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R E V I E W
Nurse–physician communication – An integrated review
Tit-Chai Tan RN, MSc, Nurse Clinician1 | Huaqiong Zhou RN, BSc, MCN, PhD Candidate,
Research Officer, Lecturer2 | Michelle Kelly PhD, MN, BSc, Associate Professor, Director:
Community of Practice2
1Tan Tock Seng Hospital, Singapore,
Singapore
2School of Nursing, Midwifery and
Paramedicine, Curtin University, Perth, WA,
Australia
Correspondence
Tit-Chai Tan, Tan Tock Seng Hospital,
Singapore, Singapore.
Email: [email protected]
Aim and objective: To present a comprehensive review of current evidence on the
factors which impact on nurse–physician communication and interventions devel-
oped to improve nurse–physician communication.
Background: The challenges in nurse–physician communication persist since the term
‘nurse-doctor game’ was first used in 1967, leading to poor patient outcomes such as
treatment delays and potential patient harm. Inconsistent evidence was found on the fac-
tors and interventions which foster or impair effective nurse–physician communication.
Design: An integrative review was conducted following a five-stage process: prob-
lem identification, literature search, data evaluation, data analysis and presentation.
Methods: Five electronic databases were searched from 2005 to April 2016 using
key search terms: “improve*,” “nurse-physician,” “nurse,” “physician” and “communi-
cation” in five electronic databases including the Cumulative Index to Nursing and
Allied Health Literature (CINAHL), MEDLINE, PubMed, Science Direct and Scopus.
Results: A total of 22 studies were included in the review. Four themes emerged
from the data synthesis, namely communication styles; factors that facilitate nurse–
physician communication; barriers to effective nurse–physician communication; and
interventions to improve nurse–physician communication.
Conclusion: This integrative review suggests that nurse–physician communication still
remains ineffective. Current interventions only address information needs of nurses
and physicians in limited situations and specific settings but cannot adequately
address the interprofessional communication skills that are lacking in practice. The dis-
parate views of nurses and physicians on communication due to differing training
backgrounds confound the effectiveness of current interventions or strategies.
Relevance to clinical practice: Cross-training and interprofessional educational from
undergraduate to postgraduate programmes will better align the training of nurses
and physicians to communicate effectively. Further research is needed to determine
the feasibility and generalisability of interventions, such as localising physicians and
using communication tools, to improve nurse–physician communication. Organisa-
tional and cultural changes are needed to overcome ingrained practices impeding
nurse–physician communication.
K E Y W O R D S
communication, improving, integrative review, nurse–physician communication
Accepted: 22 March 2017
DOI: 10.1111/jocn.13832
3974 | © 2017 John Wiley & Sons Ltd wileyonlinelibrary.com/journal/jocn J Clin Nurs. 2017;26:3974–3989.
1 | INTRODUCTION
The demand for multidisciplinary healthcare delivery has increased
over the last decade to address patients’ complex health needs (Pala-
nisamy & Verville, 2015). To ensure safety and quality of patient
care, it is crucial that health providers communicate effectively
within multidisciplinary teams and with patients and their families
(Palanisamy & Verville, 2015; Quan et al., 2013).
Nurses and physicians constitute the two main groups of
healthcare professions providing direct inpatient care (Seago,
2008). As it was first described as the ‘doctor-nurse game’ in
1967 (Stein, 1968), the challenges in communicating effectively
between health professionals persist today (O’Daniel & Rosenstein,
2008). Stein (1968) described the inherent complex and different
ways in which nurses and physicians engage one another. Such
complex and ineffective communication between nurses and physi-
cians has been linked with inadvertent patient outcomes, specifi-
cally prolonged patient stays, and patient harm from treatment
delays and errors (Ellison, 2015; O’Daniel & Rosenstein, 2008;
Seago, 2008). Errors arising from miscommunication among health-
care professionals have been identified as the second highest con-
tributor to sentinel events in the United States, causing an
estimated 210,000–440,000 patient deaths in 2013 (Ellison, 2015).
In addition to patient harm, poor communication also generates
feelings of diminished value, decreased job dissatisfaction and
increased attrition among the nursing workforce (O’Daniel &
Rosenstein, 2008; Seago, 2008).
There are a number of contributing factors hindering nurse–
physician communication relating to the innate characteristics of
nurses and physicians and how they tend to communicate, and the
practice environments. The variability of these confounding factors
across different practice environments has resulted in interventions
tested with inconsistent results.
The factors contributing to ineffective nurse–physician communi-
cation include inherent ways that nurses and physicians communi-
cate (Rosenthal, 2013), their understanding of others’ respective
roles (O’Daniel & Rosenstein, 2008), disruptive practice environ-
ments (O’Daniel & Rosenstein, 2008; Rosenthal, 2013) and physician
dominance (Bujak & Bartholomew, 2011). Rosenthal (2013) reported
that physicians communicate in a more succinct style, as opposed to
a more descriptive approach used by nurses (Rosenthal, 2013). In
addition, stressful work environments due to staff shortages and fre-
quent interruptions have also contributed to breakdowns in nurse–
physician communication (Bujak & Bartholomew, 2011; O’Daniel &
Rosenstein, 2008). Physicians’ dominance in decision-making within
existing organisational structures have also made it difficult for
nurses to ‘speak up’ with physicians (Bujak & Bartholomew, 2011).
In contrast, supportive practice environments, which empowered
nurse participation in hospital operations, quality matters, and pro-
moted collegial nurse–physician relations, improved nurses’ percep-
tion of nurse–physician communication and their job satisfaction
(Manojlovich, 2005; Manojlovich & DeCicco, 2007).
Interventions have been developed to improve nurse–physician
communication; however, the results have been inconsistent. One
multisite study across five Canadian hospitals by Conn, Reeves,
Dainty, Kenaszchuk, and Zwarenstein (2012) found that localising
physicians in individual units increased their availability and enabled
better multidisciplinary communication. In contrast, an initiative to
localise a nurse practitioner to a specific area (Vazirani, Hays, Sha-
piro, & Cowan, 2005) yielded mixed results as physicians in the unit
reported improved communication and collaboration with the nurses,
but nurses did not report the same benefit. Vazirani et al. (2005)
attributed difficulties in coordinating nurse–physician schedules and
multidisciplinary rounds that often coincided with the nurses’ change
of shifts as a cause of the mixed results. Similarly, a pilot study by
Burns (2011) to implement nurse–physician collaborative rounds was
also not sustainable due to heavy nursing workloads and difficulties
in coordinating nursing activities and schedules with the timings of
physicians’ rounds.
Postulating that nurses communicated narratively and physicians
(hospitalists in this context) communicated concisely, Rosenthal
(2013) introduced the Situation–Background–Assessment–Recom-
mendation (SBAR) framework across a 450-bed medical centre in
the USA as a tool to bridge the differences in nurse–physician com-
munication styles. Rosenthal (2013) found no statistically significant
improvement in nurse–physician communication. However, the use
of SBAR in general wards statistically significantly improved nurse–
physician communication, reduced unplanned intensive care unit
(ICU) admissions and unexpected patient deaths (De Meester, Ver-
spuy, Monsieurs, & Van Bogaert, 2013). Correspondingly, positive
results were also reported in a study adopting a different approach
(training medical residents with nurses – on effective communication)
in a specific clinical unit (McCaffrey et al., 2010). Studies in other
settings (medical and surgical wards) investigated the impact of two
different models of patient care (shared-care nursing versus patient
allocation model) on nurse–physician communication (Fernandez,
Tran, Johnson, & Jones, 2010). Implementing either of the two
What does this paper contribute to the wider
global clinical community?
• Effective nurse–physician communication remains a chal- lenge due to discipline-specific or workplace-embedded
cultures and practices.
• Current interventions only address information needs of nurses and physicians in limited situations and specific
settings but cannot adequately address the interprofes-
sional communication skills that are lacking in practice.
• For meaningful change, interprofessional education pro- grammes around effective communication strategies are
highly recommended to be commenced at the under-
graduate level and continue into practice.
TAN ET AL. | 3975
models of care had no significant impact on nurse–physician commu-
nication.
Given the inconsistent research findings related to nurse–physician
communication, this paper provides a comprehensive review of current
evidence about this key element of healthcare practice. The objectives
of this paper were to identify factors impacting nurse–physician com-
munication and to evaluate the effectiveness of interventions devel-
oped to improve nurse–physician communication. Effective
communication remains a critical element in improving coordination of
patient care to reduce treatment delays and errors, as well as increas-
ing job satisfaction and retention among the nursing workforce.
2 | METHOD
An integrative review was conducted to address the aim of the
study and followed the five-stage process developed by Whittemore
and Knafl (2005), namely problem identification, literature search,
data evaluation, data analysis and presentation. The integrative
review is a research method that analyses, critiques, and evaluates
the evidence. This method also allows combining a variety of
research designs such as quantitative and qualitative studies and is
not restricted to primary empirical studies (Castro, Kellison, Boyd, &
Kopak, 2010).
2.1 | Literature search strategy
Five electronic databases were searched including the Cumulative
Index to Nursing and Allied Health Literature (CINAHL), MEDLINE,
PubMed, Science Direct and Scopus from 2005 to April 2016. The
key search terms and Boolean operators used were as follows: “im-
prove*” AND “nurse-physician” AND “nurse” AND “physician” AND
“communication” in all fields of the databases. Hand searches of the
reference lists of potential papers for inclusion were also performed.
Additional hand searches were undertaken in the Journal of Interpro-
fessional Care and the Journal of Nursing Administration, as these two
journals have been known to publish studies related to the subject
of nurse–physician communication.
2.2 | Inclusion/exclusion criteria
The included studies were from peer-reviewed journals with full-text
access published in English. The studies also had to have clear evi-
dence of research methodology. Studies that focused on nurse–
physician communication regardless of healthcare setting were
included. In this integrative review, ‘physicians’ were defined as qual-
ified professionals trained and practicing medicine, irrespective of
their areas of specialisation and rank, from junior positions of House
Officers to Senior Consultants (Harris & Nagy, 2009).
Studies that have been excluded were those on nursing or medi-
cal students, as they have not fully progressed into practice. Also
excluded were studies that focused on nurses’ or physicians’ commu-
nications with other healthcare professions or personnel, that is
pharmacists, physiotherapists, occupational therapists or medical
social workers. Studies on nurse–physician relations and collabora-
tions without components of nurse–physician communication were
also excluded. Poster presentations, conference proceedings, editori-
als, opinions or discussions have also been excluded due to their
content brevity, variability and absence of peer-review process.
2.3 | Literature search results
A total of 1,480 references were initially identified through the com-
bined electronic database searches. After reviewing the titles and
abstracts for relevance to ‘nurse–physician communication’, 1,396 ref-
erences were excluded. The remaining 84 references were then con-
solidated into a referencing management programme, EndNote,
whereby 24 duplicated titles were removed. Full texts of the remain-
ing 60 references were retrieved and assessed against the inclusion/
exclusion criteria. Forty-two further references were excluded at this
point. Of these, thirty studies focused on either nurse–physician rela-
tionships or nurse–physician collaborations, six references were part
of conference proceedings or poster presentations and six references
were quality improvement projects with unclear research methodolo-
gies. Four additional studies that met the inclusion criteria of this
review were found after a hand search on the remaining 18 articles,
yielding a final total of 22 studies in this integrative review. The pro-
cess of selection for inclusion of studies is also presented in Figure 1.
2.4 | Data evaluation
The primary and secondary authors independently appraised the
quality of the 22 included studies. The appraisal included: identifying
clear study aims and objectives, ensuring that the study designs
were adequately described, clarity of results, and the discussions
that did not draw conclusions beyond the limits of the studies (Whit-
temore & Knafl, 2005). No further studies were excluded on the
basis of the quality of the research.
2.5 | Data analysis
This review adopted a qualitative analysis approach whereby the
two authors independently compared extracted data item by item
for related concepts which were then grouped and coded (Whitte-
more & Knafl, 2005). These coded data were then further corrobo-
rated, classified and summarised to identify themes to derive overall
findings and conclusions from the primary data (Whittemore & Knafl,
2005). These themes formed the basis for systematically organising
and comparing the primary data and are described below.
3 | RESULTS
3.1 | Characteristics of the included studies
The characteristics of the 22 published studies included in this inte-
grative review are presented in Table 1. The extracted data were
3976 | TAN ET AL.
classified according to first author, year, country of origin, topic,
method, study design, data collection method, study setting, study
sample and main findings. Fifteen of the included studies were con-
ducted in the United States, two in Australia, two in Belgium, and
one each in Canada, Iran and Japan.
The research designs employed in these 22 studies included
quantitative studies (n = 14), qualitative studies (n = 6), and mixed-
methods studies (n = 2). The majority of the included quantitative
studies (79%) sourced data through questionnaires. Six qualitative
studies collected data via individual interviews (n = 3), focus groups
(n = 2) and observation (n = 1). The two mixed-methods studies
used a combination of survey and interviews.
Fifteen of the studies were carried out in tertiary or general hos-
pitals; three in paediatric hospitals; and four in nonhospital settings.
Twelve studies involved nurses only, while 10 studies included both
nurses and physicians. The sample sizes across studies ranged from
7 to 378 participants.
Four main themes that emerged after data analysis were commu-
nication styles; factors that facilitate nurse–physician communication;
barriers to effective nurse–physician communication; and interven-
tions to improve nurse–physician communication. Subthemes identi-
fied from the data analysis are presented under each of the main
themes.
3.2 | Communication styles
Six studies of this integrated review identified a variety of communi-
cation styles used by nurses and physicians (Manojlovich, 2005;
McMullan, Parush, & Momtahan, 2015; Morinaga, Ohtsubo, Yamau-
chi, & Shimada, 2008; Robinson, Gorman, Slimmer, & Yudkowsky,
CINAHL 67
Medline 10
Science Direct 1,059
Scopus 289
PubMed 55
Search produced 1,480 references
84 references for further screening
Eliminated after review of titles and abstracts (n = 1,396)
Possible sample: 60 references for
inclusion Eliminated based on inclusion and
exclusion criteria (n = 42): Studies on nurse-physician
relationships and collaborations (n = 30) Conference proceedings and poster
presentations (n = 6) Quality improvement projects (n = 6)
Duplicated references eliminated from EndNote Library (n = 24)
18 references for inclusion
Final inclusion: 22 references
Hand search of selected references and two journals, resulting in further 4
references included
Computerised search of all fields: “improv*” AND “nurse–physician” AND “nurse” AND “physician”
AND “communication” Limits:
2005 to 2015; full text available; and, English
FIGURE 1 A flow chart of the process of selection of studies
TAN ET AL. | 3977
T A B L E
1 S u m m ar y o f in cl u d e d st u d ie s o n n u rs e – p h y si ci an
co m m u n ic at io n
1 st
A u th o r/
Y e ar /C
o u n tr y o f
O ri g in
T o p ic
M e th o d /S tu d y D e si g n /
D at a co
lle ct io n M e th o d
S tu d y se tt in g
S tu d y sa m p le
M ai n fi n d in g s
A st o n /2
0 0 5 /
A u st ra lia
T h e e xp
e ri e n ce s an
d
p e rc e p ti o n s o f n u rs e s
an d p h y si ci an
s ab
o u t
su rg ic al
m o rn in g
m e e ti n g s
Q u al it at iv e —
F ac e -t o -
fa ce
in te rv ie w
In fa n t an
d to d d le r
su rg ic al
w ar d o f a
p ae
d ia tr ic
h o sp it al
P h y si ci an
s: 1 0
N u rs e s:
9
S u rg ic al
m o rn in g m e e ti n g s:
� Im
p ro v e d n u rs e – p h y si ci an
co m m u n ic at io n
� P ro v id e d o p p o rt u n it y to
cl ar if y :
� P at ie n t is su e s
� P la n o f ca re
� T re at m e n t g o al s
� P ro v id e d b as e lin
e re fe re n ce
p o in t fo r d is cu
ss in g tr e at m e n t p la n s
� C o u ld
n o t im
p ro v e n u rs e – p h y si ci an
co m m u n ic at io n w h e re
p h y si ci an
s w e re
u n w ill in g to
lis te n to
n u rs e s
B ro w n /2
0 1 0 /
U S A
T o im
p ro v in g cl in ic al
co m m u n ic at io n
b e tw
e e n h o m e -c ar e
n u rs e s an
d p h y si ci an
s
th ro u g h im
p ro v in g
n u rs e s’ co
m p e te n cy
to
co m m u n ic at e
d e p re ss io n -r e la te d
in fo rm
at io n w it h
p h y si ci an
s
Q u an
ti ta ti v e —
S in g le
g ro u p p re – p o st
e xp
e ri m e n ta l d e si g n —
S u rv e y
T w o n o n p ro fi t,
M e d ic ar e -c e rt if ie d
h o m e -c ar e ag e n ci e s
N u rs e s:
2 8
T ra in in g n u rs e s to
co m m u n ic at e d e p re ss io n -r e la te d in fo rm
at io n :
� In cr e as e d n u rs e s’ ab
ili ty
to p ro v id e p h y si ci an
s w it h co
m p le te
an d o rg an
-
is e d ca se
p re se n ta ti o n s (p
= .0 0 0 3 )
� In cr e as e d n u rs e s’ co
n fi d e n ce
to co
m m u n ic at e d e p re ss io n -r e la te d in fo r-
m at io n to
p h y si ci an
s (p
= .0 0 0 5 )
B y ro n /2
0 1 2 /
B e lg iu m
T o e xp
lo re
co m m u n ic at io n
b e tw
e e n n u rs e s an
d
p h y si ci an
s in
p ra ct ic e
Q u al it at iv e —
G ro u n d e d
T h e o ry
ap p ro ac h —
S e m is tr u ct u re d fa ce -t o -
fa ce
in te rv ie w s
9 h o sp it al s
N u rs e s:
2 1
N u rs e – p h y si ci an
co m m u n ic at io n is
e ff e ct iv e w h e n :
� P h y si ci an
s:
� H av e p o si ti v e at ti tu d e s
� A re
o p e n an
d re sp e ct fu l
� N u rs e s:
� H av e co
lla b o ra ti v e at ti tu d e s
� A re
re sp e ct fu l an
d d ip lo m at ic , an
d as se rt iv e
� C o m m u n ic at io n is co
n su lt at iv e
� In fo rm
at io n an
d o p in io n s ar e e xc h an
g e d
T w o -w
ay n u rs e – p h y si ci an
co m m u n ic at io n m ad
e n u rs e s fe e l p o si ti v e
D e M e e st e r/
2 0 1 3 /B
e lg iu m
E ff e ct
o f S it u at io n –
B ac k g ro u n d –
A ss e ss m e n t–
R e co
m m e n d at io n
(S B A R ) o n th e in ci d e n ce
o f se ri o u s ad
v e rs e
e v e n ts
in h o sp it al
w ar d s
Q u an
ti ta ti v e —
p re – p o st
— S u rv e y
A 5 7 3 -b e d u n iv e rs it y
h o sp it al
N u rs e s:
P re -i n te rv e n ti o n :
2 4 5
P o st in te rv e n ti o n :
1 8 0
S B A R :
� In cr e as e d n u rs e – p h y si ci an
co m m u n ic at io n w it h S B A R d o cu
m e n te d in
p at ie n t re co
rd s fr o m
3 2 %
to 5 6 %
� In cr e as e d n u rs e s’ co
m m u n ic at io n w it h p h y si ci an
s fr o m
a sc al e o f 6 2 .9 –
6 9 .3
(C o n ti n u e s)
3978 | TAN ET AL.
T A B L E
1 (C o n ti n u e d )
1 st
A u th o r/
Y e ar /C
o u n tr y o f
O ri g in
T o p ic
M e th o d /S tu d y D e si g n /
D at a co
lle ct io n M e th o d
S tu d y se tt in g
S tu d y sa m p le
M ai n fi n d in g s
F e rn an
d e z/
2 0 1 0 /A
u st ra lia
C o m p ar e th e e ff e ct
o f
sh ar e d -c ar e n u rs in g
(S C N ) m o d e l to
e xi st in g
p at ie n t al lo ca ti o n (P A )
m o d e l o n n u rs e s’
p e rc e p ti o n o f
in te rd is ci p lin
ar y
co m m u n ic at io n
E xp
e ri m e n ta l—
In te rv e n ti o n an
d co
n tr o l
g ro u p s—
P re – p o st —
S u rv e y
F o u r m e d ic al
an d fo u r
su rg ic al
w ar d s at
a 5 0 0 -
b e d te ac h in g h o sp it al
N u rs e s in
in te rv e n ti o n w ar d s
— S C N
m o d e l: 4 0
N u rs e s in
co n tr o l
w ar d s—
P A
m o d e l:
1 4
T h e S C N
m o d e l o f n u rs in g ca re
m ad
e n o si g n if ic an
t d if fe re n ce
in n u rs e –
p h y si ci an
co m m u n ic at io n
M an
o jlo
v ic h /
2 0 0 5 /U
S A
R e la ti o n sh ip
o f n u rs e –
p h y si ci an
co m m u n ic at io n an
d
n u rs e s’ jo b sa ti sf ac ti o n
an d h o sp it al
p ra ct ic e
e n v ir o n m e n t
N o n e xp
e ri m e n ta l—
S u rv e y
N u rs e s fr o m
th e
M ic h ig an
N u rs e s
A ss o ci at io n
N u rs e s:
3 1 6
N o si g n if ic an
t re la ti o n sh ip
b e tw
e e n n u rs in g d e m o g ra p h ic
ch ar ac te ri st ic s
an d n u rs e – p h y si ci an
co m m u n ic at io n
N u rs e s’ p e rc e p ti o n o f e ff e ct iv e n u rs e – p h y si ci an
co m m u n ic at io n
si g n if ic an
tl y af fe ct s n u rs e s’ jo b sa ti sf ac ti o n
M cM
u lla n /
2 0 1 5 /C
an ad
a
P at te rn s o f
co m m u n ic at io n
b e tw
e e n n u rs e s an
d
p h y si ci an
s d u ri n g
h an
d o ff s
Q u al it at iv e —
O b se rv at io n al
P o st an
ae st h e si a ca re
u n it (P A C U ) o f a la rg e
te ac h in g h o sp it al
9 4 2 o b se rv e d
u tt e ra n ce s d u ri n g
4 0 h an
d o ff s
b e tw
e e n at
le as t
o n e P A C U
n u rs e
an d o n e
A n ae
st h e si o lo g is t
N u rs e s le d co
m m u n ic at io n s d u ri n g h an
d o ff s an
d as k e d th e m o st
q u e st io n s
o n p at ie n t st at u s (7 4 .4 %
o f o b se rv at io n s)
an d ca re
p la n (7 8 .6 %
o f
o b se rv at io n s)
an d th e an
ae st h e si o lo g is ts
co rr e sp o n d in g ly
h ad
m o re
re p lie s
M o ri n ag a/ 2 0 0 6 /
Ja p an
T y p e s o f p h y si ci an
s th at
n u rs e s fi n d e as y o r
d if fi cu
lt to
co m m u n ic at e w it h
M ix e d m e th o d s —
Q u al it at iv e —
S e m is tr u ct u re d fa ce -t o -
fa ce
in te rv ie w s—
Q u an
ti ta ti v e
S u rv e y
3 0 0 -b e d an
d 6 2 3 -b e d
h o sp it al s
N u rs e s:
S e m is tr u ct u re d
in te rv ie w s:
1 5
S u rv e y : 1 2 6
N u rs e – p h y si ci an
co m m u n ic at io n is
d if fi cu
lt w h e n
� P h y si ci an
s ar e u n w ill in g to
co m m u n ic at e w it h n u rs e s;
� P h y si ci an
s ar e b u sy , m o o d y , ir ri ta te d , q u ic k -t e m p e re d an
d d is lik e n u rs e s
� N u rs e s n e e d to
co m m u n ic at e w it h p h y si ci an
s o v e r p h o n e
N u rs e – p h y si ci an
co m m u n ic at io n is
e as ie r w h e n :
� P h y si ci an
s e xp
la in
th e ir o rd e rs
� P h y si ci an
s in it ia te
co m m u n ic at io n w it h n u rs e s
� P h y si ci an
s m ai n ta in
th e ir co
m p o su re
d u ri n g e m e rg e n ci e s
N ar as im
h an
/
2 0 0 6 /U
S A
E ff e ct iv e n e ss
o f u si n g a
g o al s w o rk sh e e t to
e n h an
ce co
m m u n ic at io n
am o n g m e m b e rs
o f
p at ie n t ca re
te am
Q u an
ti ta ti v e —
P re – p o st
in te rv e n ti o n —
S u rv e y
A 1 6 -b e d m e d ic al
In te n si v e C ar e U n it
(I C U ) o f a 6 0 7 -b e d
te ac h in g h o sp it al
N u rs e s:
P re -i n te rv e n ti o n : 1 5
P o st in te rv e n ti o n
6 w e e k s 1 3
9 m o n th s 1 4
P h y si ci an
s:
P re -i n te rv e n ti o n : 1 2
P o st in te rv e n ti o n
6 w e e k s 6
9 m o n th s 1 3
D ai ly
g o al s w o rk sh e e t in cr e as e d n u rs e – p h y si ci an
co m m u n ic at io n re p o rt e d
b y :
� N u rs e s fr o m
sc al e o f 3 .6
to 4 .3
to 4 .2
� P h y si ci an
s fr o m
sc al e o f 3 .4
to 4 .7
to 4 .4
(p = .0 3 )
(C o n ti n u e s)
TAN ET AL. | 3979
T A B L E
1 (C o n ti n u e d )
1 st
A u th o r/
Y e ar /C
o u n tr y o f
O ri g in
T o p ic
M e th o d /S tu d y D e si g n /
D at a co
lle ct io n M e th o d
S tu d y se tt in g
S tu d y sa m p le
M ai n fi n d in g s
O ’L e ar y /2
0 0 9 /
U S A
Im p ac t o f lo ca lis in g
p h y si ci an
s to
sp e ci fi c
ca re
u n it s o n n u rs e –
p h y si ci an
co m m u n ic at io n
Q u an
ti ta ti v e —
E xp
e ri m e n ta l—
P re – p o st
in te rv e n ti o n —
S tr u ct u re d in te rv ie w s o f
p at ie n ts , n u rs e s an
d
p h y si ci an
s
S ix
u n it s o f a 8 9 7 -b e d
te rt ia ry
ca re
te ac h in g
h o sp it al
as co
n tr o l an
d
in te rv e n ti o n u n it s
T h re e co
n tr o l u n it s an
d
th re e as
in te rv e n ti o n
u n it s
P re -i n te rv e n ti o n :
N u rs e s:
3 1 1
P h y si ci an
s: 3 0 1
P at ie n ts : 3 4 2
P o st in te rv e n ti o n :
N u rs e s:
2 9 1
P h y si ci an
s: 2 8 5
P at ie n ts : 2 9 4
L o ca lis in g p h y si ci an
s to
sp e ci fi c u n it s in cr e as e d :
� N u rs e s’ ab
ili ty
to re co
g n is e p h y si ci an
s fr o m
7 1 %
to 9 3 %
(p < .0 0 1 )
� F re q u e n cy
o f p h y si ci an
s co
m m u n ic at io n s to
n u rs e s fr o m
5 0 %
to 6 8 %
(p < .0 0 1 )
� F re q u e n cy
o f n u rs e s co
m m u n ic at io n s to
p h y si ci an
s fr o m
6 1 %
to 7 4 %
(p < .0 0 1 )
� F re q u e n cy
o f fa ce -t o -f ac e n u rs e – p h y si ci an
co m m u n ic at io n b y n u rs e s
fr o m
6 5 %
to 8 5 %
(p < .0 0 1 ); an
d b y p h y si ci an
s fr o m
6 9 %
to 8 4 %
(p < .0 0 1 )
O ’L e ar y /2
0 1 1 /
U S A
Im p ac t o f st ru ct u re d
in te rd is ci p lin
ar y ro u n d s
o n p h y si ci an
s’ an
d
n u rs e s’ ra ti n g s o f
co lla b o ra ti o n an
d
te am
w o rk
Q u an
ti ta ti v e —
C o n tr o lle d tr ia l—
S u rv e y
T w o 3 0 -b e d te ac h in g
u n it s in
a 8 9 7 -b e d
te rt ia ry
ca re
te ac h in g
h o sp it al
C o n tr o l u n it :
P h y si ci an
s: 4 1
N u rs e s:
2 5
In te rv e n ti o n u n it :
P h y si ci an
s: 4 7
N u rs e : 3 4
S tr u ct u re d in te rd is ci p lin
ar y ro u n d s in cr e as e d q u al it y o f co
m m u n ic at io n an
d
co lla b o ra ti o n ra ti n g s o f ‘h ig h ’ o r ‘v e ry
h ig h ’ b y :
� P h y si ci an
s: 9 1 %
(i n te rv e n ti o n ) co
m p ar e d to
8 8 %
(c o n tr o l) (p
= .5 7 )
� N u rs e s:
7 4 %
(i n te rv e n ti o n ) co
m p ar e d to
4 4 %
(c o n tr o l) (p
= .0 2 )
R o b in so n /2
0 1 0 /
U S A
E xp
lo ri n g n u rs e an
d
p h y si ci an
p e rc e p ti o n s
o f e ff e ct iv e an
d
in e ff e ct iv e
co m m u n ic at io n
Q u al it at iv e —
F o cu
s
g ro u p
L ar g e u rb an
u n iv e rs it y
h e al th
sc ie n ce
ce n tr e
N u rs e s:
9
P h y si ci an
s: 9
E ff e ct iv e n u rs e – p h y si ci an
co m m u n ic at io n in v o lv e s:
� C le ar
an d p re ci se
m e ss ag e s th at
ca n b e cl ar if ie d
� T e am
w o rk
to so lv e p ro b le m s to g e th e r
� S ta y in g ca lm
an d su p p o rt iv e u n d e r st re ss
� R e sp e ct
� U n d e rs ta n d in g o f e ac h p ro fe ss io n ’s ro le
In e ff e ct iv e n u rs e – p h y si ci an
co m m u n ic at io n in v o lv e s:
� H u m ili at in g co
lle ag u e s
� N o n -f ac e -t o -f ac e co
m m u n ic at io n th o u g h e le ct ro n ic
sy st e m s
� C u lt u ra l an
d la n g u ag e b ar ri e rs
S im
p so n /2
0 0 6 /
U S A
D e sc ri b in g
co m m u n ic at io n
b e tw
e e n la b o u r n u rs e s
an d p h y si ci an
s d u ri n g
la b o u r
Q u al it at iv e —
F o cu
s
g ro u p
L ab
o u r an
d b ir th
u n it s in
fo u r la rg e m e d ic al
ce n tr e s w it h n u rs e -
m an
ag e d la b o u r as
th e
p re d o m in an
t p ra ct ic e
N u rs e s:
5 4
P h y si ci an
s:
� In ca p ab
le o f te am
w o rk
w it h n u rs e s
� In ca p ab
le o f ta k in g su g g e st io n s fr o m
n u rs e s
� S h o w
p re fe re n ce
to in te ra ct
w it h e xp
e ri e n ce d n u rs e s
N u rs e s:
� O n ly
co m m u n ic at e w it h p h y si ci an
s “a s- n e e d e d ”
� C h an
g e th e ir co
m m u n ic at io n co
n te n t w it h p h y si ci an
s to
g e t th e ir at te n -
ti o n an
d p re se n ce
fo r th e p at ie n ts
� A v o id
p h y si ci an
s to
av o id
p ro ce d u re s th e y d id
n o t w an
t to
d o
(C o n ti n u e s)
3980 | TAN ET AL.
T A B L E
1 (C o n ti n u e d )
1 st
A u th o r/
Y e ar /C
o u n tr y o f
O ri g in
T o p ic
M e th o d /S tu d y D e si g n /
D at a co
lle ct io n M e th o d
S tu d y se tt in g
S tu d y sa m p le
M ai n fi n d in g s
T ay lo r/ 2 0 1 4 /
U S A
E ff e ct iv e n e ss
o f
e le ct ro n ic
m e d ic al
re co
rd o n
co m m u n ic at io n am
o n g
n u rs e s, p h y si ci an
s an
d
p at ie n ts
Q u an
ti ta ti v e —
P re – p o st
in te rv e n ti o n
R at e d st an
d ar d is e d
in te rv ie w s
T e rt ia ry
u n iv e rs it y -
af fi lia te d g e n e ra l
h o sp it al
N u rs e s:
P re -i n te rv e n ti o n : 5 2
P o st in te rv e n ti o n : 7 6
P at ie n ts :
P re -i n te rv e n ti o n : 5 5
P o st in te rv e n ti o n : 9 3
E le ct ro n ic
m e d ic al
re co
rd s:
� D e cr e as e d n u rs e – p h y si ci an
co m m u n ic at io n fr o m
6 9 .3 3 %
to 6 0 .9 8 %
(p = .2 8 )
� D e cr e as e d n u rs e s– p h y si ci an
fa ce -t o -f ac e co
m m u n ic at io n fr o m
6 6 .7 %
to
5 1 .2 %
(p = .0 3 )
� In cr e as e d n u rs e – p h y si ci an
d is ag re e m e n t o n e xp
e ct e d le n g th
o f st ay
(p = .0 0 2 )
T jia /2
0 0 9 /U
S A
T o id e n ti fy
an d q u an
ti fy
b ar ri e rs
to e ff e ct iv e
n u rs e – p h y si ci an
co m m u n ic at io n o n
te le p h o n e
M ix e d m e th o d s—
S u rv e y
an d st ru ct u re d
te le p h o n e in te rv ie w
2 6 n u rs in g h o m e s
N u rs e s:
Q u e st io n n ai re : 3 2 5
T e le p h o n e
in te rv ie w s:
2 1
B ar ri e rs
to n u rs e – p h y si ci an
co m m u n ic at io n :
� U n p re p ar e d n u rs e s
� P h y si ci an
s:
� U n fa m ili ar
w it h p at ie n ts ;
� A n g ry
th at
is su e s h ig h lig h te d af te r w o rk in g h o u rs
� R e fu se
to m an
ag e p at ie n ts
as co
v e ri n g p h y si ci an
s
� N o t co
n ta ct ab
le o r d o n o t ca ll b ac k
T ru st
b e tw
e e n n u rs e s an
d p h y si ci an
s e n h an
ce s n u rs e – p h y si ci an
co m m u n ic at io n
T sc h an
n e n /
2 0 1 1 /U
S A
P at te rn s o f n u rs e –
p h y si ci an
co m m u n ic at io n af te r a
co lla b o ra ti v e
in te rv e n ti o n to
im p ro v e
co m m u n ic at io n
b e tw
e e n n u rs e s an
d
p h y si ci an
s
Q u an
ti ta ti v e —
P re - an
d
p o st in te rv e n ti o n —
S u rv e y &
C o d e d
d ia lo g u e
T w o u n it s in
a te rt ia ry
ca re
ce n tr e
N e u ro -s u rg e ry
u n it :
P h as e 1
N u rs e s:
2 4
P h y si ci an
s: 7
P h as e 2
N u rs e s:
2 1
P h y si ci an
s: 5
V as cu
la r su rg e ry
u n it :
P h as e 1
N u rs e s:
2 4
P h y si ci an
s: 1 1
P h as e 2
N u rs e s:
1 7
P h y si ci an
s: 1 1
N u rs e – p h y si ci an
co lla b o ra ti v e in te rv e n ti o n d id
n o t im
p ro v e :
� O p e n n e ss
o f n u rs e – p h y si ci an
co m m u n ic at io n b e tw
e e n n u rs e s an
d p h y si -
ci an
s
� A cc u ra cy
o f n u rs e – p h y si ci an
co m m u n ic at io n
C h ar ac te ri st ic s o f co
m m u n ic at io n s:
� P h y si ci an
s ta lk
m o re
th an
n u rs e s (p
= .0 4 3 )
� P h y si ci an
s g iv e o p in io n s m o re
th an
n u rs e s (p
= .0 0 3 )
� N u rs e s su p p o rt e d o r ag re e d m o re
th an
p h y si ci an
s (p
= .0 0 1 )
(C o n ti n u e s)
TAN ET AL. | 3981
T A B L E
1 (C o n ti n u e d )
1 st
A u th o r/
Y e ar /C
o u n tr y o f
O ri g in
T o p ic
M e th o d /S tu d y D e si g n /
D at a co
lle ct io n M e th o d
S tu d y se tt in g
S tu d y sa m p le
M ai n fi n d in g s
V ai sm
o ra d i/
2 0 1 0 /I ra n
P e rs p e ct iv e s an
d
e xp
e ri e n ce s o f Ir an
ia n
n u rs e s re g ar d in g n u rs e –
p h y si ci an
co m m u n ic at io n
Q u al it at iv e —
F ac e -t o -
fa ce
se m is tr u ct u re d
in te rv ie w s
M e d ic al
an d su rg ic al
w ar d s o f tw
o u rb an
te ac h in g h o sp it al s
N u rs e s:
2 2
B ar ri e rs
to n u rs e – p h y si ci an
co m m u n ic at io n :
� P h y si ci an
s:
� O n ly
e xp
e ct
n u rs e s to
in fo rm
w it h o u t m ak in g d e ci si o n s o r re as o n in g
� In at te n ti o n to
n u rs e s’ v ie w s, co
m m e n ts
an d su g g e st io n s
� S e n se
o f g ra n d io si ty
an d su p e ri o ri ty
� D o m in an
ce o f h e al th ca re
sy st e m
� L ac k u n d e rs ta n d in g o f n u rs in g ro le s an
d re sp o n si b ili ti e s
� N u rs e s:
� P re fe rr e d to
co m m u n ic at e w it h at te n d in g p h y si ci an
s o v e r m e d ic al
re si d e n ts
� D is sa ti sf ie d w it h p h y si ci an
s’ in at te n ti o n
V az ir an
i/ 2 0 0 5 /
U S A
E ff e ct iv e n e ss
o f ad
d in g a
n u rs e p ra ct it io n e r,
ap p o in ti n g a h o sp it al is t
m e d ic al
d ir e ct o r an
d
h av in g d ai ly
m u lt id is ci p lin
ar y ro u n d s
to im
p ro v e
co m m u n ic at io n
b e tw
e e n h e al th ca re
p ro v id e rs
Q u an
ti ta ti v e —
C o n tr o lle d
tr ia l—
S u rv e y
M e d ic al
in p at ie n t u n it in
a te rt ia ry
h o sp it al
P h y si ci an
: 3 7 8
N u rs e s:
3 2 5
L o ca lis e d n u rs e p ra ct it io n e r an
d d ai ly
m u lt id is ci p lin
ar y ro u n d s:
� In cr e as e d p h y si ci an
co m m u n ic at io n w it h n u rs e s (p
< .0 0 1 )
� In cr e as e d p h y si ci an
co m m u n ic at io n w it h th e n u rs e p ra ct it io n e r (p
< .0 0 1 )
� N o d if fe re n ce
in n u rs e co
m m u n ic at io n w it h p h y si ci an
s (p
= .7 2 )
� In cr e as e d n u rs e co
m m u n ic at io n w it h n u rs e p ra ct it io n e rs
(p = .0 3 )
W al d e n /2
0 0 9 /
U S A
B ar ri e rs
an d
o rg an
is at io n al
fa ct o rs
th at
in fl u e n ce
n u rs e s’
p ar ti ci p at io n in
p at ie n t
ca re
ro u n d s (P C R )
D e sc ri p ti v e —
D e lp h i
te ch
n iq u e —
7 6 -b e d N e o n at al
In te n si v e C ar e U n it
(N IC U ) o f a 7 3 7 -b e d
p ae
d ia tr ic
h o sp it al
N u rs e s:
6 6
N e o n at al
n u rs e
p ra ct it io n e rs : 8
P h y si ci an
s: 7
A lli e d h e al th : 6
B ar ri e rs
to n u rs e s jo in in g p at ie n t ca re
ro u n d s w it h p h y si ci an
s:
� N u rs e s b u sy
w it h p at ie n ts
an d o th e r re sp o n si b ili ti e s
� N o st an
d ar d ti m e fo r ro u n d s
� N u rs in g in p u t n o t v al u e d
� N u rs e s p re se n ce
o r p ar ti ci p at io n n o t n e e d e d
W an
ze r/ 2 0 0 9 /
U S A
N u rs e -c e n tr e d
co m m u n ic at io n
b e h av io u rs
as a
p re d ic to r o r n u rs e s’
sa ti sf ac ti o n w it h
co m m u n ic at io n w it h
p h y si ci an
s
Q u an
ti ta ti v e —
S u rv e y
A L ar g e W
o m e n an
d
C h ild
re n ’s h o sp it al
N u rs e s:
2 0 5
P h y si ci an
u se
o f n u rs e ce n tr e d co
m m u n ic at io n b e h av io u r is :
� C o rr e la te d w it h n u rs e sa ti sf ac ti o n w it h n u rs e – p h y si ci an
co m m u n ic at io n
(p = .0 0 1 )
� N o t co
rr e la te d w it h le n g th
o f n u rs e – p h y si ci an
co n v e rs at io n (p
= .0 0 1 )
(C o n ti n u e s)
3982 | TAN ET AL.
2010; Simpson, James, & Knox, 2006; Tschannen et al., 2011; Wan-
zer, Wojtaszczyk, & Kelly, 2009).
Nurses’ satisfaction with regards to nurse–physician communica-
tion increased when physicians adopted a nurse-centred communica-
tion style (Wanzer et al., 2009). The characteristics of nurse-centred
communication style included: making self-introductions, immediacy
of response, clarity of information, humour, listening and empathy in
physicians’ communications. Although it was found that physicians
communicated 1.46 times longer than nurses (Tschannen et al.,
2011), the length of physicians’ communications was not related to a
nurse-centred communication style (Wanzer et al., 2009). It was fur-
ther revealed that physicians who could remain calm, supportive,
communicate clearly and accurately during emergency situations
improved the nurse–physician communication (Morinaga et al., 2008;
Robinson et al., 2010).
In terms of communication content, physicians clearly articulated
their opinions significantly more than nurses (p < .05). In contrast,
nurses tended to agree or be supportive while communicating with
physicians (Tschannen et al., 2011). However, when nurses used asser-
tive and purposeful communication styles during emergency situations,
physicians responded to patients promptly (Simpson et al., 2006).
3.3 | Factors that facilitate nurse–physician communication
Three subthemes were identified from six studies which explored
factors enhancing nurse–physician communication, and included
common understanding, trust and respect, and collaborative attitudes
(Bryon, Gastmans, & De Casterl�e, 2012; Morinaga et al., 2008;
O’Leary et al., 2011; Robinson et al., 2010; Tjia et al., 2009; Walden,
Elliott, & Gregurich, 2009).
3.3.1 | Common understanding
Two aspects of a ‘common understanding’ of nurse–physician com-
munication were identified as: the professional role of nurses and
physicians, and the information exchanged (Bryon et al., 2012; Mori-
naga et al., 2008; O’Leary et al., 2011; Robinson et al., 2010; Wal-
den et al., 2009).
A qualitative study using focus groups comprising nine nurses
and nine physicians found that mutual understanding of nurses’ and
physicians’ roles combined with opportunities to clarify information
allowed more meaningful communication between these two profes-
sional groups (Robinson et al., 2010). Appreciating professional roles
and responsibilities helped to redefine their expectations of one
another (Robinson et al., 2010). In addition, four studies found that
information sharing, with continuous updates on changes in patients’
conditions and management/care plans, enhanced nurse–physician
communication (Bryon et al., 2012; Morinaga et al., 2008; O’Leary
et al., 2011; Walden et al., 2009). Physicians’ clarification of their
orders (Morinaga et al., 2008), and environments that encouraged
knowledge sharing and questioning improved understanding and
nurse–physician communication (Walden et al., 2009).T A B L E
1 (C o n ti n u e d )
1 st
A u th o r/
Y e ar /C
o u n tr y o f
O ri g in
T o p ic
M e th o d /S tu d y D e si g n /
D at a co
lle ct io n M e th o d
S tu d y se tt in g
S tu d y sa m p le
M ai n fi n d in g s
W h it lo w /2
0 1 4 /
U S A
E ff e ct iv e n e ss
o f
sm ar tp h o n e o n
in te rp ro fe ss io n al
co m m u n ic at io n
b e tw
e e n n u rs e s an
d
p h y si ci an
s
Q u as i- e xp
e ri m e n ta l
p re te st /p o st -t e st —
S u rv e y
A 2 6 -b e d m e d ic al
u n it in
a 6 0 4 -b e d ac ad
e m ic
m e d ic al
ce n tr e
P re -i n te rv e n ti o n :
6 1 n u rs e s
4 4 p h y si ci an
s
P o st in te rv e n ti o n :
2 9 n u rs e s
1 1 p h y si ci an
s
N u rs e s an
d p h y si ci an
s ar e :
� D is sa ti sf ie d w it h o n e -w
ay p ag in g d e v ic e (p
= .0 0 0 )
� S at is fi e d w it h sm
ar tp h o n e d e v ic e (p
= .0 0 0 )
� R e d u ce d w ai t ti m e fo r p h y si ci an
to re tu rn
ca ll (p
= .0 0 1 )
� R e d u ce d ti m e aw
ay fr o m
th e ir p at ie n ts
(p = .0 2 1 )
� F e w e r w o rk
in te rr u p ti o n s (p
= .0 0 2 )
W h it so n /2
0 0 8 /
U S A
N u rs e s’ sa ti sf ac ti o n o n
af te r- h o u rs
co m m u n ic at io n w it h
p h y si ci an
s af te r an
e d u ca ti o n -b as e d
in te rv e n ti o n co
m p ri si n g
p o in t- o f- ca re
d e ci si o n -
su p p o rt
to o ls an
d
in d iv id u al is e d n u rs e
tr ai n in g se ss io n s
Q u an
ti ta ti v e —
L o n g it u d in al
st u d y —
S u rv e y —
C o d e d af te r-
h o u rs
te le p h o n e ca lls
1 2 0 -b e d lo n g -t e rm
ca re
fa ci lit y fo r v e te ra n s
N u rs e s:
1 8
T ra in in g o n d e ci si o n -s u p p o rt
to o ls in cr e as e d n u rs e s’ :
� C o n fi d e n ce
o n ty p e o f in fo rm
at io n n e e d e d b y p h y si ci an
s (p
= .0 4 )
� C o n fi d e n ce
o n am
o u n t o f in fo rm
at io n n e e d e d p h y si ci an
s (p
= .0 3 )
� P re p ar e d n e ss
to an
sw e r p h y si ci an
s’ q u e st io n s (p
= .0 1 )
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TAN ET AL. | 3983
3.3.2 | Trust and respect
Four studies highlighted the importance of mutual trust and respect
between nurses and physicians. Tjia et al. (2009) and Robinson et al.
(2010) found that relationships of trust and respect reinforced good
nurse–physician communication. The presence of such trust and
respect between nurses and physicians depended on physicians’
affirmative attitude towards nurses (Bryon et al., 2012). When physi-
cians respected nurses, trusted and valued their input, nurses were
more willing to communicate with physicians. Although physicians
were satisfied when nurses communicated their input on patient
care, nurses were indifferent about communicating with physicians.
3.3.3 | Collaborative attitudes
In addition to trust and respect, the collaborative attitudes between
professions also facilitated nurse–physician communication. Physi-
cians’ use of consultative approaches (Bryon et al., 2012) and dis-
plays of teamwork behaviours (Robinson et al., 2010) affirmed
interprofessional partnerships between nurses and physicians in the
care of their patients. Physicians’ openness and interest in nurses’
views and suggestions (Bryon et al., 2012), proactive communica-
tions with nurses (Morinaga et al., 2008), as well as their calm and
collegial dispositions (Robinson et al., 2010), encouraged nurse–
physician communication. Nurses also reported higher job satisfac-
tion in practice environments where physicians communicated effec-
tively with them (Manojlovich, 2005).
3.4 | Barriers to effective nurse–physician communication
Six subthemes that impeded nurse–physician communication were
identified in seven studies (Aston, Shi, Bullôt, Galway, & Crisp,
2005; Morinaga et al., 2008; Robinson et al., 2010; Simpson et al.,
2006; Tjia et al., 2009; Vaismoradi, Salsali, Esmaeilpour, & Cher-
aghi, 2011; Walden et al., 2009). These barriers included lack of
communication opportunities, modes of communication, preference
for autonomy and objectionable behaviours, insufficient informa-
tion, selective communication counterparts, and language and cul-
ture.
3.4.1 | Lack of communication opportunities
Two studies highlighted the lack of face-to-face communication
opportunities leading to ineffective nurse–physician communication
(Tjia et al., 2009; Walden et al., 2009). A survey by Walden et al.
(2009) of 66 nurses and seven physicians in a neonatal ICU of a
large paediatric hospital found nurses’ and physicians’ busy work
schedules and routines decreased opportunities for face-to-face
nurse–physician communication. In addition, the unpredictable timing
of physicians’ rounds in this busy environment, and physicians who
appeared to undervalue nursing presence and input, prevented
nurses from participating in the rounds (Walden et al., 2009). The
on-call physicians, who did not want to counter orders of the
assigned physician’s treatment plans, also avoided communicating
with nurses (Tjia et al., 2009).
3.4.2 | Modes of communication
Electronic medical records (EMR) have been implemented for effi-
cient documentation and access to patient information; however,
these systems have inadvertently reduced face-to-face nurse–physi-
cian communication (Robinson et al., 2010). With multiple input
locations solely via computers, communication through EMR has
been reported as passive, one-directional, fragmented and incom-
plete (Robinson et al., 2010). Most importantly, physicians erro-
neously assumed that they did not need to communicate any further
with nurses after updating the EMR, resulting in additional lapses
and errors in nurse–physician communication (Robinson et al., 2010).
3.4.3 | Preference for autonomy and objectionable behaviours
Physicians’ preference for autonomous practice often led to their
unwillingness to communicate with nurses, hindering nurse–physician
communication (Aston et al., 2005; Vaismoradi et al., 2011). Conse-
quently, physicians limited interactions to merely informing nurses of
patient issues, disregarding their opinions or decisions, leaving nurses
dissatisfied with nurse–physician communication (Vaismoradi et al.,
2011). Furthermore, physicians who displayed impatience, anger and
quick-temperedness (Morinaga et al., 2008; Robinson et al., 2010),
or humiliated nurses in the presence of patients (Robinson et al.,
2010) also led to poor nurse–physician communication and job dis-
satisfaction.
3.4.4 | Insufficient information
Insufficient information, due to inadequate knowledge of patients
and their conditions, frustrated nurses and physicians as care/treat-
ment plans could not be fully executed (Tjia et al., 2009). Nurses
have also reported not receiving information to act upon when
physicians did not respond to calls, or because physicians were unfa-
miliar with their patients (Tjia et al., 2009). Correspondingly, physi-
cians were dissatisfied when nurses were unprepared with required
information when communicating with them (Tjia et al., 2009).
3.4.5 | Selective communication counterparts
Two studies reported that nurses and physicians were selective
about how they communicated with their counterparts (Simpson
et al., 2006; Vaismoradi et al., 2011). To obtain better-quality infor-
mation on their patients, physicians preferred communicating with
more experienced nurses (Simpson et al., 2006); correspondingly,
nurses preferred communicating with attending physicians over med-
ical residents for more definitive directions on patient care (Vais-
moradi et al., 2011).
3984 | TAN ET AL.
3.4.6 | Language and culture
With the increasingly globalised healthcare workforce, the diverse
cultural and linguistic backgrounds of nurses and physicians have
contributed to the challenges of nurse–physician communication
(Robinson et al., 2010). In hospitals in the United Stated (US), where
English is commonly used, foreign-trained nurses not proficient in
English contributed to difficulties in nurse–physician communication
(Robinson et al., 2010). In addition, the cultural expectations relating
to interactions between foreign-trained clinicians and their Native
American counterparts were also cited as a cause of nurse–physician
miscommunication (Robinson et al., 2010).
3.5 | Interventions to improve nurse–physician communication
A total of 12 studies examined six interventions to improve nurse–
physician communication. The type of interventions included nurse–
physician meetings or rounds (Aston et al., 2005; O’Leary et al.,
2011); localising physicians to particular units (O’Leary et al., 2009;
Vazirani et al., 2005); communication tools/checklists (De Meester
et al., 2013; Narasimhan, Eisen, Mahoney, Acerra, & Rosen, 2006;
Taylor, Ledford, Palmer, & Abel, 2014); structured communication
training (Brown et al., 2010; Whitlow, Drake, Tullmann, Hoke, &
Barth, 2014; Whitson et al., 2008); alternative nursing care models
(Fernandez et al., 2010); and team-building through projects (Tschan-
nen et al., 2011). Three subthemes that emerged were opportunities
for face-to-face communication, information exchange and impact
on nurses’ experiences.
3.5.1 | Opportunities for face-to-face communication
Four studies attempted to increase opportunities for face-to-face
communication between nurses and physicians (Aston et al., 2005;
O’Leary et al., 2009, 2011; Vazirani et al., 2005), and one study
aimed to increase communication opportunities through EMR (Taylor
et al., 2014).
The introduction of daily nurse–physician surgical morning meet-
ings improved nurse–physician communication in an Australian pae-
diatric hospital ward, creating opportunities to jointly clarify patient
issues, treatment goals and plans (Aston et al., 2005). Similarly, in
two 30-bed teaching units of a tertiary hospital in the United States,
O’Leary et al. (2011) found increased ratings on the quality of
nurse–physician communication after introducing daily structured
interdisciplinary rounds.
However, localising staff to specific units produced inconsistent
outcomes. In a controlled-group study across six units of a tertiary
hospital in the United States, O’Leary et al. (2009) reported signifi-
cantly improved rapport between nurses and physicians, and higher
frequency of reported face-to-face nurse–physician communication
after localising physicians in three intervention units, compared to
three control units. In contrast, a study to localise a nurse
practitioner and implement daily multidisciplinary rounds in a medical
unit in another US tertiary hospital yielded mixed results. While both
nurses and physicians reported more communications with the nurse
practitioner, only the physicians reported significantly increased com-
munication with nurses (Vazirani et al., 2005).
Additionally, a study by Taylor et al. (2014) that expected the
EMR to increase nurse–physician communication found that use of
the EMR significantly decreased face-to-face communication
between nurses and physicians (p = .03).
3.5.2 | Information exchange
Four studies explored the information shared between nurses and
physicians. Nurse–physician communication was improved by train-
ing and preparing nurses to gather, systematically organise and share
comprehensive information.
One study trained nurses to gather and communicate diagno-
sis-specific information (Brown et al., 2010), while another focused
on collation of information using a decision-support algorithm tool,
accompanied by a communication tool to guide nurses on convey-
ing succinct information to physicians (Whitson et al., 2008).
Brown et al. (2010) found that home-care agency nurses were
more confident to make comprehensive and organised case pre-
sentations after training on communicating depression-specific
information. Similarly, nurses in a veterans long-term care facility
were able to gather and communicate the information physicians
preferred, after completing training using specific clinically based
decision-support tools combined with a new communication tool
(Whitson et al., 2008).
Three other studies tested communication tools as a means of
sharing succinct yet comprehensive information, using templates or
worksheets (De Meester et al., 2013; Narasimhan et al., 2006). One
study implemented Situation–Background–Assessment–Recommen-
dation (SBAR) as a communication template (De Meester et al.,
2013) and reported that this approach increased the frequency of
nurse–physician communication (De Meester et al., 2013). The study
by Narasimhan et al. (2006) used a different structure, a daily goals
worksheet, to capture pertinent information, including the daily care
goals. Both nurses and physicians reported significant improvements
in nurse–physician communication when using a shared multidisci-
plinary goals worksheet, where patients’ daily treatment goals were
collectively updated (Narasimhan et al., 2006). Aston et al. (2005)
stated that daily morning nurse–physician meetings were critical for
exchanging patients’ overnight and baseline information for making
further treatment plans.
Studying information technology as a means of exchanging infor-
mation, Taylor et al. (2014) reported that the use of the EMR did
not fulfil its intended purpose as a common information base as it
reduced nurses’ and physicians’ agreement on patients’ plan of care
(Taylor et al., 2014). Although information in the EMR was updated
asynchronously, it was incomplete because it was no longer verified
through synchronous, face-to-face communication (Taylor et al.,
2014).
TAN ET AL. | 3985
3.5.3 | Impact on nurses’ experience
Three of the 12 interventional studies identified how implementing
interventions to improve nurse–physician communication impacted
on nurses’ confidence (Brown et al., 2010; Whitson et al., 2008),
and job satisfaction (Whitlow et al., 2014; Whitson et al., 2008).
Being prepared with sufficient patient information before con-
tacting physicians increased nurses’ knowledge and confidence to
communicate with physicians (Brown et al., 2010; Whitson et al.,
2008). Consequently, nurses’ positive experiences of communicating
with physicians improved their job satisfaction (Whitson et al.,
2008). Additionally, nurses were more satisfied with the responsive-
ness of communication after physicians’ pagers were replaced with
smartphones. The smartphones allowed two-way synchronous infor-
mation exchange and opportunities for clarification; it eliminated the
wait time for physicians to respond to pages, reduced work interrup-
tions and nurses’ time away from their patients (Whitlow et al.,
2014).
4 | DISCUSSION
This review provides new perspectives but also corroborates findings
from with other research and commentaries (Bujak & Bartholomew,
2011; O’Daniel & Rosenstein, 2008; Rosenthal, 2013; Vaismoradi
et al., 2011) about factors which facilitate or hinder nurse–physician
communication. The enabling factors and corresponding barriers
were trust, respect and collaborative attitudes versus preference for
autonomy and objectionable behaviours, and, sufficient information ver-
sus insufficient information. The need for nurses and physicians to
develop mutual trust and respect, and to inculcate collaborative
behaviours, has also been reiterated in three recent studies as an
enabler for improved collaboration (Pfaff, Baxter, Jack, & Ploeg,
2014; Tang, Chan, Zhou, & Liaw, 2013; Zwarenstein, Rice, Gotlib-
Conn, Kenaszchuk, & Reeves, 2013). However, this review found
that distrust, disrespectful and negative behaviours between nurses
and physicians, which were first described by Stein (1968), still per-
sist in the practice environment. Nugus, Greenfield, Travaglia, West-
brook, and Braithwaite (2010) suggest the presence of a tenacious
culture of organisation-sanctioned role domination by physicians is a
key factor in these matters. Therefore, leadership initiatives effecting
systematic changes are crucial in supporting nurses to ‘speak up’,
and establish a culture of effective interprofessional communication
(Crawford, Omery, & Seago, 2012; Propp et al., 2010).
This review found that the majority of interventions to improve
nurse–physician communication were targeted at nurses’ communi-
cation skills. Among the identified initiatives, the SBAR communica-
tion tool was proven to be a generalisable intervention. In the
Western Australia Country Health Service, SBAR has been adapted
and modified as a comprehensive patient handover checklist and
tool to Identify, Situation, Observation, Background, Agreed Plan,
Read-back (ISOBAR) (Porteous, Stewart-Wynne, Connolly, & Crom-
melin, 2009). Other tools, worksheets and checklists found in this
review have only been tested in a single setting so further validation
is required.
Among other initiatives, this review found that use of the EMR
did not improve nurse–physician communication. By updating infor-
mation in the EMR in isolation, nurses and physicians erroneously
assumed information was communicated, read and carried out by
the receivers. As highlighted in this review, that nurses and physi-
cians have been satisfied with communication through smartphones,
future enhancements to the EMR could include smartphone alerts to
nurses and physicians about new information or updates, which have
been entered to overcome this shortcoming. However, the EMR still
needs to be supplemented by face-to-face nurse–physician conversa-
tions to enable additional perspectives and issues that have not been
documented in the EMR to be synchronously raised, discussed and
clarified (Taylor et al., 2014).
This review also found that when physicians and nurses evalu-
ated interventions to improve nurse–physician communication,
physicians consistently had a greater tendency to report that the
interventions were effective, compared to nurses (Narasimhan et al.,
2006; O’Leary et al., 2011; Vazirani et al., 2005). This tendency has
been attributed to how each profession perceives communication,
shaped by their different training and professional cultures and
expectations (Matziou et al., 2014). However, this review found
that localising physicians to single units addressed the ‘communica-
tion in practice issue’, through encouraging frequent face-to-face
interactions between nurses and physicians to enhance professional
relationships through improving mutual understanding, familiarity
and rapport (Lomax & White, 2015; O’Leary et al., 2009). This
approach also afforded nurses and physicians opportunities to iden-
tify and reflect on their unique differences, understand their roles
(MacDonald et al., 2010) and align any differing views for better
nurse–physician communication (Crawford et al., 2012). Such inter-
ventions could also result in more positive attitudes, and relation-
ships of trust and respect between the two professions, to
overcome barriers like language and culture (O’Daniel & Rosenstein,
2008), that were not adequately addressed by any of the studies in
this review. However, interventions that localise physicians to an
area have only been implemented in smaller, single units and the
feasibility should be further tested on a larger scale across different
settings.
On the different communication styles, this review found con-
flicting findings on whether nurses or physicians communicated more
than their counterparts. Of note, nurses communicated more than
physicians to elicit information they needed when receiving han-
dovers from physicians in the postanaesthesia care unit (PACU). On
the other hand, in ward settings physicians were found to communi-
cate more than nurses, contrary to Rosenthal (2013), who reported
that physicians communicated concisely. However, this review high-
lighted that physicians were more opinionated while nurses tended
to be more supportive in their communication styles. Nonetheless,
nurses appreciated physicians who communicated calmly, clearly,
accurately, respectfully, and who adopted nurse-centric communica-
tion styles. Findings revealed that nurses also knew when to
3986 | TAN ET AL.
communicate assertively and purposefully to gain prompt physician
attention for patients of concern and as such, attained the desired
outcome.
Overall, this review found that in general, nurses and physicians
were lacking in interpersonal communication skills. While algorithms
and tools have improved nurse–physician communication to the
extent of pertinent information being at the fore, such tools have
limited effect on improving healthcare providers’ overall competency
in interprofessional communication (Ellison, 2015). As differences in
foundational training was a plausible reason for the disparity in com-
munication skills between nurses and physicians, it is recommended
that further research into interventions that promote greater under-
standing between nurses and physicians, like cross-disciplinary
attachments, shadowing and interdisciplinary simulation training be
considered (Liaw, Siau, Zhou, & Lau, 2014). To further align the edu-
cation of nurses and physicians in collaborative competencies, inter-
professional practice, and interprofessional communication, through
interprofessional education from undergraduate to postqualification
levels is a recommended way forward (Ellison, 2015; Onishi, Komi, &
Kanda, 2013).
5 | LIMITATIONS
This integrative review is limited to studies published in English.
Studies conducted in specialised areas like the ICUs, single wards or
units, with relatively small study sample sizes, would limit generalisa-
tion of findings to the wider population (Nieswiadomy, 2013). The
majority of the interventional studies on nurse–physician communi-
cation in this review were nonexperimental design, so the causal
relationships of phenomena cannot be determined (Nieswiadomy,
2013).
6 | CONCLUSION
Communication between nurses and physicians remains a challeng-
ing area of clinical practice. Although communication algorithms and
checklists fulfilled the information needs of nurses when communi-
cating with physicians, this approach is structured for specific patient
diagnoses, or situations of patient deterioration and handovers.
To date, there are no interventions identified to address persistent
barriers highlighted in this review, such as diverse languages and cul-
tures in a globalised healthcare workforce, poor collaborative physi-
cian behaviours, and lack of communication opportunities. Although
localising physicians to dedicated clinical areas, and structuring nurse–
physician rounds/meetings improved nurse–physician communication,
through greater familiarity and rapport, such interventions have only
been tested in smaller controlled settings like ICUs.
Determining effectiveness of interventions to improve nurse–
physician communication has been difficult in this review, con-
founded by contradicting foci and opinions of nurses and physicians.
Outcome measurements have been affected by these disparate
views and expectations of effective communication due to differences
across disciplines in training and backgrounds.
6.1 | Implications to clinical practice, education and future research
While there are reports of interventions which improved nurse–
physician communication, these were tested in limited settings.
Overall, strong leadership and commitment are necessary to effect
organisational, cultural and structural shifts warranted for such
interventions to improve nurse–physician communication and
hence patient safety and outcomes. For meaningful change in
communication practices, strategies would need to be targeted at
university level, in undergraduate and postgraduate courses, and
interprofessional education programmes in addition to the work-
place.
This integrative review only focused on nurse–physician commu-
nication. Future studies would be required to explore interprofes-
sional communication across all healthcare professionals for greater
perspective and scope. For better representation, future studies on
nurse–physician communication should employ larger sample sizes,
engage multiple sites and adopt randomised control designs to better
examine the effects of interventions.
CONTRIBUTIONS
TCT contributed to the study design, data collection, analysis and
manuscript preparation. HZ assisted with the study design, data ana-
lysis and manuscript preparation. MK assisted with the manuscript
preparation.
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How to cite this article: Tan T-C, Zhou H, Kelly M. Nurse–
physician communication – An integrated review. J Clin Nurs.
2017;26:3974–3989. https://doi.org/10.1111/jocn.13832
TAN ET AL. | 3989
