Leadership In Nursing

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: tit_chai_tan@ttsh.com.sg

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