competence might beseen as professional posturing, still they representan enduring critique of the nursing profession, par-ticularly as it relates to professionalism and standard-ized education. Whereas some physicians grudginglycollaborate with nurses, surely some nurses—thougheager for collaboration—actively withhold the com-

munication and cooperation it requires. To the extentthat nurses play a role in perpetuating undesirablenurse–physician interactions, perhaps the nursingprofession has the power to change the rules of thenurse–physician game.M

Dana B. Weinberg is an assistant professor in the sociologydepartment at Queens College in Flushing, NY, and director

of interdisciplinary research in the Office of the UniversityDean of Health and Human Services at the City University of New York (CUNY). Dianne Cooney Miner is dean of theWegmans School of Nursing at St. John Fisher College inRochester, NY. At the time this article was written, Leetal Rivlin was a graduate student in the Applied Social ResearchProgram at Queens College, where she is currently anadjunct lecturer in the sociology department. Contact author:[email protected]. The authors of this articlehave no significant ties, financial or otherwise, to any com- pany that might have an interest in the publication of thiseducational activity.

This project was supported by grants from the Professional Staff Congress–CUNY and by the Office of the UniversityDean of Health and Human Services at CUNY. The authors gratefully acknowledge the graduate and undergraduateresearch assistants who contributed to this project: Shanit

Cohen, Chandra Holmes-Brailsford, and Aimee Pelletier. Wethank Andrew Greenberg of the Committee of Interns and

‘They get a little testy when it’s near the end of

the shift and you need something . . .’

For more than 29 additional continuing nursingeducation articles related to the topic of profes-sional issues, go to www.nursingcenter.com/ce.

7/30/2019 ward 4 pdf



Residents for his assistance. We would also like to thankRobin Newhouse, Mary Blegen, and Diane Boyle for theircomments on an earlier draft of the paper. Any opinions, mis-takes, or errors are entirely our own.

REFERENCES

1. Stein LI. The doctor–nurse game. Arch Gen Psychiatry1967;16(6):699-703.

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3. Kramer M, Schmalenberg C. Securing “good” nurse–physicianrelationships. Nurs Manage 2003;34(7):34-8.

4. Baggs JG, et al. Association between nurse–physician col-laboration and patient outcomes in three intensive careunits. Crit Care Med 1999;27(9):1991-8.

5. Knaus WA, et al. An evaluation of outcome from intensivecare in major medical centers. Ann Intern Med 1986;104(3):410-8.

6. Manojlovich M, DeCicco B. Healthy work environments,nurse–physician communication, and patients’ outcomes.Am J Crit Care 2007;16(6):536-43.

7. Miller PA. Nurse–physician collaboration in an intensive

care unit. Am J Crit Care 2001;10(5):341-50.8. Schmalenberg C, et al. Excellence through evidence: secur-

ing collegial/collaborative nurse–physician relationships,part 2. J Nurs Adm 2005;35(11):507-14.

9. Kohn LT, et al., editors. To err is human: building a saferhealth system. Washington, DC: National Academy Press;2000.

10. Page A, editor. Keeping patients safe: transforming the workenvironment of nurses. Washington, DC: National AcademiesPress; 2004.

11. Tammelleo AD. Nurses failed to ‘advocate’ for their patient.Case on point: Rowe v. Sisters of Pallottine MissionarySociety, 2001 WL 1585453 s.e.2d -WV. Nurs Law ReganRep 2002;42(8):2.

12. Gittell JH. Supervisory span, relational coordination, andflight departure performance: a reassessment of postbureau-

cracy theory. Organization Science 2001;12(4):468-83.13. Gittell JH. Coordinating mechanisms in care provider

groups: relational coordination as a mediator and inputuncertainty as a moderator of performance effects. ManageSci 2002;48(11):1408-26.

14. Gittell JH, et al. Impact of relational coordination on jobsatisfaction and quality outcomes: a study of nursinghomes. Human Resource Management Journal 2008;18(2):154-70.

15. Weinberg DB, et al. Coordination between formal providersand informal caregivers. Health Care Manage Rev 2007;32(2):140-9.

16. Gordon S. Nursing against the odds: how health care cost cutting, media stereotypes, and medical hubris underminenurses and patient care. Ithaca, NY: Cornell UniversityPress; 2005.

17. Cott C. “We decide, you carry it out”: a social networkanalysis of multidisciplinary long-term care teams. Soc SciMed 1997;45(9):1411-21.

18. Weinberg DB. When little things are big things: the impor-tance of relationships for nurses’ professional practice. In:Nelson S, Gordon S, editors. The complexities of care:nursing reconsidered . Ithaca, NY: Cornell University Press;2006.

19. Aiken LH, et al. Educational levels of hospital nurses andsurgical patient mortality. JAMA 2003;290(12):1617-23.

20. Friese CR, et al. Hospital nurse practice environments andoutcomes for surgical oncology patients. Health Serv Res2008;43(4):1145-63.

21. Estabrooks CA, et al. The impact of hospital nursing char-acteristics on 30-day mortality. Nurs Res 2005;54(2):74-84.

22. Tourangeau AE, et al. Impact of hospital nursing care on30-day mortality for acute medical patients. J Adv Nurs2007;57(1):32-44.

GENERAL PURPOSE: To present registered professionalnurses with the details of a study done to examinemedical residents’ perspectives on the quality of theircommunication and relationships with nurses.

LEARNING OBJECTIVES: After reading this article and takingthe test on the next page, you will be able to• summarize relevant background information and the

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• outline the findings of the authors’ study of medicalresidents’ perspectives on working with nurses.

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