Chapter 32. Professional Communication

Jean Ann Seago 

Background 

Instructing nurses on communication is a bit like instructing birds on flying. All nurses have 

been taught communication skills as a basic part of a prelicensure nursing program and then 

retaught communication skills in postlicensure programs, continuing education programs, 

workshops, and meetings. Some nurses would be insulted that anyone would even raise the issue 

of communication since raising the issue implies that they are deficient in one of the most basic 

aspects of nursing care. However, the problem with good communication is that it is, ironically, 

easy to talk about but hard to put into practice. In the literature, there are numerous articles that 

provide opinion, both expert and otherwise, about communication,1–7 but there is very little 

evidence about communication practices that have demonstrated an impact upon patient 

outcomes. The purposes of this chapter are to discuss evidence of professional communication 

practices or strategies that have been tested empirically and have a relationship with patient 

outcomes or patient safety, and to provide communication tools that might help practicing nurses 

maintain and improve patient outcomes and patient safety. 

This chapter will focus on communication strategies in hospitals and those related to 

communication between nurses and physicians. Studies related to communication between 

physicians and patients or nurses and patients were included if they were determined to be 

sufficiently methodologically rigorous and had a direct relationship with patient outcomes or 

patient safety. There is a large body of research on communication in other health care settings 

and among other professionals, which was not included in this chapter. 

Historical Context 

The history of communication between doctors and nurses is well documented. A series of 

publications begun in 1967 describing the “doctor-nurse game” provides insight into the way 

nurses have historically made treatment recommendations to doctors without appearing to do so, 

the way doctors have historically asked nurses for recommendations without appearing to do so, 

and how both participants strive to avoid open disagreement.8–27 Although some nurses have 

argued that much has changed—and improved—in the relationships between doctors and nurses 

since that initial 1967 article, there is little evidence, although much wishful thinking, to support 

that view.28–31 Additionally, over the years, the literature has contained descriptions of verbal 

abuse of nurses by physicians,32–35 disruptive physician behavior,36, 37 and advice on how nurses 

can better “handle” physicians.38–41 So, in spite of much discussion, communication between 

doctors and nurses often remains contentious and obscure. 

Theoretical Foundations 

Many professional groups study communication among humans, and a wide range of theories 

guides the work. For the purpose of this review, a sample of theories used to describe or study 

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

nurse-physician communication will be presented in brief. Habermas’ critical theory has been 

used to identify successful nurse-physician collaborative strategies, including a willingness to 

move beyond basic information exchange and to challenge distortions and assumptions in the 

relationships.42 Theories of Foucault and other poststructuralists that have guided concept 

analysis of collaboration and explored the notion that the relationship between power and 

knowledge (knowledge and power are not fixed, meaning not stable, and the idea that there is a 

hidden or “real” discourse) help explain the relationships between nurses and doctors.43, 44

Various perspectives from the field of organizational behavior, including the structural (behavior 

is rational) perspective, the human resource (human needs and motivation) perspective, the 

political (competition for resources) perspective, and the cultural (organizational culture and 

climate) perspective, have been used to guide activities to improve nurse-physician 

communication.45

Feminists and scientists have used oppressed-group behavior theory to explain much of 

nurses’ work and its structure in hospitals, including nurse-physician relationships.34, 46–54 Many 

scientists and writers have evoked the issue of gender as it relates to the work of nurses and the 

relationship between nurses and doctors. Early literature related to gender tends to emphasize 

nurse image, and later work focuses more on nurse job satisfaction; job retention; and differences 

in decisionmaking, attitudes, perceptions, and ethical or moral dilemmas.55–73 Mark and 

colleagues argue for theory development related to nurse staffing and patient outcomes, 

maintaining that one of the important and unexplored areas is the “why” of the nurse-physician 

relationships and the hypothesis that “enhanced” nurse-physician communication would “result 

in early recognition and intervention of potentially hazardous patient situations”74 (p. 13). 

With the recent emphasis on patient safety, hospital error, and adverse events, some hospital 

executives have embraced human factors science and training ideas taken from the aviation 

industry (Crew Resource Management)75 to try to address the issue of patient safety and the lack 

of collaboration or teamwork in hospital settings. One of the most intriguing recent ideas is the 

use of the leader-member exchange theory76–88 to describe the interactions between nurses and 

doctors in hospitals. Hughes and colleagues89, 90 used leader-member exchange theory to create a 

nurse-physician exchange relationship scale and discussed the relationship between nurses and 

doctors in terms of a supervisor-employee relationship. The physician can be thought of as being 

the leader or supervisor of patient care, and the nurse can be thought of as being one of the 

members or employees providing care. This conceptualization will undoubtedly be challenged by 

nurses and nurse leaders who advocate for nurse autonomy or nurse independence, but Hughes 

and colleagues make a compelling argument for viewing the hospital nurse-physician 

relationship through this theoretical lens. There exists a long and varied history between nurses 

and doctors, making it difficult to use only one theory to explain all the subtleties of the 

relationships or to hold the key to improving those relationships. 

Significance—Why Do We Care About Nurse-Physician 

Communication? 

Over the years, there have been repeated cries and admonitions for improving nursephysician communication and questioning why it is so difficult to achieve.1, 63, 91, 92 Some 

research has shown that the lack of interpersonal and communication skills of physicians and 

nurses is associated with errors, inefficiencies in the delivery of care, and frustration.93 There is 

evidence, though conflicting, that links better collaboration with better patient outcomes, 

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Professional Communication 

specifically reduced medication errors,45, 94 reduced risk of inpatient mortality,95–98 improved 

patient satisfaction,99 and some support for efficiency measures such as shorter hospital length of 

stay.100–103 However, several major reviews and studies found no relationship between nursephysician collaboration and patient outcomes such as mortality or self-reported health 

status.100, 102, 103 Physician satisfaction is generally not related to perceived increased 

collaboration; most frequently the evidence links perceived increased collaboration with nurse 

satisfaction.4, 36, 104, 105 Additionally, nurses and physicians view the level of collaboration very 

differently, with nurses typically perceiving less collaboration and poorer communication than 

physicians.70, 106–108 So, even though the descriptive evidence for improved patient outcomes and 

improved hospital efficiency is conflicting, it does not clearly negate the premise that better 

communication and collaboration could have an impact on patient outcomes. 

In the nursing literature, nurse-physician communication is discussed or studied using terms 

such as empowerment, autonomy, collaboration, coordination, teamwork, transitioning, 

organizational culture, climate, and relationships. Assessment of the descriptive studies listed in 

the evidence table and references from other studies provide results, information, and opinion 

about nurse-physician communication, but they are not interventional studies. Some of the more 

compelling descriptive studies are included in the evidence table but do not meet the rigor 

required of randomized controlled trials. The setting of much of the descriptive or interventional 

work is intensive care units, emergency departments, or operating rooms and is often focused on 

nurse change-of-shift report;109–112 physician/resident handoff/sign-off;113–115 nurse-physician 

interaction, both routine and emergent;91, 116–118 foreign language use by physicians and 

nurses;119–124 and communication with patients.125–131

One of the recurring themes in the literature is the difference in perceptions between nurse 

and physician.36, 69, 70, 106–108, 132–134 Nurses are typically less satisfied than physicians with the 

communication or interaction patterns and express the need for their opinions to be heard by 

physicians.133 Areas of particular difference involve those of ethical decisionmaking and the 

moral dilemmas confronted by nurses related to these decisions.135–137 There is also a body of 

literature on the differences between patient and provider (both nurses and physicians) in 

perceptions of care, quality, or comfort.138–143 Although these papers provide important 

descriptions and information about nurse, physician, and patient communication, they are only 

briefly mentioned to provide context for this chapter. The focus of the chapter is on 

communication between physicians and nurses and whether there is a relationship with patient 

safety or other patient outcomes. 

Research Evidence 

There is no shortage of manuscripts in the literature that advocate, based only on opinion, for 

one or another method of building teamwork, collaboration, or communication, including 

recognizing corporate culture,144 quality improvement,145 continuous assessment and regular 

communication,146 and reducing conflict.147 Other publications detail the experience of one 

institution or unit in improving communication or teamwork using strategies such as the 

Comprehensive Unit-Based Safety Program developed at Hopkins,148 Surgical Morning 

Meetings149 using daily goals in an intensive care unit,150 or interdisciplinary rounds.151 These 

individual experience descriptions typically report varying outcomes or lack measured outcomes. 

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

Evidence for Interventions That Improve Positive Communication—

What Works? 

This review found no randomized controlled trials (RCTs) that investigated communication 

interventions between nurses and physicians that had a patient outcome as a measure of interest. 

The RCTs included in the evidence table tested whether various communication training sessions 

for physicians improved communication with patients.152–157 The evidence indicates that 

communication training is effective in improving physician attitudes, beliefs, and communication 

ability. There is also evidence that an intervention called peer leader education155 can result in 

fewer symptom days, lower oral steroid rates, and reduced cost for children with asthma. In 

general, longer training programs (2–3 days) had greater positive effects, and the effects were 

longer lasting. Two RCTs tested the effect of training patients about care using information or 

technology and found slight improvement in patient perceptions of care.158, 159

Four systematic literature reviews were found that evaluated aspects of communication. One 

review of 14 studies measured the effect of communication training on physicians, using selfrating of the training effects, but provided no evidence of a relationship between the training and 

patient compliance or health status, and ambiguous effects on patient psychosocial health.160 The 

second review of 26 studies concluded that various interventions had no effect on patient 

expectations, had conflicting lung-function outcomes, improved systolic blood pressure with any 

interaction, and decreased pain with improved patient-practitioner interaction.161 The third 

review of 89 studies found no patient outcome changes (health status, disease incidence, cure 

rates, mortality rates, complication rates) with implementation of interprofessional education 

versus single-discipline education.162 The fourth review, covering two studies, concluded that 

after communication training, team development meetings, or weekly rounds, there was no 

difference in patient mortality rates; but staff satisfaction increased, and there were conflicting 

results on length of stay.100 

The literature search provided three nonrandomized controlled trials (NRCTs) with control 

groups related to interventions aimed at improving effective communication.163–165 One study 

described a communication training intervention, a second added personnel (nurse practitioners 

and hospitalists) and multidisciplinary rounds to the environment, and the third used weekly 

meetings to discuss role relationships. The first study improved hospital employee work 

satisfaction and perception of opportunities and decreased information overload.

163 The second 

study improved physician perception of collaboration between nurses and doctors, but produced 

no change in nurse perception of collaboration.

164 The third study decreased consumers’ belief in 

shared responsibility for care versus a physician-dominated responsibility for care, and increased 

consumers’ belief that powerful individuals influence a consumer’s health status.165 

Included in the evidence tables are seven quality improvement projects without a control or 

comparison group. These projects are included as examples of the numerous studies in the 

literature that essentially describe the experience of one or two institutions in implementing an 

organizational change to improve doctor-nurse collaboration or communication. DechairoMarino and colleagues166 report on a teamwork training program that produced no differences in 

self-reported collaboration or satisfaction; McFerran and colleagues167 describe implementation 

of a structured communication technique known as Situation-Background-AssessmentRecommendation (SBAR), changing policies, debriefing, and multidisciplinary reports in four 

Kaiser Permanente sites. No long-term measures are reported, and only the short-term 

expectations for the “communication initiative” were met. Leonard and colleagues168 report on 

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Professional Communication 

another Kaiser study of various groups in the organization trained in SBAR, assertion checklists, 

and briefings. Reported outcomes associated with the intervention include reduced wrong-site 

surgery, decreased nurse turnover, and improved employee satisfaction; however, no specifics on 

the measurement of these outcomes are provided. Lassen and colleagues169 describe development 

and education of a collaborative practice (primarily physician specialists) decisionmaking 

protocol that was associated with a decrease in rule out sepsis diagnosis, use of antibiotics, 

patient days, costs, and readmissions in one neonatal intensive care unit (NICU). 

Dutton and colleagues170 reported that daily discharge multidisciplinary rounds were related 

to decreased length of stay in the emergency department and emergency department closures in 

one trauma center. Copnell and colleagues134 reported no difference in perception of doctornurse collaboration after introduction of a nurse practitioner in two NICUs. Boyle4

 reported an 

increase in perceived doctor-nurse communication skills, nurse leadership skills, and problemsolving, and a decrease in nurse stress after a six-module training session called Collaborative 

Communication Intervention. The designs of these quality projects were too weak to allow any 

sort of conclusions to be drawn. 

Practice Implications 

There is insufficient empirical evidence to recommend any specific communication strategy 

or technology device to improve doctor-nurse communication. However, there is mixed or weak 

evidence to support using some of the techniques described in the cited literature. It is likely that 

focusing an organization on any strategy and persisting in that focus will be associated with, at 

least temporarily, a change in doctor-nurse communication patterns (e.g., Hawthorne effect). 

Given the paucity of available evidence, the following suggestions are offered for possible 

consideration in efforts to improve professional communication: 

• Carefully evaluate various strategies for doctor-nurse communication using measurable 

outcomes that are important to your organization; plan to use a strategy that meets the 

needs and culture of your organization. 

• Select a strategy, focus training, and provide organizational support and sufficient 

resources toward improving doctor-nurse communication. 

• Slowly implement the change using sufficient resources and sufficient time. 

• Do not implement multiple changes simultaneously. 

• Persist in that strategy for an extended period of time (years, not weeks or months). 

• Critically and rigorously evaluate the strategy using patient outcomes and worker 

satisfaction. 

• After allowing sufficient thought and time for implementation and evaluation, be willing 

to publicly eliminate the strategy if it does not improve the outcomes. 

Hospitals have used many communication tools such as written and verbal orders, reports, 

rounds, and team meetings. As the United States shifted to the “business model” for hospitals, 

organizations have tried to change culture or climate, create transformational leaders and 

knowledge workers, implement continuous quality improvement or total quality management, 

form quality circles, and train the one-minute manager. Some hospitals have used and are 

currently using technology ranging from pencil and paper, medication rooms and carts, orange 

vests for the medication nurse so she will have fewer interruptions, Pyxis or other automatic 

medication dispensers, landline telephones, fax machines, beepers, e-mail, personal digital 

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

assistants (PDAs), cellular telephones, wireless devices, direct information transfer, and Web 

access. 

Other recent technology includes mobile communication systems such as Vocera, electronic 

medical records, computerized physician order entry, and bar-coding for medication 

administration. A number of organizations are also trying SBAR, organizational support 

structures such as Rapid Response Teams or techniques such as customer relationship 

management from business or crew resource management from aviation. Other organizations are 

trying systems such as Situation-Trajectory-Intent-Concern-Calibrate (STICC) using the Handson Automated Nursing Data System Method from the University of Illinois at Chicago and 

funded by AHRQ, or Gerontology Interdisciplinary Team Training from the Hartford Foundation 

and the American Geriatrics Society. Few, if any, of these methods or devices have been 

empirically tested. Without careful consideration and evaluation, efforts to improve 

communication problems that exist in present-day hospitals may lead to implementation of 

strategies that will be ineffective. 

Research Implications 

Based on the literature review, future research is needed to assess the following: 

• What should be the communication competencies of physicians and nurses; and should 

these competencies be assessed periodically? 

• How can health information technologies be used to ensure effective communication 

between physicians and nurses, across settings and among the various care delivery 

models? 

• What is the impact of effective communication strategies on hospitalized patient 

outcomes and medical errors? 

• What is the impact of effective communication strategies on nurse and physician job 

satisfaction, and how does provider satisfaction relate to patient outcomes? 

• How can communication skills training for practicing physicians and nurses have a 

career-long impact on their communication skills?

Conclusion 

Within health care, there have been and will continue to be many approaches to professional 

communication. Unfortunately, the body of evidence is very limited, and the research findings to 

support professional communication and the relationship with patient safety and quality are not 

available at this time. There were limited studies that tested specific interventions aimed at 

changing nurse-physician communication, and there is some evidence that focusing on a doctornurse communication may have a positive effect. Health care organizations and providers will be 

challenged as they seek to improve the effectiveness of professional communication, given all 

the subtleties of the nurse-physician relationships. 

Search Strategy 

Search strategies employed included the use of the electronic databases PubMed®, 

CINAHL®, the Cochrane Collection, and relevant AHRQ reports. Keywords included physician, 

nurse, relationships, communication, coordination, collaboration, autonomy, teamwork, MD, 

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Professional Communication 

RN, patient, outcome, safety, and adverse event. Reference lists of select publications were 

investigated for potential manuscripts, and literature related to relevant measurement instruments 

was sought. 

Author Affiliation 

Jean Ann Seago, Ph.D., R.N., associate professor, Department of Community Health 

Systems, School of Nursing, University of California, San Francisco. E-mail: 

jean.ann.seago@nursing.ucsf.edu. 

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13 
14

Evidence Table Source Communication Targets Design Type Study Design, Study Outcome Measure(s) Study Setting & Study Population Study Intervention KRandomized Controlled Trials Ellison 2004159 Patients Design Type 2 (RCT) (Level 2) questionnaire Patient satisfaction (Level 3) 1 hospital 85 patients Standard care plus1 day telerounding; standard care substituting 1 day with robotic telerounding Im

teexqupocoMimof 

Fallowfield 2003153 MD/patient Design Type2 (RCT)— pre/postvideotape (Level 2) At 12 months, same as 3 months (Level 3) Oncology MDs, UK 3 day residential communication skills training course S

leenreiminsuex

Jenkins 2002152 MD/pt Design Type 2 (RCT)—P-P videotape (Level 2) At 3 months attitudes, empathy, responses (Level 3) Oncology MDs, UK 3 day residential communication skills training course Im

beiscoexopreanseco
15

Source Communication Targets Design Type 

Study Design, Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

K

Joos 1996157 MD/pt Design Type 2 

(RCT)—P-P questionnaire (Level 2) 

Communication skills (Level 3), and compliance and utilization (Level 2) 

42 MDs and 348 patients with chronic conditions 

4.5 hours of training 

InMcopeinchcomappa

Levinson 1993156 MD/pt Design Type2 

(RCT)—P-P audiotape (Level 2) 

Communication skills (Level 3) 

53 communitybased MDs and 473 patients 

A short CME program (4.5 hours) and a long CME program (2.5 days) 

SLoenpabipainnepaou

Lozano 2004154 MD/children (3–17) with 

asthma 

Design Type2 (RCT)—cluster PP interview and questionnaire (Level 2) 

Asthma symptom days, asthmaspecific functional status, frequency of oral steroid courses (Level 1) 

42 primary care practices in 3 locations 

Peer leader education (PLE) and peer leader + nursemediated organizational change (PACI) 

PdastPsygtr

Sullivan 2005155 MD/children (3–17) with 

asthma 

Design Type 2 (RCT)—cluster PP interview and questionnaire (Level 2) 

Symptom-free days (SFDs); asthmarelated health care costs (Level 1) 

42 primary care practices in 3 locations 

Peer leader education (PLE) and peer leader + nursemediated organizational change (PACI) 

Sususinef$anP
16

Source Communication Targets Design Type 

Study Design, Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

K

Tran 2002158 ED patients Design Type 2 

(RCT) (Level 2) questionnaire 

Patient length of stay (LOS), wait time, perception of LOS, ratings of nurse skills and MD skills (Levels 3 & 4) 

1 hospital ED 619 patients 

Providing patients with information q 15 minutes during stay 

NtimDanin 

Nonrandomized Controlled Trials and Quality Improvement (QI) ProjectsBoyle 20044 MDs/RNs Design Type 6 PP 2 units no 

control (Level 5) 

Communication skills, increased staff satisfaction, lower stress, increased problem-solving using videotape vignettes, questionnaire 

1 ICU from 2 hospitals 

Collaborative Communication Intervention over 8 months: 23.5 hours for 6 modules 

Inansklesonu

Copnell 2004134 MDs/RNs Design Type 6 PP 2 units no 

control (Level 5) 

Perception of collaboration 

2 NICUs Added NP N

afdicosc

Dechairo-Marino 2001166

RNs Design Type 6 

action research—P-P 1 group-no control (Level 5) 

RN reports of collaboration with MDs and RN Satisfaction with decisionmaking process- (Level 3) 

1 university teaching hospital; RNs in 3 med-surg units and 2 ICUs 

Activities to promote interdisciplinary teamwork between MDs/RNs, including developing principles, discussion in meetings, 1 4-hour class on decisionmaking 

N

Dutton 2002170 MDs, nurses, patients 

discharge planners 

Design Type 8-no control group (Level 5) 

Patient volume, LOS, ED closure (Level 3, 4) 

1 hospital trauma service 

Daily discharge multidisciplinary rounds 

Indein 
17

Source Communication Targets Design Type 

Study Design, Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

K

Lassen 1997169 Well-newborn nurses, 

pediatricians, neonatologists 

Design Type 13-QI project with a control time (Level 5) 

# of admissions with R/O sepsis, LOS, # of doses of antibiotics, costs, # of readmissions, reduction in practice variation (Levels 1, 2, 3) 

1 tertiary hospital 

Collaborative practice decisionmaking protocol development; education 

Ddipaanpacore

Leonard 2004168 Various groups in Kaiser 

Permanente 

Design Type 14-QI project-no control (Level 5) 

Improve communication and teamwork by standardized communication (Level 3) 

different groups of MDs and RNs 

Introduce standardized communication methods such as SBAR, assertion, checklists, critical event training, and briefings 

Sresinuemimcorefe

McFerran 2005167

Perinatal RNs, certified registered nurse anesthesists and MDs 

Design Type 13 QI project-no control (Level 5) 

Long-term measures: birth event data, medicallegal data, patient satisfaction data (Levels 1 & 2); short-term measures: implementation of 2-3 interventions using human factors technique during 1 year (Level 3) 

4 Kaiser Permanente medical centers perinatal staff 

4-hour human factors education program, SBAR communication technique, revising escalation policy, identifying safe communications, debriefs after adverse events, multidisciplinary reports, assertion, just culture statement (Level 3) 

Nre4 exco
18

Source Communication Targets Design Type 

Study Design, Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

K

Roberts 1976163 Hospital employees (non-MD 

and nonsupervisors) 

Design Type 3— NRCT-P-P 2 groups with 1 being control (Level 3) 

Employee perception of organizational communication, job satisfaction, and opportunities for innovative job behavior (Level 3) 

1 urban hospital; ED staff members 

2.5-3 hour training sessions weekly for 4 consecutive weeks 

Inwinopinindeov

Weiss 1985165 MD/RN/consumer Design Type 3— 

NRCT with 3 groups, with 2 being matched control groups (Level 3) 

Belief regarding value of shared versus physiciandominated responsibility for health care and beliefs that powerful individuals influence consumer health status (Level 4) 

Recruited in large urban area 

Discussion of role relationships, and problems for 2.5 hours 1 evening/month for 20 months 

Dvereanpoinhe

Vazirani 2005164 Unit organization; RN, MD, 

residents, hospitalist, NP 

Design Type 3—NCRT 2 groups with 1 being control (Level 3) 

Collaboration, communication (Level 3) 

1 hospital; 1 control unit and 1 intervention unit 

Added NP, hospitalist, daily multidisciplinary rounds 

PgbenuwphcoMpecoconupecoth
19

Source Communication Targets Design Type 

Study Design, Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

K

Systematic Literature ReviewsDi Blasi 1996 (Cochrane CollaborationCentre for Reviews and Dissemination)161

Patients with various health problems 

Design Type 11 structured review (Level 1) RCTs with and without placebo 

Health outcome, symptom resolution, functional status (Level 1); health service use, medication adherence, anxiety, satisfaction (Level 3) 

26 studies with 3,811 participants: poor quality studies with small sample sizes 

Various treatments or disease management, including labeling, changing patient expectations, combining treatment information with emotional support 

Lachexrefudsyfocosuoustpapof phsm

Hulsman 1999 (Cochrane CollaborationCentre for Reviews and Dissemination)160

Graduate or postgraduate MDs 

Design Type 11 structured review (Level 1); evaluation studies RCT and NRCT P-P video, discussion, role play, audio, written, self-rating 

Receptive behaviors, information behavior, interpersonal and affective behavior, psychosocial problems and emotions (Level 3); compliance, health status, psychosocial status (Level 2) 

14 studies, 408 participants, 135 controls 

Training, education using lecture, modeling, discussion, role play—4-96 hours over 2 days to 6 months 

10 trdeefof repacocoon efhere
20

Source Communication Targets Design Type 

Study Design, Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

K

Zwarenstein 2000 (The Cochrane Collaboration)100

Chiropodists/podiatrists, dentists, dietitians, MDs, hygienists, psychologists, nurses, pharmacists, occupational therapists, and others 

Design Type 11 structured review (Level 1); RCT, controlled before and after, and interrupted time series 

Self-reported health status, disease incidence, cure rates, mortality, complication rates (Level 1); adherence, satisfaction, continuity of care, costs (Level 3) 

89 studies; none met the inclusion criteria 

Interprofessional education (IPE) versus singlediscipline education 

Nthrep

Zwarenstein 2000 (The Cochrane Collaboration)100

MDs/RNs Design Type 11 

structured review (Level 1); RCT, controlled before and after, and interrupted time series 

MD/RN collaboration/joint decisionmaking (Level 3), costs(Level 4); LOS, mortality (Level 1) 

2 studies with 1,102 admissions in one and 417 admissions in the other 

Training, workshops, ward reorganization, team development, meetings, patient-centered care, 4 times weekly rounds, weekly case conference 

1srein st2nLOm

DescriptiveAiken 1994171 MDs/RNs Design Type 4 

cross-sectional (Level 5) 

Medicare mortality rates (Level 1) 

39 Magnet hospitals, 139 controls 

None M

auremm

Aiken 199999 MDs/RNs Design Type 4 

cross-sectional (Level 5) 

30-day mortality, patient satisfaction, nurse-patient ratios, control by bedside nurses; specialty physicians (Levels 1, 3) 

40 units in 20 hospitals; 1,205 patients and 820 nurses 

None B

locosa

Alt-White 1983105

MDs/RNs Design Type 4, 8 

cross-sectional no comparison group (Level 5) 

Nurse-physician collaboration (Level 3) 

46 units, 446 nurses 

None P

uncosabe
21

Source Communication Targets Design Type 

Study Design, Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

K

Baggs 1997107 MDs/RNs Design Type 4, 8 

cross-sectional no comparison group (Level 5) 

Nurse/physician collaboration and satisfaction with decisionmaking, nurse retention (Level 3) 

3 ICUs in 3 hospital 

None C

asfonuwnore

Baggs 199995 MDs/RNs Design Type 4, 8 

cross-sectional no comparison group (Level 5) 

Mortality, ICU readmission (Level 1) 

3 ICUs in 3 hospitals 

None In 

wnucoof recoasou

Estabrooks 200598

MDs/RNs Design Type 4, 8 

cross-sectional no comparison group (Level 5 

30-day mortality 49 hospitals None G

retenuricw

Kaissi 2003106 MDs/RNs Design Type 4, 8 

cross-sectional no comparison group (Level 5) 

Nurse-physician interpersonal interaction/teamwork (Level 3) 

2 hospitals None 78

exve

King 1994108 MDs/RNs Design Type 4, 8 

cross-sectional no comparison group (Level 5) 

Nurse-physician collaboration (Level 3) 

90 nurses, 40 physicians, 4 hospitals, and 2 hospital ships 

None M

Mco

Knaus 198697 MDs/RNs Design Type 4, 8 

cross-sectional with no comparison group (Level 5) 

Actual and predicted mortality, coordination of care (Levels 1, 3) 

13 hospitals None H

mbeanbeam
22

Source Communication Targets Design Type 

Study Design, Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

K

Rosenstein 200236

RNs/MDs/executives Design Type 4, 8 

cross-sectional with no comparison group (Level 5) 

Nurse-physician relationship (Level 3) 

Network of hospitals; 1,200 responses from RNs, MDs, executives 

None M

siRdimbenupecoMre

Zimmerman 1993103

MDs/RNs Design Type 4, 8 

cross-sectional with no comparison group (Level 5) 

Strong medical and nursing leadership, collaboration, coordination, communication, mortality, LOS (Levels 1, 3) 

9 ICUs in 9 hospitals; 316 RNs and 202 MDs 

None N

adbean

Shortell 1994101 MDs/RNs Design Type 4, 8 

cross-sectional no comparison group (Level 5) 

LOS, nurse turnover, technical quality of care, meeting family needs (Levels 3, 4) 

42 ICUs None H

lecomwtegne

Thomas 200370 MDs/RNs Design Type 4, 8 

cross-sectional no comparison group (Level 5) 

Collaboration, communication (Level 3) 

8 ICUs in 2 hospitals; 90 MDs, 230 RNs 

None M

cocoveas 

Zimmerman 1991102

MDs/RNs Design Type 4, 8 

cross-sectional no comparison group (Level 5) 

ICU LOS, predicted hospital mortality (Levels 1, 3) 

40 hospitals None Lo

wadenascocom
Appendix 

Measurement Instruments Source Measurement Instrument Concepts Number of Shortell 1991172 ICU Nurse-Physician Questionnaire; 48 items selected 

from the Organizational Culture Inventory (OCI) 

Organizational culture, leadership, communication, coordination, problem-solving 

48 items; 1–5 point L

Roberts 1974173 Organizational Communication Communication 35 items; 7–Choi 2004174 Perceived Nursing Work Environment (PNWE) Nursing management, nursing 

process, RN/MD collaboration, nursing competence, scheduling climate 

42 items; 4 

Weiss 1985175 Collaborative Practice Scales RN/MD interaction and influence on 

patient care 

9 items RN Likert scale 

Aiken 2000176 Nursing Work Index-Revised (NWI-R) Autonomy, RN/MD relationships, 

control of practice 

57 items; 4 

Temkin-Greener 2004177 PACE team performance questionnaire Interdisciplinary team performance 59 items; 5 Baggs 1994178 Collaboration and Satisfaction About Care Decisions 

(CSACD) 

RN/MD collaboration 14 items; 7 

Dougherty 2005179 A review of instruments measuring RN/MD collaboration RN/MD collaboration Collaborativ

CollaboratioCare DecisiQuestionnaQuestionnaScale of AttNurse Colla

23