Chapter 20. Leadership 

Bonnie M. Jennings, Joanne Disch, Laura Senn 

Background 

Reports from the Institute of Medicine (IOM) have emphasized that leadership is essential to 

achieving goals related to quality care1

 and patient safety.2 Leadership is expected from 

individuals at all levels of an organization, from the executive suite to those working directly 

with patients. Leadership is also expected regardless of where care is delivered—inpatient units, 

clinics, settings for ambulatory procedures, long-term care facilities, or in the home. 

Because of the breadth and complexity of the literature on leadership, the authors narrowed 

the focus to leadership at two distinct levels of health care organizations. First, the literature on 

executive leadership was reviewed, with a particular focus on the relationship between the chief 

executive officer (CEO) and chief nurse officer (CNO), to examine leadership by individuals 

responsible for setting the organization’s vision and direction related to quality of care and 

patient safety. Second, an exploration of the literature related to the leadership exerted by nurses 

and physicians as co-leaders of the patient care areas—that is, the type of leadership provided by 

co-leaders who are responsible for actualizing the vision and creating the local environment in 

which care is provided—was conducted. 

A search of the relevant literature yielded little useful information on either of these 

leadership topics. Studies relating to the CNO or the individual in an equivalent position focused 

on hospital directors,3

 nursing home administrators,4 CEOs and boards of directors,5 and 

CNOs,6–29 with no empirical evidence regarding the CEO-CNO relationship. Thus, the focus on 

the CNO shifted to reporting findings regarding the CNO’s leadership style and its impact on the 

organization. 

On the second level, that of nurse-physician co-leadership, there was a similar void in the 

literature. Thus, this chapter describes the very few studies that have examined nurse-physician 

co-leadership and reports findings from interventional studies on the broader context of nursephysician collaboration and its impact on quality and safety of patient care. Collaboration is 

certainly a precursor to nurse-physician co-leadership. 

Research Evidence 

Executive Level 

Only two investigations were found that linked CNO leadership to quality care and patient 

safety. A case study was done to examine the influence of the CNO in revitalizing the flagship 

hospital of a large, integrated health system.7

 Features of patient safety were among the 

outcomes evaluated at baseline, 18 months, and 36 months. Patient falls and nosocomial 

bloodstream infections declined over time from baseline; patient satisfaction with nursing care 

improved. The other investigation examined the relationship of both leadership and 

communication to quality care in 15 nursing homes from four States.4

 The nursing home 

administrators were invited to participate, but the findings did not reflect how many actually 

responded. Nonetheless, clinical staff (n = 656) provided important insights regarding what 

1 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

promoted the best care possible. The top three responses regarding what facilitated good care and 

what interfered with providing good care were communication, staffing, and leadership. The 

study findings were not specific, however, as to whether the participants were addressing 

executive leadership. 

Studies involving CNOs frequently examined leadership styles and behaviors. 

Transformational leadership captured the interest of several investigators.11–13, 21, 23, 24 Although 

these studies were often framed to indicate a preference for a transformational style, the findings 

reflected that leadership is complex and multidimensional. CNOs typically used combinations of 

transformational, transactional, and laissez-faire leadership.13, 21, 23 Moreover, four homogeneous 

leadership groupings were found among 84 CNOs based on combinations of high and low 

transformational and transactional behaviors.11 

The need for a comprehensive assessment of leadership was put into perspective in a study 

involving a random sample of 477 CNOs who were members of the American Organization of 

Nurse Executives (AONE).21 Both transformational and transactional leadership had a negative 

relationship with alienative (unfavorable) organizational commitment among registered nurses 

(RNs). However, transactional leadership demonstrated a stronger (r = –0.31; P < 0.01) 

association with alienative organizational commitment than transformational leadership (r = –

0.24; P < 0.05). 

Other styles of leadership were also assessed; however these findings could not be explicitly 

linked to CNOs. Rather, the investigators considered leadership from nurse administrators, 

allowing the possibility that participants may have reflected on leadership from nurse managers. 

Nevertheless, authoritarian leadership interfered with work empowerment.20 Conversely, 

connective leadership—which was largely composed of the elements of transformational 

leadership—was predictive of empowerment.18 A study involving 6,526 RNs from Canada 

illustrated the need to examine the full repertoire of leadership styles.30 A heretofore 

unrecognized leadership style—resonant leadership—lessened the impact of restructuring. 

Another approach to assessing CNO leadership was to compare how CNOs perceived their 

leadership with how various other individuals perceived the CNO leadership style. These studies, 

involving CNO direct reports,11 the individuals to whom CNOs reported (usually the chief 

operating officer, COO),13 nurse managers (NMs),15, 19, 21 staff nurses,21 and influential 

colleagues,14, 17 further verified the complexities of leadership. For example, although there were 

discrepancies between CNOs and their direct reports regarding how often CNOs used 

transformational leadership, the direct reports were more satisfied with the CNO leadership style 

than the CNOs expected.13 Based on data from the same study, however, no differences in 

ratings of work group effectiveness were found, among the three groups (CNOs, direct reports, 

CNO supervisors). 

NMs (n = 87) who agreed with their CNOs’ (n= 22) leadership style were more likely to be 

satisfied with their jobs.15 In another study conducted in a 700-bed acute care setting during an 

organizational transition, a rating scale and interviews were used to identify the executive 

behaviors that were most important to NMs.19 Although it was not clear whether CNOs per se 

were considered, communication and high visibility on work units were the top 2 of the 10 most 

desired behaviors. 

A study of nurse leadership in four hospitals—two with Magnet status and two without 

Magnet status—found that leadership affected staff nurse job satisfaction.25 Based on survey 

responses from 305 staff nurses and interviews with 16 nurse leaders, some of whom were 

CNOs, the investigator concluded that staff nurses were more satisfied when nurse leaders were 

2 
Leadership

visible and responsive, when they supported autonomous decisionmaking, and when there was 

adequate staffing. 

Another group of studies examined skills essential to being a successful CNO, especially 

given how the role is changing.8, 10, 17, 27, 28 For example, in a study conducted in one U.S. city 

involving CNOs and female leaders in other fields, six categories of essential leadership skills 

were identified: (a) personal integrity, (b) strategic vision/action orientation, (c) team 

building/communication, (d) management and technical competence, (e) people skills, and (f) 

personal survival skills.10 A Delphi study conducted in 22 European countries identified 16 

relevant CNO qualities.17 Communication ranked first, followed by teamwork, leadership, 

strategic thinking, political astuteness, professional credibility, integrity, personal qualities, 

innovation, decisionmaking, promotion of nursing, research skills, physical characteristics, 

information handling, good management, and conflict resolution. The rankings from a European 

study differed from rankings derived from a U.S. study in which clinical knowledge ranked first 

of 14 items, communication ranked eighth, and teamwork was not in the rankings.8 Attributes of 

successful nurse leadership in acute care settings were compared between 16 leaders at Magnet 

(n = 7) and non-Magnet hospitals (n = 9).27, 28 

Additionally, researchers have found that organizational characteristics such as culture and 

size may alter the expression of leadership.13, 27 Gender is another factor that has been assessed 

regarding CNO leadership. In one study, gender was deemed irrelevant because of the effective 

way in which the hospital leadership teams interacted.27 

A final set of studies concerning CNOs provided evidence using qualitative 

methods.6, 9, 16, 24, 26, 29 Some of these studies were conducted to delineate key executive 

leadership characteristics.24, 26 For example, based on interviews with 10 CNOs, key 

characteristics included knowing how to use power; being visible; having a vision for the 

organization; motivating staff; empowering staff; and being open, honest, and personable.24

Similarly, 16 nurse leaders—some of whom were CNOs—from four acute care hospitals were 

interviewed to identify effective leadership traits.26 The categories that emerged were (a) core 

principles and value system guiding leadership (e.g., leading to serve, striving for excellence, a 

passion for nursing); (b) use of quantitative data to influence decisionmaking; and (c) 

collaborative teamwork among patient care staff to provide excellent care, and among 

management to support one another and staff. Findings from other qualitative investigations 

included a serendipitous finding about obstacles CNOs face in all aspects of their work;9

determining CNO leadership behaviors across three hierarchical domains of leadership: strategic, 

organizational (administrative management), and production (creating goods and services);16

how the merger of business (managed care) and medicine widened the gender gap in health care 

leadership;6 and thought processes used by expert CNOs in making decisions.29

Nurse-Physician Co-Leaders 

While there is a growing body of research described later in this chapter on the impact of 

collaboration between nurses and physicians who are caregivers,31–45 there is a notable absence 

of research on the impact of a collaborative relationship between the nurse and physician coleaders of patient care units. Presented in this section is a brief history of the concept of partnered 

leadership and a description of the one study found on this specific type of nurse-physician 

relationship. 

The importance of a focus on collaboration and partnered leadership between nurse and 

physician is not a new concept, but rather one that has been in the literature for more than 25 

3
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

years. In 1981, the National Commission on Nursing urged trustees and administrators to 

“promote and support complementary practice between nurses and physicians” and to “examine 

organizational structure to ensure that nurse administrators are part of the policymaking bodies 

of the institution and have authority to collaborate on an equal footing with the medical leaders 

in the institution”46 (p. 62). Similarly, the Joint Commission (formerly the Joint Commission on 

Accreditation of Healthcare Organizations, JCAHO) required that activities of critical care units 

be guided by a multidisciplinary approach, including nursing and medical input.47 Shortly 

thereafter, the American Association of Critical Care Nurses and the Society of Critical Care 

Medicine jointly developed a position statement outlining 10 principles for optimizing resources 

in critical care units. While all of the principles reflect a commitment to medical and nursing coleaders, the following two are particularly relevant48 (p. 43). 

• #1—Responsibility and accountability for effective functioning of a critical care unit 

must be vested in physician and nurse directors who are on an equal decisionmaking 

level. 

• #10—Close collaboration between the directors is essential for successful management. 

More recently, Gilmore49 has advanced the concept of productive pairs. He noted that as 

organizations become increasingly complex with rapid change, leaders are less able to possess all 

of the knowledge and expertise needed. Thus, a model of leadership that is based on a 

partnership between two individuals who share common goals and come from different, yet 

complementary, disciplines could be very effective. 

Productive pairs possess several characteristics: separate, yet complementary, bodies of 

knowledge; understanding and valuing each other’s areas of expertise; enough time or history 

together to explore the interdependencies; trust of one another that enables direct, frank 

exploration of issues; a commitment to the partnership and avoidance of efforts at triangulation; 

and a shared passion for a common goal or vision. 

One study that specifically examined how physician leaders and nurse administrators worked 

together was by Tjosvold and MacPherson.50 Physician and nursing administrator pairs were 

interviewed on how they worked together in managing areas within the hospital. Incidents they 

used to describe their relationship were coded as cooperative, competitive, or independent, and 

then related to outcomes. 

Incidents in which goals were cooperative were ones in which physicians and nurse 

administrators discussed their issues constructively, had positive effect, strengthened their 

relationship, made progress on the task, promoted the organization’s effectiveness, developed 

confidence in future work, and fostered quality care. Incidents in which goals were competitive 

were negatively related to productive interaction and outcomes. When the partners felt 

competitive, they were unable to exchange ideas openly, initiatives did not progress, and the 

relationship and quality of care were compromised. Constructive controversy (open-minded 

discussion, occurring within a strong cooperative context, or various perspectives that allow 

disagreement and exploration in a respectful manner) enabled the pairs to discuss their views 

productively and resulted in constructive outcomes. On the other hand, when constructive 

controversy occurred in a competitive context, problems ensued, such as resistance, a closeminded discussion of ideas, and an impaired working relationship. 

4 
Leadership

Nurse-Physician Collaboration 

As a backdrop for considering collaboration between nurse and physician leaders of the team, 

we examined the research on collaborative relationships between nurses and physicians. 

Collaboration is the “process of joint decision making among independent parties involving 

joint ownership of decisions and collective responsibility for outcomes. The essence of 

collaboration involves working across professional boundaries”31 (p. 186). Assumptions have 

been advanced that greater collaboration between nurses and physicians results in improved 

quality of patient care. 

One of the first, and most often cited, studies on collaboration was conducted by Knaus, 

Draper, Wagner, and Zimmerman in 1986.32 These researchers analyzed patient outcomes in 13 

intensive care units (ICUs) and found a significant relationship between the presence of excellent 

interaction and coordination of care among nurses and physicians and improved patient 

outcomes. In subsequent work, Shortell, Zimmerman, and Rousseau 38 looked at communication 

and coordination in 42 ICUs, but they were unable to differentiate ICUs according to riskadjusted survival. However, these researchers noted that communication and coordination helped 

decrease length of stay. 

Baggs and others34, 35 investigated the perceptions of physician-nurse collaboration and either 

negative outcomes (e.g., death or readmission to the ICU) or the transfer of patients from the 

ICU to an area of less intensive care. In the first study of one ICU,34 these researchers found that 

the more collaboration nurses reported, the lower the risk of a negative patient outcome. In the 

second study in three different types of ICUs,35 reports of collaboration by nurses in the medical 

ICU correlated significantly with patient outcomes: When the nurse reported full collaboration, 

the patient’s risk of negative outcome was 3 percent; when the nurse reported no collaboration, 

the patient’s risk increased to almost 14 percent. These findings were not observed in the surgical 

ICU or the community hospital ICU. Interestingly, in both of the studies, the reports of 

collaboration by attending physicians and residents were not associated with patient outcomes in 

any site. Differences in perceptions about collaboration have been found by other researchers as 

well, with physicians consistently perceiving higher levels of collaboration than nurses.33, 40, 43 A 

study by Hojat and colleagues39 in Mexico, however, found the opposite. 

Evidence-Based Practice Implications 

Executive Level 

It is very difficult to link leadership to patient safety because the evidence pool is quite 

limited. Across studies of CNO leadership, weak designs prevail and the specific topics studied 

are very diffuse. As a result, it is difficult to make statements to guide practice. 

A modest body of evidence is accruing about leadership styles. These studies illustrate that 

multiple styles of leadership may be operationalized concurrently. Evidence related to 

transformational leadership suggests that researchers need to consider multiple types of 

leadership and how the types work together, helping to limit bias created by studying only 

transformational leadership—or advocating for transformational leadership as a superior style. 

The evidence simply does not support that view. 

5
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Nurse-Physician Collaboration 

On behalf of the Cochrane Collaboration, Zwarenstein and Bryant51 completed an 

international review on collaboration and found several hundred studies on the topic. After 

examining the abstracts, these colleagues reviewed the full text of 31 studies and found three 

studies that were “methodologically adequate and evaluated relevant interventions”51 (p. 4), 

although one study eventually had to be excluded because it was difficult to sort out the impact 

of combined interventions.52 The first retained study by Curley and colleagues53 used a 

randomized, controlled method to examine the impact of interdisciplinary rounds on aspects of 

inpatient care. These researchers found a shorter length of stay (5.46 vs. 6.06 days) and lower 

total charges ($6,681 vs. $8,090) for patients receiving care from the interdisciplinary team. 

The second retained study at a Thai academic hospital54 compared average lengths of stay for 

females in a control ward with those for females in a second ward in which frequent rounding 

and weekly team case conferences occurred. There were no significant differences found, 

although patients in the interventional ward had shorter lengths of stay, when patients who died 

while in the hospital were excluded. These studies are reported in Evidence Table 2. 

The inclusion criteria for the Cochrane Collaboration report were very restrictive and the 

results do not provide health care leadership with enough relevant information to guide quality 

improvement projects. However, a recent critical review55 was completed that incorporated a 

wider range of methodological designs to help illuminate findings from experimental research on 

the impact of nurse and physician collaboration on quality and safety of patient care. 

The review was limited to outcome-based experimental studies completed in the United 

States that focused on the acute care setting and nurse-physician collaboration. Seventeen studies 

met the inclusion criteria,31, 37, 53, 56–69 and the findings from this review demonstrated that 

outcomes could be grouped into three categories: professional outcomes, organizational 

outcomes, and patient outcomes. 

Professional outcomes were measured in several different ways, but the most frequent 

evaluation was in communication skills. Other areas measured were teamwork, leadership, job 

satisfaction, and collaboration. Organizational outcomes were very straightforward and consisted 

of only three major types: length of stay (LOS), readmission rates, and hospital costs. Eight of 

the studies that were reviewed focused on patient outcomes. Patient care outcomes ranged from 

anxiety, depression, and pain to functional status, length of time on a ventilator, and diabetes 

management. Usually the data collected were from medical records and interviews with patients 

or their proxies and could be considered reasonably reliable. 

The types of interventions used to improve collaboration had four basic threads: 

interdisciplinary rounding, development of protocols, staff education of patient care guidelines, 

and easier access to information at the patient’s bedside. These threads are closely related to the 

attributes of collaboration: people working together, cooperation, sharing responsibility in 

decisionmaking, communication, and coordination of care. 

The studies that surveyed health care providers’ perceptions used a little broader spectrum of 

interventions. Similarities were in the use of patient rounds, patient care guidelines, and 

increased access to patient information. But these studies employed other interventions that 

included such things as establishing contacts with key stakeholders to discuss roles and 

responsibilities, appointing more physician helpers (NPs), appointing medical directors, 

providing classes on the processes of communication and teamwork, and restructuring of the 

organization to decentralize professionals. One study,61 which identified nine significant 

6 
Leadership

findings, employed a high-quality, randomized controlled design that used five interventions to 

achieve its results: (1) daily review by medical director of medications and procedures; (2) daily 

rounds by multidisciplinary teams; (3) daily assessments by nurses; (4) protocols to improve 

patients’ self-care; and (5) early, ongoing emphasis on returning home. The design and 

interventions of this complex study were well thought out, and the study subsequently 

demonstrated significantly improved patient outcomes in very elderly (older than 70 years), frail 

patients, as well as improvement in organizational outcomes. Details of the 17 studies are in 

Evidence Tables 2 and 3. 

It is apparent that there is a dearth of methodologically sound studies on nurse-physician 

collaboration. While nurses and physicians universally acknowledge the importance of 

collaboration, we actually know very little about what it is, how it works, and whether it makes a 

difference. Furthermore, we have some evidence to suggest that nurses and physicians define 

collaboration differently and use different criteria to assess whether it’s present.33, 40 To a large 

extent, this is because collaboration is part of a complex set of related concepts, often defined 

and operationalized very differently, e.g., as teamwork,36, 70, 71 collegiality,45, 72

communication,73–75 trust,31, 76 and coordination.32, 38 

Additional challenges to establishing a strong evidence base include the following: 

• Current studies focused on only one of several possible interconnecting factors. Without 

adequate theoretical frameworks or sophisticated methodology, it is difficult to sort out 

the contributions of individual factors in a complex situation. 

• Studies typically focused on interventions within one or a few patient care areas, and 

usually within one institution. 

• Outcomes measured tended to be objective and easily quantifiable, such as length of 

stay,53 cost,53 mortality,32, 34, 35, 38, 57 or readmission rates,34, 35 which are certainly 

important. However, we also need more studies on some of the more qualitative 

outcomes, such as patient satisfaction and morbidity, staff morale and retention, and 

patient safety. 

Findings indicated only one study that specifically targets the physician and nurse as coleaders,50 and this was a correlational study in British Columbia. A second study, by Boyle and 

Kochinda,74 implemented a collaborative communication intervention to ICU nursing and 

physician leaders, along with several other identified leaders such as the clinical nurse specialist, 

in two diverse ICUs, using a pretest–post-test, repeated measures design. The intervention 

included a series of educational and experiential modules, yielding improved communication 

skills, leader satisfaction, and perceived problem-solving ability. Though this study included 

nursing and physician leaders, several other individuals were included in the intervention and did 

not target or emphasize the special role of the clinical co-leaders. 

Why are there so few studies examining the relationships between and impact of co-leaders 

in health care, given the extensive emphasis on leadership in health care today? Dougherty and 

Larson77 noted that most research done on collaboration was conducted by nurses, and thus, the 

idea of examining aspects of a partnership wasn’t equally valued. Fagin78 noted that physicians 

are not interested in interprofessional relationships in general, and that health professions’ 

curricula do not include sufficient content in this area, although thoughts are changing as the 

result of a number of national initiatives to promote interprofessional education and common 

competencies.79–82 Two other factors that contribute to this gap are that (1) the role of medical 

director as co-leader of a clinical area is not a widespread phenomenon and, if in place, is usually 

seen in ICUs, emergency rooms, and other specialty areas; and (2) funding by the National 

7
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Institutes of Health and other major funding agencies follows the biomedical model of health 

care research. 

What We Do Not Know—Research Implications 

Executive Level 

Although there is a strong belief that executive leadership is essential to underpin patient 

safety, it is difficult to support that idea from an empirical base. The strongest statement that can 

be made based on empirical studies is that it is unwise to view transformational leadership as a 

preferred style, particularly when this style is assessed independent of other leadership styles and 

organizational variables. We actually know very little about leadership—what works, what does 

not, and leadership style impact on patients, staff, and the organization. Ironically, although 

leadership is a topic of tremendous interest, little empirical evidence exists. 

Nurse-Physician Collaboration 

While the impact of collaboration between nurses and physicians has been studied, we have 

scant strong, empirical evidence that collaboration makes a difference. What is needed are 

consistent definitions of the concept, use of tools with appropriate psychometric properties to 

measure the concepts, interventional studies, and sampling from more than one or a few 

organizations. 

There is much work to be done, and there are a number of helpful resources for getting 

started. The recent work of Gene Nelson, Paul Batalden, and their colleagues83–85 at Dartmouth 

and elsewhere on clinical microsystems provides a framework for examining the role of 

leadership in the patient care area. Ingersoll and Schmitt86 wrote a comprehensive review of the 

literature on work groups and patient safety that highlights teamwork, collaboration, 

communication, and other relevant concepts. Dougherty and Larson77 recently reviewed the 

scope, psychometrics, and use of five instruments that have been used to measure nursephysician collaboration; while the instruments differ significantly from each other, the authors 

concluded that they offer a good starting place for aiding future research. 

A final comment and return to an original point: In addition to research needed on nursephysician collaboration, significant attention must be paid to examining the experience and 

impact of nurses and physicians functioning as co-leaders of clinical areas. What are the factors 

that enhance their ability to model collaboration and co-create healthy work environments that 

benefit patients, families, and all members of the health care team? What are the barriers? What 

are individual, institutional, and societal strategies that can be implemented to a healing 

environment for patients, families, and all caregivers? 

Acknowledgments 

Tremendous gratitude is expressed to the staff of the Armed Forces Medical Library for their 

considerable support of this work. They conducted the database searches and assisted in 

acquiring numerous papers considered in the review of leadership at the executive level. 

8 
Leadership

References 

1. Committee on Quality of Health Care in America. 

Crossing the quality chasm: a new health system for 

the 21st century. Institute of Medicine. Washington, 

DC: National Academy Press; 2001. 

2. Page, A, ed. Keeping patients safe. Transforming the 

work environment of nurses. Washington, DC: 

National Academies Press; 2004. 

3. Al-Mailam FF. Transactional versus transformational 

style of leadership—employee perception of 

leadership efficacy in public and private hospitals in 

Kuwait. Q Manage Health Care 2004;13(4):278-84. 

4. Scott-Cawiezell J, Schenkman M, Moore L, et al. 

Exploring nursing home staff’s perceptions of 

communication and leadership to facilitate quality 

improvement. J Nurs Care Qual 2004;19(3):242-52. 

5. Molinari C, Hendryx M, Goodstein J. The effects of 

CEO-board relations on hospital performance. Health 

Care Manage Rev 1997;22(3):7-15. 

6. Brandi CL. Relationships between nurse executives 

and physicians. The gender paradox in healthcare. J 

Nurs Adm 2000;30(7/8):373-8. 

7. Burritt JE. Organizational turnaround. The role of the 

nurse executive. J Nurs Adm 2005;35(11):482-9. 

8. Byers JF. Knowledge, skills, and attributes needed for 

nurse and non-nurse executives. J Nurs Adm 

2000;30(7/8):354-6. 

9. Cameron A, Masterson A. Managing the 

unmanageable? Nurse executive directors and new 

role developments in nursing. J Adv Nurs 

2000;31(5):1081-8. 

10. Carroll TL. Leadership skills and attributes of women 

and nurse executives. Challenges for the 21st century. 

Nurs Adm Q 2005;29(2):146-53. 

11. Dunham-Taylor J, Klafehn K. Identifying the best in 

nurse executive leadership. Part 1, questionnaire 

results. J Nurs Adm 1995;25(6):68-70. 

12. Dunham-Taylor J. Identifying the best in nurse 

executive leadership. Part 2, interview results. J Nurs 

Adm 1995;25(7/8):24-31. 

13. Dunham-Taylor J. Nurse executive transformational 

leadership found in participative organizations. J Nurs 

Adm 2000;30(5):241-50. 

14. Fosbinder D, Parsons RJ, Dwore RB, et al. 

Effectiveness of nurse executives: measurement of 

role factors and attitudes. Nurs Admin Q 

1999;23(3):52-62. 

15. Gresham JS, Brown HA. Supervision. How satisfied 

are middle nurse managers? Nurs Manage 

1997;28(1):41-3. 

16. Hemman EA. Leadership profiles of senior nurse 

executives. Can J Nurs Leadersh 2000;13(1):21-30. 

17. Hennessy D, Hicks C. The ideal attributes of chief 

nurses in Europe: a Delphi study. J Adv Nurs 

2003;43(5):441-8. 

18. Klakovich MD. Registered nurse empowerment. 

Model testing and implications for nurse 

administrators. J Nurs Adm 1997;27(11):33-9. 

19. Knox S, Irving JA. Nurse manager perceptions of 

healthcare executive behaviors during organizational 

change. J Nurs Adm 1997;27(11):33-9. 

20. Kuokkanen L, Katajisto J. Promoting or impeding 

empowerment? Nurses’ assessments of their work 

environment. J Nurs Adm 2003;33(4):209-15. 

21. Leach LS. Nurse executive transformational 

leadership and organizational commitment. J Nurs 

Adm 2005;35(5):228-37. 

22. Murray BP, Fosbinder D, Parsons RJ, et al. Nurse 

executives’ leadership roles. Perceptions of 

incumbents and influential colleagues. J Nurs Adm 

1998;28(6):17-24. 

23. Perkel LK. Nurse executives’ values and leadership 

behaviors. Conflict or coexistence? Nurs Leadersh 

Forum 2002;6(4):100-7. 

24. Redmond GM. “We don’t make widgets here.” Voices 

of chief nurse executives. J Nurs Adm 1995;25(2):63-

9. 

25. Upenieks VV. Assessing differences in job 

satisfaction of nurses in Magnet and Nonmagnet 

hospitals. J Nurs Adm 2002;32(11):564-76. 

26. Upenieks VV. What constitutes successful nurse 

leadership? A qualitative approach utilizing Kanter’s 

theory of organizational behavior. J Nurs Adm 

2002;32(11):622-32. 

9
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

27. Upenieks VV. Nurse leaders’ perceptions of what 

compromises successful leadership in today’s acute 

inpatient environment. Nurs Admin Q 

2003;27(2):140-52. 

28. Upenieks VV. What constitutes effective leadership? 

Perceptions of Magnet and Nonmagnet nurse leaders. 

J Nurs Adm 2003;33(9):456-67. 

29. Young C, Eberhart CP, Kovac R. Organizational 

understanding. Understanding the practice of expert 

nurse executives. Nurs Leadersh Forum 

1995;1(4):122-31. 

30. Cummings G. Investing relational energy: the 

hallmark of resonant leadership. Nurs Leadersh 

2004;17(4):76-87. 

31. Liedtka JM, Whitten E. Enhancing care delivery 

through cross-disciplinary collaboration: A case study. 

J Healthcare Mgmt 1998;43(2):185-205. 

32. Knaus WA, Draper EA, Wagner DP, et al. An 

evaluation of outcomes from intensive care in major 

medical centers. Ann Intern Med 1986;104:410-8. 

33. King L, Lee JL. Perceptions of collaborative practice 

between Navy nurses and physicians in the ICU 

setting. Am J Crit Care 1994;3(5):331-6. 

34. Baggs, JG, Ryan SA, Phelps CE. The association 

between interdisciplinary collaboration and patient 

outcomes in medical intensive care. Heart Lung 

1992;21:18-24. 

35. Baggs JG, Schmitt MH, Mushlin AI, et al. Association 

between nurse-physician collaboration and patient 

outcomes in three intensive care units. Crit Care Med 

1999;27(9):1991-8. 

36. Cohen IL, Bari N, Stosberg MA, et al. Reduction of 

duration and cost of mechanical ventilation in an 

intensive care unit by use of a ventilatory management 

team. Crit Care Med 1991;19(10):1278-84. 

37. Henneman E, Dracup K, Ganz T, et al. Effect of a 

collaborative weaning plan on patient outcome in the 

critical care setting. Crit Care Med 2001;29(2): 297-

303. 

38. Shortell SM, Zimmerman JE, Rousseau DM. The 

performance of intensive care units: does good 

management make a difference? Med Care 

1994;32:508-25. 

39. Hojat M, Nasca TJ, Cohen MJM, et al. Attitudes 

toward physician-nurse collaboration: a cross-cultural 

study of male and female physicians and nurses in the 

United States and Mexico. Nurs Res 2001;50(2):123-

8. 

40. Rosenstein AH. Nurse-physician relationships: impact 

on nurse satisfaction and retention. Am J Nsg 

2002;102(6):26-34. 

41. Wilkinson CS, Hite KJ. Nurse-physician collaborative 

relationship on nurses’ self-perceived job satisfaction 

in ambulatory care. Lippincott’s Case Mgmt 

2001;6(2):68-78. 

42. Copnell B, Johnston L, Harrison D, et al. Doctors’ and 

nurses’ perceptions of interdisciplinary collaboration 

in the NICU, and the impact of a neonatal nurse 

practitioner model of practice. J Clin Nsg 

2004;13:105-13. 

43. Thomas EJ, Sexton JB, Helmreich RL. Discrepant 

attitudes about teamwork among critical care nurses 

and physicians. Crit Care Med 2003;31(3): 956-9. 

44. Baggs JG, Ryan SA. ICU nurse-physician 

collaboration and nursing satisfaction. Nurs Econ 

1990;8(5):386-92. 

45. Feiger SM, Schmitt MH. Collegiality in 

interdisciplinary health teams: its measurement and its 

effects. Soc Sci Med 1979;31A:217-29. 

46. National Commission on Nursing. Initial report and 

preliminary recommendations. Chicago, IL: The 

National Commission on Nursing; 1981. p. 62. 

47. Accreditation manual for hospitals. Chicago, IL: Joint 

Commission on Accreditation of Hospitals; 1982. 

48. American Association of Colleges of Nursing. The 

organization of human resources in critical care units. 

Focus on Crit Care 1983;10(1):43-4. 

49. Gilmore TN. Productive pairs. Philadelphia, PA: 

Center for Applied Research, University of 

Pennsylvania; 1999. p. 1-4. 

50. Tjosvold D, MacPherson RC. Joint hospital 

management by physicians and nursing administrators. 

Health Care Manage Rev 1996;21(3):43-54. 

51. Zwarenstein M, Bryant W. Interventions to promote 

collaboration between nurses and doctors (Review). 

The Cochrane Database of Systematic Reviews 2000, 

Issue 2. Art. No.: CD000072. DOI: 

10.1002/14651858. 

52. Schmidt I, Claesson CB, Westerholm B, et al. The 

impact of regular multidisciplinary team interventions 

on psychotropic prescribing in Swedish nursing 

homes. J of the Am Ger Soc 1998;46(1):77-82. 

53. Curley C, McEachern JE, Speroff T. A firm trial of 

interdisciplinary rounds on the inpatient medical 

wards. Med Care 1998;36(8, Supplement):AS4-12. 

10 
Leadership

54. Jitapunkul S, Nuchprayoon C, Aksaranugraha S, et al. 

A controlled clinical trial of multidisciplinary team 

approach in the general medical wards of 

Culalongkorn Hospital. J Med Assoc Thai 

1995;78(11):618-23. 

55. Senn, LA. Collaboration between nurses and 

physicians: a critical review of outcome based, 

experimental studies. Unpublished manuscript, 

University of Minnesota. 2006. 

56. Inouye S, Wagner DR, Acampora D, et al. A 

controlled trial of a nursing-centered intervention in 

hospitalized elderly medical patients: the Yale 

Geriatric Care Program. J Am Geriatr Soc 

1993;41:1353-60. 

57. Gallager A. Innovations in practice: interdisciplinary 

performance improvement in the intensive care unit of 

a community hospital. Top Clin Nutr 1998;13(4):79-

83. 

58. Lassen AA, Fosbinder DM, Minton S, et al. 

Nurse/Physician collaborative practice: improving 

health care quality while decreasing cost. Nurs Econ 

1997;15(2):87-91. 

59. Jordan-Marsh, M, Hubbard, J, Watson, R, et al. The 

social ecology of changing pain management: do I 

have to cry? J Pediatr Nurs 2004;19(3):193-203. 

60. Kollef M, Shapiro S, Silver P. et al. A randomized, 

control trial of protocol-directed versus physiciandirected weaning from mechanical ventilation. Crit 

Care Med 1997;25(4):567-74. 

61. Landefeld CS, Palmer R, Kresevic D, et al. A 

randomized trial of care in a hospital medical unit 

especially designed to improve the functional 

outcomes of acutely ill older patients. N Engl J Med 

1995;332:1338-44. 

62. Vazirani S, Hays RD, Shapiro MF, et al. Effects of a 

multidisciplinary intervention of communication and 

collaboration among physicians and nurses. Am J Crit 

Care 2005;14(1):71-7. 

63. Trey B. Managing interdependence on the unit. Health 

Care Manage Rev 1996;21(3):72-82. 

64. Dechairo-Marino AE, Jordan-March M, Traiger G, et 

al. Nurse / Physician collaboration: action research 

and the lessons learned. J Nurs Adm 2001;31(5):223-

32. 

65. Boyle D, Kochinda C. Enhancing collaborative 

communication of nurse and physician leadership in 

two intensive care units. J Nurs Adm 2004;34(2):60-

70. 

66. Wyly MV, Allen J, Pzalzer SM, et al. Providing a 

seamless service system from hospital to home: the 

NICU training project. Infants Young Child 

1996;8(3):77-84. 

67. Foley M, Nespoli G, Conde E. Using standardized 

patients and standardized physicians to improve 

patient-care quality: results of a pilot study. J Contin 

Educ Nurs 1997;28(5):198-204. 

68. Narasimhan M, Eisen L, Mahoney C, et al. Improving 

nurse-physician communication and satisfaction in the 

intensive care unit with a daily goals worksheet. Am J 

Crit Care 2006;15:217-22. 

69. Lorenzi EA. The effects of comprehensive guidelines 

for the care of sickle-cell patients in crisis on the 

nurses’ knowledge base and job satisfaction for care 

given. J Adv Nurs 1993;18:1923-30. 

70. Schofield RF, Amodeo M. Interdisciplinary teams in 

heath care and human services settings: are they 

effective? Health Soc Work 1999;24:210-9. 

71. Wheelan SA, Burchill CN, Tilin F. The link between 

teamwork and patients’ outcomes in intensive care 

units. A J Crit Care 2003;12:527-34. 

72. Schmalenberg C, Kramer M, King DR, et al. 

Excellence through evidence: securing collegial, 

collaborative nurse-physician relationships, Part 1. J 

Nurs Adm 2005;35(10):450-8. 

73. Acerra FL, Eisen LA, Mahoney CD, et al. Improving 

nurse-physician communication and satisfaction in the 

intensive care unit with a daily goals worksheet. Am J 

Crit Care 2006;15:217. 

74. Boyle DK, Kochinda C. Enhancing collaborative 

communication of nurse and physician leadership in 

two intensive care units. J Nurs Adm 2004;34(2):60-

70. 

75. Cowan M, Hays RD, Shapiro MF, et al. Effect of a 

multidisciplinary intervention on communication and 

collaboration among physicians and nurses. Am J Crit 

Care 2005;14(1):71-6. 

76. Succi MJ, Lee SD, Alexander JA. Trust between 

managers and physicians in community hospitals: the 

effects of power over hospital decisions. J Healthc 

Mgmt 1998;43(5):397-414. 

77. Dougherty MB, Larson E. A review of instruments 

measuring nurse-physician collaboration. J Nurs Adm 

2005;35(5):244-52. 

78. Fagin CM. Collaboration between nurses and 

physicians: no longer a choice. Acad Med 

1992;67(5):295-303. 

11
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

12 

79. Building the nurse-physician partnership: Restoring 

trust, fostering collaboration. Washington, DC: The 

Advisory Board; 2005. 

80. Greiner AC, Knebel E, eds. Health professions 

education: a bridge to quality. Washington, DC: 

Institute of Medicine; 2003. 

81. Wagner EH, Glasgow RE, Davis C, et al. Quality 

improvement in chronic illness care: a collaborative 

approach. Jt Com J Qual Impr 2001;27(2):63-80. 

82. American Association of Critical-Care Nurses. AACN 

standards for establishing and sustaining healthy work 

environments: a journey to excellence. Aliso Viejo, 

CA: The Association; 2005. 

83. Nelson EN, Batalden PB, Huber TP, et al. 

Microsystems in health care: Part l. Learning from 

high-performing front-line clinical units. J Qual Imp 

2002;28:472-97. 

84. Batalden PB, Nelson EC, Mohr JJ, et al. Microsystems 

in health care: Part 5: How leaders are leading. Jt 

Comm J Qual Safety 2003;29(6):297-308. 

85. Mohr JJ, Barach P, Cravero JP, et al. Microsystems in 

health care: Part 6: Designing patient safety into the 

microsystem. Jt Comm J Qual Safety 2003;29:401-8. 

86. Ingersoll GL, Schmitt M. Interdisciplinary 

collaboration, team functioning, and patient safety. In: 

Page A (editor). Keeping patients safe:Transforming 

the work environment of nurses. Washington, DC: 

National Academy Press, 2003; p.341-83. 
Evidence Table 1. Findings on Impact of CNO Leadership Style

Source Safety 

Issue Related to Clinical Practice

DesignType Study Design, 

Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Finding

DunhamTaylor 200013 Leadership Cross- sectional (4) Design: Level 3. Outcomes: CNO 

leadership style, work group effectiveness. 

National study from all States; 396 CNOs, at least 3 direct reports for each CNO (N = 1,115), CNO’s boss (N = 360); most CNOs were married (77%) females ((93%) in their 40s (54%) with a master’s degree (61%). On average, they had 24 years experience in nursing and 9 years in executive positions. Direct reports and boss characteristics were not described except to note that most bosses were COOs. 

Comparing scores on leadership styles, workgroup effectiveness. 

There was a how CNOs rratings from transformatiolaissez-faire significant diamong CNOCNO bosses effectivenesswith the CNO CNO expectcharacteristictransformatiothat were pa

13
14

Source Safety 

Issue Related to Clinical Practice

DesignType Study Design, 

Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Finding

Leach 200521 Leadership Crosssectional (4) Design: Level 3. Outcomes: 

Organizational commitment which was assessed according to 3 types-moral (normative, internalized identification), calculative (remunerative or compliance), and alienative (negative resistance). 

A national random sample of CNO AONE members working in hospitals and a convenience sample of NM (n = 148) who reported to the CNO and 651 staff nurses who reported to a participating NM. CNOs from 35 States returned 102 usable surveys. All but one CNO were women. They had more than 15 years experience in nursing, and 70% had more than 15 years experience in management. Almost 80% had master’s degrees. NMs were mostly women (95%). Most had been in nursing for more than 15 years (75%), most had more than 15 years experience in management, and 40% held a master’s degree or higher. The staff nurses were mostly women (64%), and most had 11 or more years experience in nursing (62%). Almost 40% had a BSN. 

Leadership and nurses’ organizational commitment. 

CNOs and Nprofile that illtransformatioleadership. Bshowed a nesignificant reorganizationleadership ststatistically sNMs. No relabetween NM organization
Evidence Table 2. Cochrane Collaborative Results: Randomized Controlled Trial Focused on Increasing Collabora

and Physicians Source Safety Issue 

Related to Clinical Practice

Design Type

Study Design, Study Outcome Measure(s)

Study Setting & Study Population 

Study Intervention 

Key Finding

Curley 199853 Collaboration Randomized 

controlled trial–6 month prospective trial, with patients randomly admitted to different doctor groups (Firms). 

Variables measured were length of stay (LOS), hospital charges, provider satisfaction, ancillary service efficiency, readmission rates, and quality of patient care. Using hospital billing system, medical records, and surveys. 

Medical unit inpatients at large county hospital affiliated with university; used a 30-bed nursing unit; each firm had 25 attending physicians and 25–30 residents. 1,102- total number of patients: 535 in control group 567 in intervention group 

Interdisciplinary rounds—MDs, RN (patient care coordinator), pharmacist, nutritionist, and social worker daily rounding; orders written during rounds; chart taken with MD on rounds. 

Significant insatisfaction acollaboration understandincommunicatdecreases in and hospital 

15
Evidence Table 3. Outcome-Based, Experimental Studies Focused on Increasing Collaboration between Nurses an

Source Safety Issue Related to Clinical Practice Design Type Study Design, Study Outcome Measure(s) Study Setting & Study Population Study Intervention Key 

Inouye 199356 Nurse- physician collaboration Prospective cohort study with stratified and matched cohort analysis; not randomized. Variables measured were functional decline—overall; functional decline— matched cohort analysis; using interviews; self reported activities of daily living (ADLs); mini-mental exam; confusion assessment; physical exam; and medical records for risk assessment. Medicine units. Huge differences in baseline data. Required matched cohorts to further analyze data. 216 total 85 intervention 43 RN/MD group 42 RNonly group 131 control 66 matched cohorts Identification and surveillance of frail older people. Twice weekly rounds of the geriatric care team. Nursing-centered educational program. Imp

decusinana

Gallager 199857 Nurse- physician collaboration Retrospective and prospective study, convenience sample, repeated measures done quarterly; for 11- month period. Variables measured were frequency of blood glucose monitoring; nutrition assessment; insulin management; change to glucose intolerance enteral formula as recommended by protocol; using medical records 

review. 

All tube-fed patients admitted to a 16-bed ICU, community hospital; 65 eligible 35 participants who met criteria. 

Interdisciplinary collaboration in study design, organization, and implementation of a performance improvement initiative using the Plan/Do/Check/Act process: a group formed; critical blood glucose levels defined; interventions defined. 

Impmoassmahyp

16
17

Source Safety Issue 

Related to Clinical Practice

Design Type

Study Design, Study Outcome Measure(s)

Study Setting & Study Population 

Study Intervention Key 

Lassen 199758 Nursephysician 

collaboration 

Design – retrospective and prospective comparisons of patient charts 1 year prior to intervention, right after intervention, and then 1 year after intervention, for a 3-month period of time during each interval. 

Variables measured were quality of patient care; costs; length of stay (LOS), number of antibiotics received, and readmissions rates. Using medical records review. 

350-bed tertiary hospital. All children admitted with sepsis during study period. 

Protocol development for management of rule-out sepsis – Education of RNs and MDs in the nursery for 3 months. 

Decand decand rea

Jordan-Marsh 200459

Nursephysician collaboration 

Pre- and postintervention data collection, total 14 quarters; 2–8 were implementation, 9–13 were maintenance. 

Variables measured were documentation of pain; evaluation of effectiveness; improved pain management measured as doses of analgesia; improved pain management measured by analgesia type. Using chart audit (10% of charts each month), pharmacy records of drugs dispensed to ward, and census. 

Patients on a pediatric ward in large urban hospital. Between 715 and 840 patient days per quarter. 

Multifocal approach for QIReferral book; resident experts; flow sheet; classes, policy, and protocol; rounds weekly; interdisciplinary plans; change nurses’ scope of practice to include giving morphine IV; agenda item for P&T Comm; etc. 

Decpatof eimpma
18

Source Safety Issue 

Related to Clinical Practice

Design Type

Study Design, Study Outcome Measure(s)

Study Setting & Study Population 

Study Intervention Key 

Kollef 199760 Nursephysician 

collaboration 

Randomized controlled trial during a 4-month period; stratification according to ICU site. 

Variables measured were duration on mechanical ventilation; need for reintubation; LOS; hospital mortality rate; and cost. Using medical records review. 

In medical ICU and surgical ICU in 2 teaching hospitals; 4 units total. 377 total 179 intervention group (protocol directed) 178 control group (physician directed) 

Protocol-directed weaning from mechanical ventilation developed by medical director; education of nursing and respiratory staff before implementation. 

Sigdurvenand with 

Landefeld, 199561

Nursephysician collaboration 

Randomized control trial – randomly assigned to acute care program for elderly or usual care. 

17 different measures looking at ability to perform ADLs – using different time frames, controlling for risk factors; plus LOS and costs. Using interviews, medical records and Universal Bill (1982). 

>70 yr, admitted to general medical unit 651 total 327 intervention group 324 control group 

Daily review by medical director of meds and procedures; daily rounds by multidisciplinary team, daily assessments by nurses; protocols to improve selfcare; early, ongoing emphasis on returning to home. 

Numcare signdecand rea
19

Source Safety Issue 

Related to Clinical Practice

Design Type

Study Design, Study Outcome Measure(s)

Study Setting & Study Population 

Study Intervention Key 

Henneman. 200137

Nursephysician collaboration 

Pre- and postquasiexperimental; compare patient outcomes 1 year before and 1 year after intervention. 

Variables measured were length of time of mechanical ventilation; length of time in the ICU; cost and complications. Using Medical records; mortality rates, readmission rates to any ICU; staffing patterns, years of experience of nursing and respiratory therapy staff, and management choices. 

8-bed medical ICU; no differences between control and experimental groups 207 total 77 control group 124 intervention group 

Multidisciplinary rounds every morning; assessment data and progress available in medical record (both groups); assessment data and weaning progress flow sheet on board and flow sheet at patient’s bedside (for intervention group only). 

Sigof tsignsomcosrea

Vazirani 200562

Nursephysician collaboration 

Quasiexperimental; 1 control and 1 intervention unit; over a 2-year period. 

Variables measured were collaboration with MDs; NPs, RNs; communication; LOS; cost and readmission rates. Using surveys of nurses (biannually); attending MD (every 2 weeks), and residents (every month). 

2 acute care inpatient medical units; no crossover between units with MDs or RNs; staffing and demographics of patients and nurses same between units. House staff – 111 (58%) Attending physicians – 45 (69%) Nurses – 123 (91%) 

Appointment of an NP; appointment of hospitalist medical director; institution of daily multidisciplinary rounds–lasted 15 minutes per team. 

Sigperhad only bettfelloincramodeccosrea
20

Source Safety Issue 

Related to Clinical Practice

Design Type

Study Design, Study Outcome Measure(s)

Study Setting & Study Population 

Study Intervention Key 

Trey 199663 Nursephysician 

collaboration 

Descriptive, retrospective 

Variable measured was clarity of roles. Using nurse manager’s report. 

Ambulatory care center of a large teaching hospital. Nurses, surgeons and anesthesia staff; no size given 

Clarification, discussion, and resolution of ambiguous roles. Job descriptions of nurse manager and medical director were written and implemented. 

Nurinteidenres

DechairoMarino 200164 Nurse- physician 

collaboration 

Pre- and post-test, intervention study – convenience sample. Surveyed at baseline and 1 month prior and 3 months after completion of interventions. 

Variables measured were perceived collaboration scores and satisfaction with decisionmaking. Using Bagg’s Collaboration and Satisfaction about Care Decisions questionnaire (adapted version). 

RNs working on 3 medical-surgical units and 2 ICUs; 87 pretest 65 post-test; approx 50% response rate: 60% attendance rate for intervention. 

Activities – developed the Operating obtained endorsement; incorporated principles into unit activities; offered 4 hour, one session class re: concepts. 

Sigpercollsatidec

Boyle 200465 Nursephysician 

collaboration 

Quasiexperimental, prospective, intervention study. Intervention group – Pretest–posttest, followupimmediately after intervention. Control group (unit staff) – F/U pretest and 6 months after intervention to explore penetration. 

Variables measured were communication skills and leadership skills; situational stress and personal stress. Using collaboration skill simulation vignettes, ICU nurse-physician questionnaire, and ICU outcomes. 

2 ICU units used; both had same leadership, staffing levels, and technology. Unit A = 4 beds with only 11 diagnoses; 9 nurses; 3 MDs. Unit B = 22 beds with 162 diagnoses; 38 nurses; 14 MDs. 10 leaders for both units. 

6 modules on Interaction Process – 23.5 hours using adult learning methods; 2 4-hr sessions over 8 months. Participants also received coaching and reinforcement between sessions. 

Sigcomleadleadexhimpsatipersiturespar
21

Source Safety Issue 

Related to Clinical Practice

Design Type

Study Design, Study Outcome Measure(s)

Study Setting & Study Population 

Study Intervention Key 

Wyly 199666 Nursephysician 

collaboration 

Descriptive study of quality improvement project. 

Variables measured were satisfaction with workshop and staff’s plan to use elements in their work. Using surveys. 

600 staff nurses 2-day training 

workshop, creating a learning climate that facilitates participation. Focused on Interdisciplinary teams; high-risk infant and family interventions in the neonatal ICU and through transition to community. 

Higworintewor

Foley 199767 Nursephysician 

collaboration 

Pre- and post-test; control and intervention groups; tested 2 months after intervention; convenience sample; 

Variables measured were communication skills with physicians and interactions with patients. Using Nurse-PhysicianPatient Interaction/Communication Survey and demographics. 

Control group from 2 units, intervention group from another unit 66 total 28 intervention group 38 control group 

Nurses engage in 2 different 15-minute videotaped case scenarios using standardized patients and standardized physicians, 1 week apart; rate themselves on a “Performance Assessment Checklist.” 

No nurwith 
22

Source Safety Issue 

Related to Clinical Practice

Design Type

Study Design, Study Outcome Measure(s)

Study Setting & Study Population 

Study Intervention Key 

Narasimhan 200668

Nursephysician collaboration 

Prospective, quasiexperimental, with testing at baseline, 1 week, 6 weeks, 9 months after implementation of intervention. 

Variables measured were staff’s level of understanding goals for the day; communication; desire to continue to use worksheet; and belief the worksheet had a positive effect on patient outcomes. Using surveys. 

16-bed medical ICU, closed unit RNs – baseline – 21 6 wk – 14 9 mo – 18 MDs – baseline – 12 6 wk – 14 9 mo – 17 Response rate not given. 

Daily goals worksheet that included consents, tests, medications, sedation, analgesia catheters, consults, nutrition, mobilization, family discussions, and dispositions (not part of the Medical Record). 

Incrcollundand for 

Lorenzi 199369 Nursephysician 

collaboration 

Single group preand post-test design, repeated measures at baseline, 3 months, and 6 months. 

Variables measured were job satisfaction; level of nurse-physician collaboration; broad knowledge base of sicklecell; and demographics variable (years of experience and present employment status). Using knowledge-based test, job satisfaction tool, and surveys. 

42 eligible 18 participants 40% response rate 

Education program for nurses; 10 hours of sickle-cell disease process, treatment, interventions, and relaxation techniques; Implementation of a comprehensive guideline for the care of sickle-sell patients. 

Sigcollan for varyeapre
23

Source Safety Issue 

Related to Clinical Practice

Design Type

Study Design, Study Outcome Measure(s)

Study Setting & Study Population 

Study Intervention Key 

Liedtka 199831 Nursephysician 

collaboration 

Postintervention survey. 

Variables measured were differences and similarities of nurses’, physicians’, and administrators’ perceptions of factors correlated with successful collaboration. Using questionnaires and interviews. 

Large, academic health center, 3 service lines, and 3 professions surveyed 346 eligible 124 participants 36% response rate 

Organization restructure to service lines; Implementation of a new organizational structure that has nonnursing professionals report to unit managers instead of central department. 

Incrfactwith in Radm