Isaiah Baiyekusi

PHYSICIAN-NURSE RELATIONSHIP
- NURSES PERCEPTION IN INTERNAL MEDICINE AND
SURGICAL UNITS

Thesis
CENTRAL OSTROBOTHNIA UNIVERSITY OF APPLIED SCIENCES
Degree Programme in Nursing
October 2010

ABSTRACT
CENTRAL OSTROBOTHNIA
UNIVERSITY OF APPLIED
SCIENCES
Degree programme

Date
October 2010

Author
Isaiah Baiyekusi

Degree Programme in Nursing

Name of thesis
PHYSICIAN-NURSE RELATIONSHIP. NURSES PERCEPTION IN INTERNAL
MEDICINE AND SURGICAL UNITS
Instructor
Raakel Solvin, MNsc

Pages
41 + Appendices (4)

Supervisor
Marja-Liisa Hiironen, PhD
This research focused on the perception of nurses who worked in the internal
medicine and surgical units on physician-nurse relationship. The aim of the
research was to find out the types of physician-nurse relationship in clinical
settings, the associated factors and how patients could benefit from physiciannurse collaboration.

The research methodology was quantitative descriptive approach by survey

design. For data collection, a questionnaire with 20 fixed questions was targeted
at all 125 nurses working in the internal medicine and surgical units over a period
of six weeks. The number of participants that partook in the study was 73 which
represented 58,4% of the target group.

The results indicated 5 different types of physician-nurse relationships existed; the

most common type was collegial relationship. Several factors were responsible for
the types of physician-nurse relationship that existed; predominantly nurse
autonomy and accountability. It also indicated that professional collaboration and
patient education were beneficial to patient care.

Key words
Nurses

perception,

patient-centred

care,

professional collaboration, specialised units

physician-nurse

relationship,

TABLE OF CONTENTS
1 INTRODUCTION

2 THEORIES AND CONCEPTUAL MODELS IN NURSING

2.1 Needs-based theories

2.2 Interactive-based theories

2.3 Outcome-based theories

2.4 Humanistic-based theories

3 PHYSICIAN-NURSE RELATIONSHIP IN CLINICAL SETTING

3.1 Overview of physician-nurse relationship

8
8

3.1.1 Ethical foundation on physician-nurse relationship

3.1.2 Short background on Medical and Nursing professions

3.2 Types of physician-nurse relationship

11

3.2.1 Collegial relationship

12

3.2.2 Collaborative relationships

12

3.2.3 Guidance relationship

13

3.2.4 Neutral relationship

13

3.2.5 Negative relationships

14

3.3 Factors affecting physician-nurse relationship

14

3.3.1 Nurse competency

15

3.3.2 Nurse autonomy

15

3.3.3 Nurse accountability and responsibility

15

3.3.4 Common ground of physician and nurses

16

3.3.5 Nursing knowledge

16

3.3.6 Educational collaboration

17

3.3.7 Physicians dominance

17

3.3.8 Trust and respect

17

3.4 Patients benefit from physician-nurse collaboration

18

3.4.1 Patient education

19

3.4.2 Professional collaboration

19

4 PREVIOUS STUDIES ON PHYSICIAN-NURSE RELATIONSHIP

20

5 RESEARCH PROBLEM

22

6 IMPLEMENTATION OF THE RESEARCH

23

6.1 Collection of the material

23

6.2 Analysis of the material

25

6.3 Ethics of the research

25

7 FINDINGS OF THE RESEARCH

27

7.1 Background information of study

27

7.2 Types of physician-nurse relationship

28

7.3 Factors affecting physician-nurse relationship

29

7.4 Benefits of patient-centred care

35

8 CONCLUSIONS

37

9 DISCUSSION

38

REFERENCES

39

APPENDICES

1
1 INTRODUCTION

The perception on physician-nurse relationship is complicated because it is

believed to have many conflicts.

The physician-nurse relationship like other

professional relationships is not determined by a single factor but by a combination

of factors. These associated factors will determine whether the outcome of a
relationship would be positive or negative.
This research is aimed at providing healthcare professionals with information
regarding different types of physician-nurse relationships in clinical settings, their
associated factors and ways they could be improved. The improved relationship
would lead to an improvement in patient care and subsequently raising the
standard of care.
The general purpose of this research was to unveil the physician-nurse
relationship from a nursing perspective. Information was collected from nurses
working in the internal medicine and surgical units of Central Ostrobothnia Central
Hospital in Kokkola, Finland. Professional teamwork in these units is essential
similar to many other specialised units because it increases physician-nurse
interaction and affects the physician-nurse relationship. The physician-nurse
relationship impacts the care and outcomes of patients. The interest in this subject
was motivated by the researchers desire to observe optimal patient care from
physician-nurse relationship.
The research problem was to determine the types of relationships that existed
between physicians and nurses, the associated factors to these relationships and
ways that patients can benefit from physician-nurse teamwork.
The results revealed five different types of physician-nurse relationship existed;
the most common type being collegial relationship. Several factors were
responsible

for

the

types

of

physician-nurse

relationship

that

existed;

predominantly nurse autonomy and accountability. It also indicated that

professional collaboration and patient education were beneficial for patient care.

2
2 THEORIES AND CONCEPTUAL MODELS IN NURSING

Theories and conceptual models in nursing were developed by nurse theorists.

These theories and conceptual models were subsequently utilised by nurse
researchers. It is imperative to note and appreciate the contributions made by
nurse theorists, which have led to nursing theories application to nursing
research. These theories and conceptual models formally explain nursing
discipline and nursing process, with the viewpoint of the theorist or model
developer emphasised (Polit & Beck 2008, 145). Discoveries do not generate
theories, conceptual frameworks and models but creation and invention. Theory
construction does not only depend on facts and observable evidence but also the
theorists ingenuity to obtain facts and derive meaning from them. Theory building
is a creative and intellectual venture that can be engaged in by any insightful
individual based on existing evidence and carefully knitting the observation and
evidence together to produce an intelligible pattern. (Polit & Beck 2008, 144.)
Nursing theories help to propel research and knowledge extension. Both nursing
theory and nursing research are reciprocal and mutually beneficial. Theory guides
and initiates ideas for research; research utilises the existing theory and provides
a foundation for new theories. (Polit & Beck 2008, 144.)
Some important theories and their theorist with relevance to nursing research are
outlined. The Nursing theories can be divided into four types: Needs-based
theories, Interactive-based theories, Outcome-based theories, and Humanisticbased theories. (Nursing theories 2010.)

2.1 Needs-based theories

Leininger (2006) developed the theory of culture care diversity and universality
which stated that caring is a universal phenomenon but varies trans-culturally
(Polit & Beck 2008, 146). Plowden and colleagues (2005) research on cultural and
social factors that influence high-risk behaviour among inner-city HIV positive
African Americans benefitted from Leiningers theory (Polit & Beck 2008, 146).

3
Besides that, different cultures perceive, know, and practice care in different ways,
yet there are some commonalities about care among all cultures of the world
(George 2002, 491). Culture was defined as learned, shared, and transmitted
knowledge of values, beliefs, norms and lifeways of a particular group that guides
an individual or group in their thinking, decisions and actions in patterned ways
(George 2002, 510). Care as a noun was defined as those abstract and concrete
phenomena related to assisting, supporting or enabling experiences or behaviours
toward or for others with evident or anticipated needs to ameliorate or improve a
human condition or lifeway (George 2002, 511).
Neuman (2001) designed the health care systems model which stated that Each
person is a complete system; the goal of nursing is to assist in maintaining client
system stability. Jones-Canon and Davis (2005) used Neumans model as a
framework in their study on coping strategies of African-American daughters who
functioned as caregivers (Polit & Beck 2008, 146). The Neuman systems are
founded on two major components stress and the reaction to stress. The
inherent parts of the model are the environment, health and nursing. (George
2002, 341.)

2.2 Interactive-based theories

Allen (2002) developed the McGill model of nursing which stated that Nursing is
the science of health-promoting interactions. Health promotion is a process of
helping people cope and develop; the goal of nursing is to actively promote patient
and family strengths and the achievements of life goals. An example of a nursing
research based on the McGill model is Cossette and colleagues (2002) work on
nursing approaches associated with psychological distress reduction among
patients after myocardial infarction. (Polit & Beck 2008, 146.)
Orem (2003) in her model called Self-care deficit nursing theory stated that Selfcare activities are what people do on their own behalf to maintain health and
wellbeing; the goal of nursing is to help people meet their own therapeutic selfcare demands. Kreulen and Braden (2004) used Orems model to develop a

4
model of relationship between self-helppromoting nursing interventions and
health status outcomes. (Polit & Beck 2008, 146-147.)
Orems theory is composed of three theories which are interrelated - self-care,
self-care deficit and nursing systems. This is supported within these three theories
are six central concepts of self-care; self-care agency, therapeutic self-care
demand, self-care deficit, nursing agency and nursing systems as well as the
peripheral concept of basic conditioning factors. (Foster & Bennett 2002, 149.)
The contribution of Orems work remains as an outstanding tool because of its
versatility and pragmatism to nursing practice. She provided interpretation to
nursings metaparadigm of human beings, health, nursing and the society. She
also played a vital role in defining three steps in the nursing process parallel to the
six step nursing process. They are diagnosis and prescription, design of a nursing
system and planning for the delivery of care and production and management of
nursing systems as compared to assessment, diagnosis, outcomes, planning,
implementation and evaluation. The nursing school curricula and nursing
information systems have been designed based on Orems theory of self-care. Her
work continues to impact nursing globally as it offers a unique way of looking at
the nursing phenomenon. (Foster & Bennett 2002, 149.)
Watson (2005) founded the theory of caring which stated that Caring is the moral
ideal, and entails mind-body-soul engagement with one another. Hemsley and
colleagues (2006) used Watsons model in a phenomenological study of the
transformational experiences of nurse healers (Polit & Beck 2008, 147). Watson
played a vital role in the reorientation of nursing from a biomedical, mechanistic
model to one of caring as an interpersonal, interactive process. However, she
attempted to explain the whole being of an individual but undermined the
importance of the physical. Watson believed that caring-healing consciousness of
a caring occasion unveils potential for healing beyond body and self, leading to
harmony, wholeness, health and spiritual evolution. (Kelley & Johnson 2002, 422.)

5
2.3 Outcome-based theories
Levine (1973) developed the conservation model, which stated that Conservation
of integrity contributes to maintenance of a persons wholeness. Melancon and
Millers (2005) research on the effect of massage therapy versus traditional
therapy for relief of lower back pain used Levines model (Polit & Beck 2008,
146). Levines work touched on adaptation, conservation and integrity.
Conservation is achieved through the process of adaptation and its purpose is
integrity. Adaptation is the life process by which, over time, people maintain their
wholeness or integrity as they respond to environmental challenges in effect, it
means that an individual is in relationship with his or her environment. Adaptation
is characterised by concepts such as historicity, specificity and redundancy.
Conservation defends the wholeness of living systems by ensuring their ability to
confront change appropriately and retain their unique identity (George 2002, 226227).
Levines theory is founded on four principles of conservation such as the
conservation of energy of the individual; the conservation of the structural integrity
of the individual; the conservation of the personal integrity of the individual and the
conservation of the social integrity of the individual (George 2002, 228).
Newman (1994; 1997) postulated the health as expanding consciousness model
which stated that Health is viewed as an expansion of consciousness with health
and disease parts of the same whole; health is seen in an evolving pattern of the
whole in time, space and movement. Berry (2004) used Newmans theory to
study behaviour changes and personal self discovery in women who maintained
weight loss for one year or more (Polit & Beck 2008, 146). She synthesized a new
view of health formed from disease and non-disease to explain the theory of health
as expanding consciousness. She also explained pattern of a person and
environment, stating that humans are unitary beings moving in time and space,
thereby creating a harmonised organisation. Change was associated with periods
of organisation and disorganisation (George 2002, 533).

6
2.4 Humanistic-based theories
Parse (1999) established the theory of human becoming which stated that Health
and meaning are co-created by indivisible humans and their environment; nursing
involves having clients share views about meanings. Jonas-Simpson and
colleagues (2006) used Parses theory to study the experience of being listened to
among older adults in long-term care settings (Polit & Beck 2008, 147).
Deductions on the principles, concepts, and theoretical structures of human
becoming were obtained by assumptions made by Parses theory on humans and
health. These postulations were based on Rogers principles and concepts and the
works of Heideger (1962, 1972), Sartre (1963, 1964, 1966) and Marleau-Ponty
(1973, 1974) on existential-phenomenological thought. Rogers three major
principles used by Parse included helicy, integrality and resonancy. She also used
four other concepts and pan-dimensionality as part of the theoretical basis for her
own postulations about man and health. Parse fused these principles and
concepts with the following tenets and concepts of existential-phenomenological
thought: intentionality, human subjectivity, co-constitution, coexistence and
situated freedom (Hickman 2002, 429).
Parses postulations lead to three principles of human becoming. These principles
are as follows: Principle I Structuring meaning multidimensionally is cocreating
reality through the languaging of valuing and imaging. Principle II Cocreating
rhythmical patterns of relating is living the paradoxical unity of revealingconcealing and enabling-limiting while connecting-separating. Principle III
Cotranscending with the possible is powering unique ways of originating in the
process of transforming. (Hickman 2002, 433-435.)
Parses school of thought of human becoming is a science system of interrelated
concepts which describes the unitary humans mutual process with the universe in
cocreating becoming. Human participation in health is the fundamental tenet of the
ontology of human becoming. (Hickman 2002, 429.)
Roger (1970, 1986) in her theory called science of unitary human beings stated
that the individual is a unified whole in a constant interaction with the
environment; nursing helps individuals achieve maximum well-being within their

7
potential. Wright (2004) used Rogers theory to study the relationship between
trust and power in adults as a way of illuminating nurse-client relationships (Polit
&Beck 2008, 147). Rogers conceptual theory is being credited for its broad scope
and its applicability to all nursing practice settings. It has a great impact on both
nursing education and nursing practice. It has also contributed enormously to the
growth of nursing research and development of further theoretical knowledge
(Garon 2002, 284).
Roy (1999) founded the adaptation model which stated that Human are adaptive
systems that cope with change through adaptation; nursing helps to promote client
adaptation during health and illness. Shyu and associates (2004) in their study of
environmental barriers and mobility among elders in Taiwan tested Roys model
(Polit & Beck 2008, 147). Roys model outlined the important concepts of nursing
as the human adaptive system, the environment, health and nursing. There is a
constant interaction between the human adaptive systems and the internal and
external environmental stimuli. It is either active or reactive to these stimuli
(Galbreath 2002, 330).

3 PHYSICIAN-NURSE RELATIONSHIP IN CLINICAL SETTING

3.1 Overview of physician-nurse relationship

The Oxford English dictionary defines a Physician as a person who is trained and
qualified to practice medicine and is also referred to as a Medical Doctor (MD). A
Nurse refers to a person who nurtures or cares for others; a registered nurse (RN)
is a qualified nurse who has been entered into an official register. Relationship
refers to a connection formed between two or more people or groups based on
social interactions and mutual goals, interests or feelings. (Oxford English
Dictionary 2010.)
Physician-nurse relationship can be defined as the professional interaction, cooperation, communication and collaboration that exist between physicians and
nurses. Collaboration is working with colleagues towards an agreed objective and
is advanced through consultations with patients and colleagues. (Bor, Gill, Miller &
Evans 2009, 56.)
Figure 1 shows a pictorial representation of physician-nurse collaboration with the
patient.
PHYSICIAN

NURSE

COLLABORATION

PATIENT
FIGURE 1. Physician-nurse collaboration with the patient.

9
Collaboration is not an event but a process when it is accepted as a core value
and translated into behaviour, collaboration becomes an organisation norm.
Collaboration is best seen as a relationship, a process with ongoing interactions.
(Kramer & Schmalenberg 2005, 450.)

3.1.1 Ethical foundation on physician-nurse relationship

An ethical approach to the foundations of health professionals is multidimensional.
It includes professional etiquette, chores and responsibilities to patients and
colleagues or politics with its focus on the society. The focus should be doctors
and nurses responsibility towards patients and professional relationship. This
focus can help in providing a foundation for setting up a new health care team.
(Storch & Kenny 2007, 479.)
The working relations between physicians and nurses, as any set of relations
between a pair in the place of work, are threatened to some degree by interprofessional conflicts. These conflicts can be attributed to differences such as
gender, educational gap and socio-economic state, misunderstanding and
incompatibility. And also the recent decision of nurses to undertake greater
responsibilities. (Tabak & Koprak 2007, 321.)
Therefore, it is important to examine the landmarks that constitute both the
medical profession and the nursing profession to obtain facts on the professional
ideals and realities.

3.1.2 Short background on Medical and Nursing professions

Western (allopathic) medicine is rooted in the Hippocratic tradition that blended the
birth of priestly healing with practical science. The history of medicine is
characterised by diverse conceptions of science. However, the union of the
practical science and the moral commitment is a trademark of this tradition. The
relationship between the brilliant and authoritative physician and the unprotected

10
patient requires a base of moral commitment and general promise to use the
power of medicine for a patients well-being. (Storch & Kenny 2007, 480.)
The background of nursing is closely linked to medicine, religion and healing.
According to Hindu records, a nurse is expected to be trustworthy, skilful and to be
of high standard. Although enjoying early identification, nursing received rather
slow development compared to medicine. Florence Nightingale regarded as the
mother of nursing who cared for soldiers during the Crimean war of 1854, after
which she stated in Notes in Nursing ethical admonitions such as listening to
patients, upholding confidentiality and putting patients needs first. Many nurses
were influenced by her care philosophy and viewed nursing as a calling of healing
the body and saving the soul. (Storch & Kenny 2007, 481.)
Parse (1998) differentiated the paradigms of nursing by stating that the totality
paradigm views nursing as an applied science, drawing knowledge from all other
sciences while the simultaneity paradigm views nursing as a basic science with its
own body of distinct knowledge. Hence, totality-paradigm-based nursing practice
focuses on diagnosis and treatment in curing, controlling, and preventing disease.
(Hickman 2002, 428.)
Updated versions of the Hippocratic Oath are taken by all graduating medical
students even up to this day. The essential ethic of the profession is contained in
all versions stated: to act for the patients welfare; to do no harm; to keep in
confidence what is learned in functioning as a physician; and to provide help for
those in need. A school of thought believed the technological advancements
medicine underwent, questions the moral core of the profession. However, the
revival of the professional interest with its focus on the moral core is viewed as a
way of redeeming medicine. (Storch & Kenny 2007, 480.)
The Florence Nightingales Pledge (written by Lystra Gretter in the USA in 1893,
but ascribed to Nightingale) was used as the pledge for thousands of probationary
and graduate nurses in North America. Nursing education provides great
importance to aspects of spiritual care as well as gaining mutual trust and
reciprocity in interactions with a patient and his family (Storch & Kenny 2007, 481).

11
The Pledge also reminds us of the importance of both autonomy and collaboration
with physicians:
I solemnly pledge myself before God and in the presence of this assembly,
to pass my life in purity and to practice my profession faithfully. I will abstain
from whatever is deleterious and mischievous, and will not take or
knowingly administer any harmful drug. I will do all in my power to maintain
and elevate the standard of my profession, and will hold in confidence all
personal matters committed to my keeping and all family affairs coming to
my knowledge in the practice of my calling. With loyalty will I endeavour to
aid the physician, in his work, and devote myself to the welfare of those
committed to my care (Lewis 2006).

3.2 Types of physician-nurse relationship

Kramer & Schmalenberg (2003) conducted a study on securing a good physiciannurse relationship in which they analysed responses from 14 magnet hospitals and
resulted in a five-category physician-nurse relationship scale. Literature regularly
revealed that nurses in magnet hospitals had a good physician-nurse
relationship. However, the question here was what do nurses refer to as a good
relationship with the physicians? Was there any connecting factor between the
quality of physician-nurse relationship and the quality of patient care delivery? Are
the qualities of these relationships quantifiable? The answers to these questions
might serve as an enhancer to the level of nurse job satisfaction, the quality of
patient care outcomes and other outcomes closely related and affected by
physician-nurse relationships.
Collaboration is often associated with goodness by healthcare professionals
which has led many researchers into linking physician-nurse relationship or
collaboration to augmented staff and patient satisfaction, enhanced retention and
diminished costs of care. Even though some argue that a solid physician-nurse
relationship is based on mutual respect, good communication, and a positive
attitude towards patients. Previous studies from 1888 to late1990s have shown a
disparate power differentiation in physician-nurse relationships in favour of the
physicians. (Kramer & Schmalenberg 2003, 35.)

12
In a classic study, all Intensive Care Units (ICU) in 13 large hospitals nationwide
were examined. ICU patients cared by physicians and nurses who worked
collaboratively, revealed lower mortality rate records than those who were cared
by less collaborative nurses and physicians. (Kramer & Schmalenberg 2003, 35.)

3.2.1 Collegial relationship

Collegial relationships are described as excellent relationships. The core
ingredient in these relationships is different but equal power and knowledge. It
can be clarified with an instance; one nurse said that physicians at her facility
recognise that nurses see subtle changes in patients because they are with them
all the time. This in effect means that physicians value and respect the
knowledge that working with nurses will create the best care plan which can help
to decide whether to discharge a patient or to insert a central line. There is also
expectation from the nursing managers in these relationships that requires nurses
to contribute their clinical input regarding patients. (Kramer & Schmalenberg 2003,
36.)
The collegial relationships are further characterised by equal trust, power and
respect. Physicians and nurses often regard themselves as peers or colleagues in
describing these relationships as illustrated in the following excerpt: Physicians
are excellent. They value our opinion and ask for input. The physician asked
me whether or not this patient is ready to go home, and I said No, he is
complicated and still needs 24 hour home care. We have got to get that
completely arranged. We discussed what type of central line to put in before the
patient goes. It happens on a daily basis that the physician seeks us out because
they know that we know. (Kramer & Schmalenberg 2009, 77.)

3.2.2 Collaborative relationships

Collaborative relationships are described as good or great relationships. It is
based on mutual trust, respect and power producing the willingness of nurses and
physicians to co-operate with one another. It also affords the opportunity for both

13
nurse and physician to provide their views on issues and adequate audience be
granted. Care plan is designed by the physician together with the nurse. However,
the principle guiding this type of relationships is based on mutuality and not
equality, the physician is still superior. (Kramer & Schmalenberg 2009, 77.)

3.2.3 Guidance relationship

In guidance relationship, the teacher can be either the physician or the nurse.
These can be seen when a physician deemed to be well experienced and
knowledgeable and willingly explains and teaches the nurse. However, the case of
a nurse teaching can occur when a specialising physician or specialised physician
who is attending to a medical case not in his or her own specialty. Therefore, they
would rely upon the nurses competence and experience in that field in teaching
and guiding them. (Kramer & Schmalenberg 2009, 77.)

3.2.4 Neutral relationship

Neutral relationship can also be called a friendly-stranger relationship. It is
characterised by the exchange of formal information and the conservations are
neutral. Nurses description of this relationship can be illustrated in the following
excerpt: The physician comes in, checks the patient, write orders and leaves. If I
watch for him, to tell him something about his patient, he may listen, and then he
just grunts and walks off. Sometimes I do not know the physician has been in
until I see the orders on the patients chart. I have been with this physician for
over 17 years, and he still does not know my name, although I address him by his
name every morning. (Kramer & Schmalenberg 2009, 77.)
The above illustration shows how formal, neutral and distant the friendly-stranger
relationship can be. It outlines the indication a friendly-stranger relationship can be
detrimental to quality of care delivered since communication is limited, formal and
sometimes even absent.

14
3.2.5 Negative relationships
Negative relationships are characterised by anger, verbal abuse, real or implied
threats, or resignation. It can be illustrated in the following excerpt: Physicians are
sharp; they snap at you, is not just when they are tired but all the time. Heads roll
around if the physician complains about anything. I watch myself very carefully.
(Kramer & Schmalenberg 2009, 77.)
A poor physician-nurse relationship has a great impact on the health care system.
Studies have revealed that abusive or disruptive behaviour by physicians has
significantly led to nurse burnout, reduction in job satisfaction and decisions to
leave the profession. Nurses have expressed difficulty dealing with the physicians
who are rude, unpleasant, dismissive or intimidating. It is more prevalent among
older physicians than younger which, relates to gender issues, power gaps,
hierarchical traditions and an attitude that nurses are their handmaidens rather
than valued professional collaborators. (Sirota 2007, 53.)

3.3 Factors affecting physician-nurse relationship

The physician-nurse relationships have been the focus of several ongoing
debates.

Researchers have sought answers to the evolving relationships that

exist and the factors that affect the type of physician-nurse relationship. In
practice, most professional relationships including physician-nurse relationships
consist of several elements that determine either a positive or negative
relationship (Pullon 2008, 134). Physician-nurse interaction leads to a process of
perception and communication which is characterised by verbal and nonverbal
behaviours. Perception is ones representation of reality and is related to past
experiences, concept of self, biological inheritance and educational background.
Communication, however, means the passage of information from one person to
another either directly face to face or through other means. Communication forms
the information component of interaction. (King 1981, 145-146.)

15
3.3.1 Nurse competency
Competence is defined by the Oxford English Dictionary (2010) as the ability to
do and competent as adequately qualified for a task, to do, effective, adequate,
appropriate. Competence can be defined as a potential capability for undertaking
a job and competency as the actual performance in complying with standards of
care. Nurse competence is related to the nurses ability to apply his or her
knowledge while competencies are results derived from utilised skills through
practice. The notion of competence is very broad. It involves a diverse set of
qualities such as skills, knowledge, attitudes, motives, personal interest,
perception, reception, maturity and some aspects of personal identity. (Cowan,
Norman & Coopamah 2005, 356-359.)

3.3.2 Nurse autonomy

Autonomy is the freedom to make discretionary and binding decisions that are
consistent within ones scope of practice and freedom to act on those decisions.
Nurse autonomy is the ability of a nurse to freely make discretionary and binding
decisions. The nurse has control over the required knowledge needed for decision
making. The training and education of the nurse equips him or her with the
requisite information and understanding to make a decision. (Lewis 2006.)
The priority of a nurse should be on functioning both as a collaborator with
physicians and as an autonomous professional. The journey of an autonomous
nurse is not an individual journey but a journey for both nurses and physicians and
health care agencies. Ultimately, autonomy will benefit patients, medicine and the
nursing discipline. Highly essential to remember is that in nursing, ones work is
ones honour. (Lewis 2006.)

3.3.3 Nurse accountability and responsibility

The concept of accountability consists of two major attributes: answerability and
responsibility. Accountability can be defined as being answerable for ones actions
and entail giving satisfactory reasons and explanations for ones action or how one

16
has carried out ones responsibility. Responsibility includes everything which one
is seen to have a casual relationship and not only ones intentional conduct (Fry &
Johnstone 2008, 41.)
In the International Council of Nurses (ICN) code of ethics for Nurses (2006), the
responsibility of the nurse is to promote health, prevent illness, restore health and
alleviate suffering. A nurse is said to be accountable when he or she is able to
explain how his or her responsibility has been carried out by justifying the choices
and actions in accordance with accepted principles and standards of professional
nursing conduct and ethics (Fry & Johnstone 2008, 41-42.)

3.3.4 Common ground of physician and nurses

Physicians and nurses both share a common ground in their historical background
of caring for the sick through skill and knowledge but at present the two
professions fail to understand their complementary roles. Most of Hippocratess
teachings were essentially nursing care. However, from earlier times nursing was
regarded as secondary to the role of the physician (Storch & Kenny 2007, 483).
The differences between physicians and nurses are that nurses concentrate on
personal relationship with patients while physicians are technical and emotionally
neutral (Tabak & Koprak 2007, 322).

3.3.5 Nursing knowledge

Merriam Webster Dictionary (2010) defined knowledge as the acquaintance with
or understanding of a science, art or technique. In Nursing, knowledge is a key
part of the preparation towards competence which involves the care of patients
and assessing the personal qualities of the nurse. It includes their moral character
and how well they relate with their patients and colleagues alike. (Cowan, Norman
& Coopamah 2005, 356.)

17
3.3.6 Educational collaboration
Cook (1913) noted that Miss Nightingale said to pit the medical school against the
nursing school is to pit the hour hand against the minute hand, since both hands
are necessary for telling the time (Graham 2007, 1816). In a study, Rosenstein
(2002, 31) identified that most of the respondents comprised of nurses, physicians
and executives, advocated for educational collaboration between physicians and
nurses. They advocated a design focused on education and training of nurses and
physicians towards improving teamwork and working relationships. They included
trainings on the following: sensitivity, assertiveness, conflict management, stress
management, time management and courtesy such as respect, promptness and
preparation. (Rosenstein 2002, 31.)

3.3.7 Physicians dominance

Dominance is defined by the Merriam Webster dictionary (2010) as dominant
position especially in social hierarchy and dominant as commanding, controlling,
or prevailing over others. In medical practice, dominance is closely attributed to
power and authority especially in the decision making process (Ersser & Coombs
2002, 246). Physicians Dominance has led to power imbalance in medicine and
the failure of physicians to understand and respect the role, expertise and moral
responsibility of nurses (Storch & Kenny 2007, 484).

3.3.8 Trust and respect

The Merriam-Webster dictionary (2010) defines trust as assured reliance on the
character, ability, strength or truth of someone or something and respect as high
or special regard; the quality or state of being esteemed. The Cambridge
Dictionary (2010) defines trust as to have belief or confidence in the honesty,
goodness, skill or safety of a person, organization or thing. It defines respect as
politeness, honour and care shown towards someone or something that is
considered important.

18
The concept of trust and respect in Nursing is highly regarded as it includes
aspects of the behaviour of one person towards another. It is based on an attitude
which values other peoples uniqueness and individuality and also recognises
dignity. Trust and respect are important prerequisites for physician-nurse
collaboration; they increase openness, communication and improved patient
outcome. The development of interprofessional trust and respect begins with
identification of professional roles which is based on professional competence.
Figure 2 shows the link between physician and nurse in the development of
interprofessional trust (Baldwin 2008, 278-279; Pullon 2008, 139-143.)

FIGURE 2. The development of interprofessional trust. (Pullon 2008, 143.)

3.4 Patients benefit from physician-nurse collaboration

Patients can benefit from physician-nurse collaboration in any culture and also
contribute to better communication and satisfaction within the professions
(Rosenstein 2002). The collaboration between physicians and nurses has an
impact on the patients.

19
3.4.1 Patient education
Patient education is an important role for the nurse which is fostered by physiciannurse collaboration. Patient education is an interactive process that involves
teaching and learning. Teaching consists of a conscious, deliberate set of actions
designed to help an individual gain new knowledge or skills while learning is the
intentional acquisition of a new skill or knowledge. Physician-nurse collaboration
enhances a guidance relationship between the nurse and the patient. (Hall 2001,
472-474.)

3.4.2 Professional collaboration

Boyle & Kochinda (2004, 61) defined collaboration as nurses and physicians
working together co-operatively to achieve shared problem solving, conflict
resolution, decision making, communication and coordination. Collaboration can
also be seen as a process which allows the interaction of colleagues within a flat
hierarchy with individuals being able to make decisions both independently and as
part of a team (OBrien-Pallas, Hiroz, Cook & Mildon 2005, 10).
Collaborative physician-nurse relationships are responsible for improved patient
outcomes, patient satisfaction, patient transfer and discharge decisions, patient
care or outcomes; decreased risk-adjusted length of stay for patients and reduced
medication errors. It has also been found that collaboration is an integral factor in
positive patient outcomes regardless of the severity of the patients condition.
(OBrien-Pallas et al. 2005, 11.)

20

4 PREVIOUS STUDIES ON PHYSICIAN-NURSE RELATIONSHIP

Coombs & Esser (2004) examined the role of Nursing in clinical decision making in
three ICU in relation to the closed physician-nurse relationship that is needed in
acute and complex care settings. The study was conducted in the United Kingdom
with an ethnographic approach used to investigate the intensive care cultures and
how physicians and nurses formulate their clinical decisions. It was in two phases,
both lasting approximately one year of fieldwork, in which data collection and
analysis were performed concurrently. The findings revealed a variation of roles
and degree of authority in clinical decision making between the nurses and the
physicians. The physicians dominated the decision making process.
Tabak & Koprak (2007) studied the relationship between how nurses resolve their
conflicts with physicians, stress and job satisfaction. It was targeted at nurses of
varying seniority approach to conflict resolution with physicians in relation to their
stress levels. This study was carried out in Israel where 117 nurses of different
status by answering four questionnaires. The result showed that five approaches
emerged, in accordance to Rahim and Bonomas conflict-resolution model (1979).
They

are:

integrating,

obliging,

dominance,

avoidance

and

compromise

approaches. Integrating and dominance approaches in resolving conflict was

associated with low stress levels. Obliging and avoidance approaches were
associated with high stress levels. Furthermore, the seniority and status of nurses
determined which tactics were used to resolve conflict.
Malloy, Hadjistavropoulos, McCarthy, Evans, Zakus, Park, Lee & Williams (2009)
studied the nurses insight into their relationship with physicians; the study was
completed from a cultural and organisational viewpoint. The study was
implemented with participants who were experienced nurses (n = 42) in four
countries: Canada (n = 14), Ireland (n = 13), Australia (n = 6), Korea (n = 9) from
2005 to 2007. The experience of the nurses ranged from 6,5 to 37 years. They
were drawn from different specialities. Data collection was through a qualitative
approach using interviews. Data analysis was performed by thematic content
analysis. The results showed a sense of lack of empowerment related to the

21
hierarchical nature of the nursing and the medical cultures. Diverging views were
also perceived regarding patients ontology; science versus care, for example. The
following four themes emerged from the data analysis: philosophy of health - care
versus treatment; decision process - constrained obligation; silenced voice;
professional respect.
Thompson (2007) compared the attitudes of nurses and physicians to physiciannurse collaboration. The study was conducted in the medical-surgical patient care
setting in the United States. The demographic characteristics of nurses and
physicians as well as the measurement of their different attitudes toward
physician-nurse collaboration were the aim of the study. Data collection utilised the
Jefferson scale of attitude toward physician-nurse collaboration. This tool was
validated with high reliability from previous studies. The results were not significant
statistically even though trends were demonstrated: Nurses attitude was more
positive than those of physicians. The results of this study reiterated the need for
continued efforts towards improving physician-nurse collaboration.

22

5 RESEARCH PROBLEM

The aim of the research was to explore the types of physician-nurse relationship
that exist in the surgical and internal medicine units of Central Ostrobothnia
Central Hospital, Kokkola. Moreover, the research aim was to explore the different
factors that influence the types of relationship that currently exist and how patient
centred care could be enhanced from improved physician-nurse relationship.
The research problem aimed to provide answers to the following questions:
1. What are the types of relationship that exist between physicians and nurses in
surgical and internal medicine units?
2. What are the associated factors influencing physician-nurse relationship?
3. How can patients benefit from physician-nurse teamwork?

23
6 IMPLEMENTATION OF THE RESEARCH

This research was conducted using a quantitative descriptive study by survey

design. The aim of a descriptive study is to explore and describe phenomena in
real life situations. In practice, a descriptive design could be used to develop
theory, identify problems and come to a decision (Burns & Grove 2005, 232). The
descriptive study is considered as quantitative when data are collected numerically
through surveys or questionnaires. Descriptive studies can help to identify
relationship between variables. In this research, the exploration of physician-nurse
relationship associated factors and patient outcomes were analysed. The only way
to understand the beliefs and values of various people in nursing is to describe
them (Houser 2008, 325-326).
The questionnaires (APPENDIX 1) were first prepared in English language and
subsequently translated into Finnish language by a professional language teacher
in order to limit translation errors. The translation of the questionnaires was
necessary to improve nurses participation in the study, since the official language
is Finnish. The questionnaire was first approved by Thesis Supervisor and
subsequently, by the Nursing Director and Managing Director of Central
Ostrobothnia Central Hospital to allow the research to be conducted in the
hospital. A trial was conducted (n=1) to find out whether there were obscurities in
the questions and the time required to answer the questionnaire. The time taken
for answering was approximately 5 minutes.

6.1 Collection of the material

In a quantitative study, the data collection phase is called the empirical phase
which involves the collection of research data. It is also called the pre-analytic
phase, that involves distribution of questionnaires used in the study. (Polit & Beck
2008, 67.)
The questionnaires included 20 questions, all closed and four background
questions. The questionnaire was adapted from Jefferson scale of attitudes

24
towards physician-nurse collaboration. It was modified by the researcher to fit the
purpose and research problem of the study. This was to ensure the validity of the
questionnaires. The questionnaires were distributed to all wards and units included
in the study through the ward nurses who served as contact person. The
questionnaires were sent in sealable envelopes to ensure confidentiality and
anonymity of the respondents. Moreover, a cover letter (APPENDIX 2) was
attached to the questionnaire which explained the aim of the research to help the
respondent understand the questions.
The time frame set for the data collection was initially three weeks. However, the
deadline was extended because some nurses were on vacation at the time of the
study. It was conducted during the summer holiday period. The overall time frame
taken for the data collection was six weeks. Responses were collected at twoweek intervals during July and August 2010. The surgical and internal medicine
polyclinics were partially closed at the time of the data collection. The outpatient
surgical ward was also closed during the period of data collection, hence their
exclusion from the study.
The target group was 125 nurses working in the internal medicine and surgical
units. The surgical unit consists of the operating room, orthopaedic ward (Ward 7)
and soft tissue ward (Ward 10). The internal medicine unit consists of the cardiac
ward (Ward 8) and internal diseases ward (Ward 4). Ward 4 underwent renovation
at the time of the study and its nurses were deployed to Ward 12. Hence, Ward 12
was included in the study.
Priority was given to the ethical standards of the research to avoid negligence.
Completed questionnaires were returned sealed through the ward nurse to the
researcher. Any unsealed returned envelope was declared invalid. Therefore, data
submitted through an unsealed envelope was not examined or analysed.

25
6.2 Analysis of the material
After receiving all the completed questionnaires, it was skimmed through by the
researcher to obtain an overview of responses. The responses were subsequently
categorised according to their respective wards for easy analysis.
The background information was presented in tables and the closed ended
questions were presented in graphs. Emphasis was given to research problem
questions, interesting results, surprising outcomes and beneficial outcomes. Each
question asked specific information that would contribute to the research based on
the research problems and theoretical framework. One step used by the
researcher is called coding in the analysis of the data that involves the process of
translating verbal data into numeric form. Subsequently, the data was transferred
from word document to the Microsoft Excel program for analysis. (Polit & Beck
2008, 67-68.)

6.3 Ethics of the research

The permission to conduct the research in the hospital (APPENDIX 3) was given
by the Director of Nursing and Managing Director of Central Ostrobothnia Central
Hospital, who at that time was substituting the Medical Director on matters related
to research approval. All the necessary documents related to the research
approval were signed. Details regarding the number of nurses working in each
ward were obtained from their respective ward nurses who all received a copy of
the research approval. This was necessary to formalise the research process. A
cover letter was also attached to the questionnaire explaining the purpose of the
research and detailing how it should be returned. The researchers email and
telephone number were added in case of questions concerning the research. The
confidentiality and anonymity of the respondents were protected. Only the
researcher has accessed to the data. The development of this procedure is
needed to ensure that ethical standards are strictly followed in this study, since its
participants are human subjects. (Polit & Beck 2008, 67,167.)

26
The literature used in this research was obtained from original sources. The
literature used is at most 10 years old except for classics which provided great
significance to the research topic or whose authors work has not been updated.
The literature was explored widely to receive the best glimpse of the subject
matter. The target group used in this research was relatively large in order to
obtain a reliable result.

27

7 FINDINGS OF THE RESEARCH

7.1 Background information of study

The study was carried out over a period of six weeks in July and August 2010. The
study was carried out in the Central Ostrobothnia Central Hospital (APPENDIX 4),
Kokkola, Finland. Information was collected from nurses working in the internal
medicine and surgical units of the hospital. Information of the following background
factors were collected in the questionnaire: gender, age, working ward and
working experience in that ward. Out of the total sample (n=125), 73 nurses
participated in the study. The result reached 58,4 % participation which was
comprised of 95,9 % females (n=70) and 4,1 % males (n=3).
TABLE 1. Age distribution and work experience of respondents.
Age distribution
(n=73)

Work experience
(n=73)

23 yr or less

1,4 (n=1)

1 yr or less

8,2 (n=6)

24 - 29 yr

18,9 (n=14)

2 -5 yr

20,5 (n=15)

30 - 35 yr

17,6 (n=13)

6 - 9 yr

16,4 (n=12)

36 - 41 yr

12,2 (n=9)

10 - 25 yr

42,5 (n=31)

42 - 47 yr

20,3 (n=15) more than 25 yr

48 - 53 yr

17,6 (n=13)

54 - 59 yr

10,8 (n=8)

60 yr or over
Total

1,4

12,3 (n=9)

(n=1)
100

Total

100

Table 1 shows that most of the respondents (n=15) are from age 42 to 47 years,
and closely followed by 24 to 29 years (n=14), the average age stood at 40 years.
The highest work experience was 10 to 25 years (n=31) followed by 2 to 5 (n=15),
the average work experience stood at 15,4 years.

28
TABLE 2. Ward distribution of participants
Name of ward
Surgical unit (S),
Internal medicine
unit (I)
Ward 12 (I)

Participants
%

15,1

11

Ward 10 (S)

15,1

11

Ward 7 (S)

12,3

Ward 8 (I)

23,3

17

Operating room (S)

34,2

25

Total

100

73

Table 2 shows the ward distribution of participants. 15,1 % (n=11) worked in Ward
12, 15,1 % (n=11) worked in Ward 10, 12,3 % (n=9) worked in Ward 7 , 23,3 %
(n=17) worked in Ward 8 and the largest participation were from the operating
room which represented 34,2 % (n=25).

7.2 Types of physician-nurse relationship

This research was focused on getting the types of physician-nurse relationship.
The target group was asked to describe their perception of their relationship with
the physicians. There were five choices, each indicating a type of relationship,
adapted from Kramer & Schmalenbergs (2009, 77) research on physician-nurse
relationship.

29

35,8 %

frequency (%)

29,6 %
22,2 %

11,1%

1,2 %
collegial

collaborative

Guidance

Neutral

Negative

Types of physician-nurse relationship

GRAPH 1. Types of physician-nurse relationship

Graph 1 reveals that 35,8% (n=29) of respondents had collegial relationship with
the physicians, 29,6% (n=24) admitted collaborative relationship, guidance
relationship accounted for 22,2% (n=18), the neutral relationship stood at 11,1%
(n=9) and the negative relationship was the lowest with 1,2% (n=1). Interestingly,
19 participants indicated more than one relationship type with the physicians. The
total response on types of physician-nurse relationship was 81 from 55
respondents.

7.3 Factors affecting physician-nurse relationship

There were several associated factors that contributed to the types of physiciannurse relationship that existed such as nurse autonomy, nurse accountability and
responsibility, Nursing knowledge and experience. Closed ended questions were
asked on different factors that contributed to physician-nurse relationship. Some
questions had Yes and No alternatives. Some questions were designed
according to the Likert scale with four choices: strongly agree, agree, disagree and
strongly disagree. Other questions had five options that reflected nurses
perception on different factors that contributed to physician-nurse relationship. The
options were always, often, sometimes, rarely and never.

30
Nurse autonomy analysis revealed 100% (n=73) of the participants answered Yes
to the question. Nurse autonomy was a pointer to the type of physician-nurse
relationship that existed.
On the question on Nurse accountability the nurses response was similar to that
on nurse autonomy. 98,6% (n=72) answered Yes to the question while 1,4%
(n=1) answered No. Nurse accountability was a strong indicator of the type of
physician-nurse relationship in existence.

11,3 %

Yes
No

88,7 %

GRAPH 2. Nurse competency on patient education and psychological counselling

Graph 2 reveals 88,7% (n=63) answered Yes to the question on Nurse
competency on patient education and psychological counselling while 11,3% (n=8)
answered No to the question. The total number of participants who answered the
question was 71.

31

Frequency (%)

50,7 %

28,8 %
16,4 %
2,7 %

1,4 %
Always

Often

Sometimes

Rarely

Never

Nurses' perception

GRAPH 3. Nurse competencies on patient care approach

Graph 3 shows that the nurses competencies on patient care approach. 1,4%
(n=1) noted that they always suggested the patient care approach they perceived
to be useful to the physicians. 28,8% (n=21) answered often did, 50,7% (n=37)
indicated they sometimes did, 16,4% (n=12) indicated they rarely did, and 2,7%
(n=2) revealed that they never did.
The nurses perception on trust and respect in their relationship with the
physicians was inquired. Graph 4 shows the response of nurses on trust and
respect.

52,2 %

Frequency (%)

36,1 %

38,9 %
31,3 %
Trust
15,3 %
11,9 %

4,5 %
0,0 %
Always

Respect
9,7 %
0,0 %

Often

Sometimes

Rarely

Never

Nurses' perception

GRAPH 4. Nurses perception on trust and respect in physician-nurse relationship.

32
Graph 4 shows that the perception of nurses on trust and respect in physiciannurse relationship. 52,2% (n=35) and 31,3% (n=21) of nurses perceived they were
often and sometimes appreciated by physicians respectively. 38,9 (n=28) nurses
indicated that they were trusted sometimes while 36,1% (n=26) revealed that they
were often trusted. All the nurses were never disrespected meanwhile and none of
the nurses were always trusted.

45,4 %

Frequency (%)

44,7 %

7,1 %
2,8 %
Strongly agree

Agree

Disagree

Strongly disagree

Nurses' perception

GRAPH 5. Nurses perception on educational collaboration between Nursing and

Medical students.
Two questions that related to educational collaboration between Nursing and
Medical students and whether inter-professional teamwork should be taught in
their educational programmes was inquired. 44,7% (n=63) of nurses strongly
agreed, 45,8% (n=64) agreed, however 7,1% (n=10) of nurses disagreed and
2,8% (n=4) strongly disagreed.

33

Frequency (%)

43,8 %

28,8 %
19,2 %
5,5 %

Always

Often

Sometimes

2,7 %

Rarely

Never

Nurses' perception

GRAPH 6. Nurses perception on Nursing knowledge.

The perception of nurses on providing information to physicians on unique areas
of Nursing was inquired. The highest percentage of nurses which accounted for
43,8% (n=32) indicated that they often provided information. 28,8% (n=21) of
nurses indicated that they always did, 19,2% (n=14) indicated that they sometimes
did, 5,5% (n=4) said they rarely did. The lowest percentage of nurses, 2,7% (n=2),
indicated they never contributed information to physicians on unique areas of
Nursing.

Frequency (%)

51,4 %

35,9 %

7,0 %

5,6 %

Strong Agree

Agree

Disagree

Strong Disagree

Nurses' perception

GRAPH 7. Nurses perception on physicians dominance.

Two questions were asked regarding physicians dominance in practice. The
highest percentage of nurses, 51,4% (n=73) disagreed while the lowest
percentage of nurses, 5,6% (n=8) strongly agreed with physicians dominance.

34
Also, 35,9% (n=51) of nurses agreed with physicians dominance while 7,1%
(n=10) of nurses strongly disagreed with the notion of physician dominance in
practice.

34,8 %

33,3 %
Frequency (%)

30,4 %

1,4 %
Always

0,0 %
Often

Sometimes

Rarely

Never

Nurses' perception

GRAPH 8. Nurses perception on common ground with physicians.

The perception of nurses concerning overlapping areas whilst working with
physicians was inquired. The perception were as follow: 1,4% (n=1) indicated that
they always, 33,3% (n=23) answered often, the highest respondents, 34,8%
(n=24), answered sometimes, 30,4% (n=21) indicated that they rarely did while
none of nurses had never had overlapping areas whilst working with physicians.

Frequency (%)

55,1 %

31,9 %

10,1 %
2,9 %
Strongly agree

Agree

Disagree

Nurses' perception

GRAPH 9. Nurses perception on responsibility

Strongly disagree

35
The perception of nurses regarding responsibility on monitoring medical treatment
was inquired. 10,1% (n=7) strongly agreed, 55,1% (n=38) being the highest
agreed, 31,9%(n=22) disagreed while 2,9% (n=2) strongly disagreed.

7.4 Benefits of patient-centred care

The benefits a patient can derive from physician-nurse teamwork was inquired as
a result of the type of physician-nurse relationship that existed and different factors
that are associated with the physician-nurse relationship. Two important benefits
were outlined from previous studies; physician-nurse collaboration and patient
education.

Frequency (%)

62,5 %

32,6 %

4,9 %
Strongly agree

Agree

Disagree

0,0 %
Strongly disagree

Nurses' perception

GRAPH 10. Nurses perception on professional collaboration.

Two questions were inquired of the nurses regarding their perception on
physician-nurse collaboration and its impact on patient care. The result revealed
that 62,5% (n=90) strongly agreed with collaboration to benefit patient care, 32,6%
(n=47) agreed with the notion of physician-nurse collaboration while 4,9% (n=7) of
the nurses disagreed with physician-nurse collaboration.

36

Frequency (%)

60,6 %

29,6 %

9,9 %
0,0 %
Strongly agree

Agree

Disagree

Strongly disagree

Nurses' perception

GRAPH 11. Nurses perception on patient education.

The perception of nurses regarding patient education and its role towards
improved patient care was asked. The result revealed that 60,6% (n=43) strongly
agreed, 29,6% (n=21) agreed, while 9,9% (n=7) disagreed with the notion of
patient education.

37
8 CONCLUSIONS

The goal of this thesis was to study the perception of nurses working in internal
medicine and surgical units on physician-nurse relationship. The thesis discussed
the important nursing theories related to nursing research to provide an overview
on the topic and understand the nursing perception and key principles on which
nursing is built. The types of physician-nurse relationship in clinical settings,
associated factors of physician-nurse relationship and patients benefit from
physician-nurse collaboration were outlined in this thesis. A brief review of
literature was given.
The methodology used in this thesis was quantitative descriptive approach by
survey design. The collection of data was carried out over a period of six weeks in
the Central Ostrobothnia Central Hospital in Kokkola, Finland during summer
2010.
A number of findings were identified based on the obtained results. The results
suggested that the nurses perception on physician-nurse relationship was very
good. Similar to the results obtained by Kramer and Schmalenberg (2003 & 2009),
five types of relationships were revealed with collegial relationship (35,8%) being
the most common type while negative relationship (1,2%) was the least.
The key factors responsible for the types of relationship that emerged were nurse
autonomy, nurse accountability, nursing competency, trust, respect, knowledge,
responsibility, professional and educational collaboration (Baldwin 2008; Fry &
Johnstone 2008; Lewis 2006; Pullon 2008). Surprisingly, the nurses were slightly
divided as 58,5% disagreed with physicians dominance while 41,5% agreed with
the notion regarding physicians dominance in health matters.
The results indicated that professional collaboration in terms of joint decision
making played a vital role towards improved patient care. Moreover, patient
education was an important tool for improved quality of care. (OBrien-Pallas et al.
2005.)

38
9 DISCUSSION

Conducting this study was more challenging than originally anticipated. The
chosen subject matter motivated the interest of the researcher but the process
required time and commitment. The process of writing this thesis took about two
years and at every phase of writing, new ideas, perspectives and modifications
were introduced into the study.
The limitation of the study was the time frame of the research which affected the
number of participants as it was conducted during summer and a number of
nurses were on vacation. Meanwhile, obtaining the physicians perception would
have augmented the success of this research. The use of questionnaires did not
provide in-depth findings from the study. Language constraints and time
consumption hampered the utilisation of a qualitative approach in the study. The
questionnaire could have been improved but due to time constraints it was done
during the time frame available to meet the deadline.
The implication of this study is that it creates the awareness of the relevance of
physician-nurse relationship in clinical settings. Furthermore, it equips nursing
students and newly graduated nurses with the necessary information regarding
relationships with physicians. It also raises the awareness of the importance of
educational collaboration between nursing and medical schools. The incorporation
of inter-professional teamwork in their educational curriculum would be highly
beneficial to working relationships and subsequently, the quality of patient care.
Future studies on this subject matter are highly recommended as this work only
forms an introduction to a very interesting phenomenon. Obtaining the physicians
perception would be beneficial and an empirical study of the individual elements
on the subject matter could be examined. An in-depth study with a qualitative
approach could be conducted on the subject matter.

39

REFERENCES

Baldwin, M.A. 2008. Respect. In Mason-Whitehead, E. Mcintosh, A. & Mason, T

(eds.) Key Concepts in Nursing. London: Sage Publishers, 278-284.
Blaxter, L., Hughes, C. & Tight, M. 2006. How to Research. 3rd Edition. Open
University Press.
Bor, R. Gill, S. Miller, R. & Evans, A. 2009. Counselling in Health Care Settings.
United Kingdom: Palgrave Macmillan.
Boyle, D.K. & Kochinda, C. 2004. Enhancing Collaborative Communication of
Nurse and Physician Leadership in Two Intensive Care Units. Journal of Nursing
Administration, 34(2), 60-70.
Burns, N. & Grove, S.K. 2005. The Practice of Nursing Research. 5th Edition.
Elsevier Health Sciences.
Cambridge Advanced Learners Dictionary. 2010. Available:
http://dictionary.cambridge.org/dictionary/british/respect_2 Accessed 11 October
2010.
Coombs, M. & Essers, S. 2003. Medical Hegemony in Decision-making A
Barrier to Interdisciplinary Working in Intensive Care. Journal of Advanced Nursing
46 (3), 245-252.
Cowan, D.T. Norman, I. & Coopamah, V.P. 2005. Competence in Nursing
Practice: A Controversial Concept A Focused Review of Literature. Nurse
Education Today 25, 355-362.
Foster, P.C. & Bennett, A.M. 2002. Self-Care Deficit Nursing Theory. In George,
J.B. Nursing Theories: The Base for Professional Nursing Practice. 5th Edition.
New Jersey: Prentice Hall, 125-154.
Fry, S.T. & Johnstone, M. 2008. Ethics in Nursing Practice: A Guide to Ethical
Decision Making. 3rd Edition. Oxford: Blackwell Publishing.
Galbreath, J.S. 2002. Roy Adaptation Model. In George, J.B. Nursing Theories:
The Base for Professional Nursing Practice. 5th Edition. New Jersey: Prentice
Hall, 295-338.
Garon, M. 2002. Science of Unitary Human Beings. In George, J.B. Nursing
Theories: The Base for Professional Nursing Practice. 5th Edition. New Jersey:
Prentice Hall, 269-294.
George, J.B. 2002. The Conservation Principles: A Model for Health. In George,
J.B. Nursing Theories: The Base for Professional Nursing Practice. 5th Edition.
New Jersey: Prentice Hall, 225-240.

40
George, J.B. 2002. The Neuman Systems Model. In George, J.B. Nursing
Theories: The Base for Professional Nursing Practice. 5th Edition. New Jersey:
Prentice Hall, 339-384.
George, J.B. 2002. Theory of Culture Care Diversity and Universality. In George,
J.B. Nursing Theories: The Base for Professional Nursing Practice. 5th Edition.
New Jersey. Prentice Hall, 489-518.
George, J.B. 2002. Health as Expanding Consciousness. In George, J.B. Nursing
Theories: The Base for Professional Nursing Practice. 5th Edition. New Jersey:
Prentice Hall, 519-538.
Graham, I.W. 2007. Consultant NurseConsultant physician: A New Partnership
for Patient-Centred Care. Journal of Clinical Nursing 16, 1809-1817.
Hall, A. 2001. Client Education. In Potter, P.A. & Perry, A.G. Fundamentals of
Nursing. 5th Edition. London: Mosby, 470-499.
Hickman, J.S. 2002. Theory of Human Becoming. In George, J.B. Nursing
Theories: The Base for Professional Nursing Practice. 5th Edition. New Jersey:
Prentice Hall, 427-461.
Houser, J. 2007. Nursing Research. London: Jones and Bartlett Publishers
Malloy, D.C. Hadjistavropoulos ,T. McCarthy, F.E. Evans, R.J. Zakus, D.H. Park, I.
Lee, Y. & Williams, J. 2009. Culture and Organizational Climate: Nurses Insights
into their Relationship with Physicians. Nursing Ethics 16, 719-733.
Kelley, J.H. & Johnson, B. 2002. Theory of Transpersonal Caring. In George, J.B.
Nursing Theories: The Base for Professional Nursing Practice. 5th Edition. New
Jersey: Prentice Hall, 405-425.
Keski-Pohjanmaan erikoisairaanhoito- ja peruspalvelukuntayhtym 2010.
Available:
http://www.kpshp.fi/fi/default.asp?a=3&b=&c=300&d=keski/sairaalapalvelut/erikois
alat_sairaansijat.htm. Accessed 28 September 2010.
King, I.M. 1981. A theory for Nursing: Systems, Concepts, Process. New York:
Delmar Publishers.
Kramer, M. & Schmalenberg, C. 2003. Securing Good Nurse-Physician
Relationships: Explore the Link between Collaboration and Quality Patient Care.
Nursing Management 7, 34-38.
Kramer, M & Schmalenberg, C, 2005. Excellence Through Evidence: Securing
Collegial/Collaborative Nurse-Physician Relationships, Part 1. Journal of Nursing
Administration 35(10), 450-458.
Kramer, M. & Schmalenberg, C. 2009. Nurse-Physician Relationships in Hospitals:
20 000 Nurses Tell Their Story. Critical Care Nurse 29 (1), 74-83.
Lewis, F.M. 2006. Autonomy in Nursing. Ishikawa Journal of Nursing 3(2), 1-6.

41
Mason-Whitehead, E. Mcintosh, A. & Mason, T. 2008. Key Concepts in Nursing.
London. Sage Publishers.
Nursing Theories: A Companion to Nursing Theories and Models. 2010. Available:
http://currentnursing.com/nursing_theory/understanding_works_nursing_theorists.
html. Accessed 7 October 2010.
OBrien, L. Hiroz, J. Cook, A. & Mildon, B. 2005. Nurse-Physician Relationships:
Solutions and Recommendation for Change. Canada.
Polit, D.F. & Beck, C.T. 2008. Nursing Research: Generating and Accessing
Evidence for Nursing Practice. 8 Edition. Philadelphia: Lippincott Williams &
Wilkins.
Pullon, S. 2008. Competence, Respect and Trust: Key Features of Successful
Interprofessional Nurse-Doctor Relationships. Journal of Interprofessional Care
22(2), 133-147.
Rosenstein, A.T. 2002. Nurse-Physician Relationships: Impact on Nurse
Satisfaction and Retention. American Journal of Nursing 102(6), 2634.
Sirota, T. 2007. Nurse/Physician Relationships: Improving or Not? Issues in
Nursing 37(1), 52-56.
Storch, J.L. & Kenny, N. 2007. Shared Moral work of Nurses and Physicians.
Nursing Ethics 14 (4), 478-491.
Tabak, N. & Koprak, O. 2007. Relationship between how Nurses resolve their
Conflicts with Doctors, their Stress and Job Satisfaction. Journal of Nursing
Management 15, 321-331.
The Merriam-Webster Dictionary. 2010. Available: http://www.merriamwebster.com/dictionary/trust Accessed 11 October 2010.
The Oxford English Dictionary. 2010. Available: http://www.dictionary.oed.com
Accessed 3 July 2010.
Thompson, S. 2007. Nurse-Physician Collaboration: A Comparison of the Attitudes
of Nurses and Physicians in The Medical-Surgical Patient Care Setting.
MEDSURG Nursing 16 (2), 87-104.

APPENDIX 1/1

PHYSICIAN-NURSE RELATIONSHIP SCALE

INSTRUCTION: Please indicate your response by marking (X) in the appropriate box or write
where necessary, from the choices given in each question.

Gender:

Male

Female

Age: ____________ years

Your working unit:

Ward 8

Ward 12

Ward 7

Ward 10

Operating room. If other(s), please state __________________

Your working experience: ____________ years

(1) Should nurses be involved in making policy decision affecting their working conditions?
Yes

No

(2) Should nurses be accountable to patients for the nursing care they provide?
Yes

No

(3) Do you think you have the special expertise in patient education and psychological
counselling?

Yes

No

(4) Do you have a better working relationship with younger physicians than older ones?
Yes

No

(5) Do the physicians think you are capable to assess and respond to psychological
aspects of patients needs?

Yes

No

APPENDIX 1/2

(6) Medical and nursing students during their education should be involved in teamwork in
order to understand their respective roles

Strongly agree
Agree
Disagree
Strongly disagree

(7) Physician should be the dominant authority in all health matters

Strongly agree
Agree
Disagree
Strongly disagree

(8) Patient care is better with joint decision from both physicians and nurses.
Strongly agree
Agree
Disagree
Strongly disagree

(9) Physicians and nurses should contribute to decisions regarding the hospital discharge
of patients.
Strongly agree
Agree
Disagree
Strongly disagree

(10)

The primary function of the nurse is to carry out the physicians orders.
Strongly agree
Agree
Disagree
Strongly disagree

APPENDIX 1/3

(11)

Nurses should have the responsibility for monitoring the effects of medical

treatment.
Strongly agree
Agree
Disagree
Strongly disagree

(12)

Nurses should clarify a physicians order when they think it might have the

potential for detrimental effects on the patient.

Strongly agree
Agree
Disagree
Strongly disagree

(13)

Inter-professional relationships between physicians and nurses should be

included in their educational programmes.

Strongly agree
Agree
Disagree
Strongly disagree

(14)

The physician seeks for my opinion and advice on a patients condition before a

decision is reached.

(15)

Always

Often

Sometimes

Rarely

Never

I suggest to the physicians, the patient care approach that I think is useful.
Always
Often
Sometimes
Rarely
Never

The physician appreciates and respects the work I do as a nurse.

Always

(16)

Often

Sometimes

Rarely

Never

The physician makes me feel like an important part of the patient-care team
Always
Often
Sometimes
Rarely
Never

APPENDIX 1/4

(17)

I inform the physicians about areas of practice which are unique to nursing
Always

(18)

Sometimes

Rarely

Never

I encounter overlapping areas of responsibility while working with the physicians

Always

(19)

Often

Often

Sometimes

Rarely

Never

Which of the statements below best describe your relationship with the

physicians:
We both have different roles but equal power and knowledge
There is mutual trust, respect, power, and cooperation based on mutuality not
equality
Either I or physician teaches and it is a learning process
The relationship formal and there is a near absence of feeling in the relationship

The relationship is frustrating, hostile and resigned

Thank you!

APPENDIX 1/5

LKRI-HOITAJA AMMATILLINEN TYSUHDESKAALA

OHJE: Merkitse vastauksesi oikeaan ruutuun (X) tai vastaa kysymykseen.

Sukupuoli:

Mies

Nainen

Ik: ____________ vuotta

Osasto, jolla tyskentelet:

Osasto 8

Osasto12

Osasto 7

Osasto10

Leikkaussali. Muu, mik: __________________

Tykokemus: ____________ vuotta

(1) Pitisik

hoitajien

osallistua

tyskentelyolosuhteisiinsa?

ptksentekoon,
Kyll

joka

vaikuttaa

heidn

Ei

(2) Pitisik hoitajien olla vastuussa potilaille tekemstn hoitotyst?

Kyll

Ei

(3) Onko sinulla mielestsi potilaiden opastamiseen ja

tarvittavia taitoja?

Kyll

psykologiseen ohjaamiseen

Ei

(4) Onko sinulla parempi ammatillinen tysuhde nuorempiin lkreihin kuin vanhempiin
lkreihin?
Kyll

Ei

(5) Kykenetk lkreiden mielest vastaamaan potilaiden psykologisiin tarpeisiin?

Kyll

Ei

APPENDIX 1/6

(6) Lketieteen ja hoitotieteen opiskelijoiden tulisi koulutuksen aikana osallistua

ryhmtyskentelyyn, jotta he ymmrtisivt tyn vaatimia rooleja.

Vahvasti samaa mielt

Samaa mielt
Eri mielt
Vahvasti eri mielt

(7) Lkreiden pitisi ptt kaikista terveyteen liittyvist asioista

Vahvasti samaa mielt
Samaa mielt
Eri mielt
Vahvasti eri mielt

(8) Potilaiden

hoito

on

parempaa,

kun

sek

lkrit

ett

hoitajat

ptksentekoon.
Vahvasti samaa mielt
Samaa mielt
Eri mielt
Vahvasti eri mielt

(9) Lkreiden ja hoitajien tulisi osallistua potilaiden kotiuttamisptksiin.

Vahvasti samaa mielt
Samaa mielt
Eri mielt
Vahvasti eri mielt

(10)

Hoitajan pasiallinen ty on toimeenpanna lkrin mrykset.

Vahvasti samaa mielt
Samaa mielt
Eri mielt

osallistuvat

APPENDIX 1/7

Vahvasti eri mielt

(11)

Hoitajilla tulisi olla vastuu lkityksen seurannasta.

Vahvasti samaa mielt
Samaa mielt
Eri mielt
Vahvasti eri mielt

(12)

Hoitajan tulisi selvent lkrin mrys, jos mryksell voi mahdollisesti olla

vahingollisia vaikutuksia potilaalle.

Vahvasti samaa mielt
Samaa mielt
Eri mielt
Vahvasti eri mielt

(13)

Lkrin

ja

hoitajan

ammatillinen

tysuhde

tulisi

olla

osa

molempien

koulutusohjelmaa.
Vahvasti samaa mielt
Samaa mielt
Eri mielt
Vahvasti eri mielt
(14)

Lkri kysyy mielipidettni ja neuvoani potilaan tilasta ennen ptksentekoa.

Aina

(15)

Usein

Harvoin

Ei koskaan

Ehdotan lkrille potilaan hoitotapaa, kun se on mielestni hydyllist.

Aina

(16)

Joskus

Usein

Joskus

Harvoin

Ei koskaan

Lkri arvostaa ja kunnioittaa tytni hoitajana.

Aina

Usein

Joskus

Harvoin

Ei koskaan

APPENDIX 1/8

(17)

Lkri saa minut tuntemaan trkeksi osaksi hoitotiimi.

Aina

(18)

Usein

Usein

Ei koskaan

Joskus

Harvoin

Ei koskaan

Lkreiden kanssa tyskennelless kohtaan pllekkisi vastuualueita.

Aina

(20)

Harvoin

Informoin lkreit hoitotylle ominaisista asioista.

Aina

(19)

Joskus

Usein

Joskus

Harvoin

Ei koskaan

Mitk seuraavista vitteist pitvt paikkansa ammatillisessa tysuhteessasi

lkreiden kanssa:
Molemmilla on erilaiset roolit, mutta yht suuri vastuu ja tieto
Yhtlinen

luottamus,

kunnioitus,

toimivalta

ja

yhteisty

vastavuoroisuuteen, ei tasa-arvoisuuteen
Joko min tai lkri opettaa ja yhteisty on oppimista
Tysuhde on hyvin virallinen ja tysuhde on lhes vailla tunteita
Tysuhde on turhauttava, vihamielinen ja alistunut

Kiitos!!

perustuu

APPENDIX 2/1
Unit of Health Care and Social Services

Isaiah Baiyekusi
Terveystie 1,
67200, Kokkola
Finland.

Cover Letter
Dear Respondent,
I am Isaiah Baiyekusi, a fourth year student of public health nursing. I am conducting a study
on nurses view of physician-nurse relationship in surgical and internal medicine units of the
Central Ostrobothnia Central Hospital, Kokkola.
The objective of this research to attempt to understand the relationships that exist between
physicians and nurses, the associated factors and the benefits patients derive from physiciannurse teamwork. Through your participation, I hope to eventually achieve my research
objectives.
Please complete this questionnaire and send it back to me in a sealed envelope through the
ward nurse.
Your participation is voluntary, if you have any questions or concerns about completing the
questionnaire or about participating in this study, you may contact me at
Isaiah.baiyekusi@cou.fi or +358449511196.
Yours Sincerely,
Isaiah Baiyekusi
Encl. Questionnaire

APPENDIX 2/2
Sosiaali- ja terveysalan yksikk, Kokkola
Isaiah Baiyekusi
Terveystie 1
67200 Kokkola
Finland

Tutkimus lkrien ja hoitajien vlisest ammatillisesta tysuhteesta

Hyv vastaanottaja,
Nimeni on Isaiah Baiyekusi, opiskelelen neljtt vuotta hoitotyn koulutusohjelmassa
(terveydenhoitaja).
ammatillisesta

Teen

tutkimusta

tysuhteesta

kirurgian

hoitajien
ja

nkemyksest

sistautien

lkrien

osastoilla

ja

hoitajien

Keski-Pohjanmaan

Keskussairaalassa, Kokkolassa.
Tutkimuksen tarkoituksena on ymmrt sit ammatillista tysuhdetta, joka on lkrien ja
hoitajien vlill, thn tysuhteeseen liittyvi tekijit ja mit hyty tst tysuhteesta ja
lkrien sek hoitajien vlisest tiimityst on potilaille. Osallistumisenne on merkittv apu
tutkimuksessani.
Tyttk tm kyselylomake ja palauttakaa se suljetussa kirjekuoressa osastonhoitajalle.
Osallistumisenne on vapaaehtoista. Jos teill on kysyttv lomakkeen tytst tai
tutkimukseen osallistumisesta, voitte ottaa minuun yhteytt: Isaiah.baiyekusi@cou.fi or
+358449511196.
Ystvllisesti,
Isaiah Baiyekusi
liite: kyselylomake

APPENDIX 3/1

APPENDIX 3/2

APPENDIX 4/1
BACKGROUND INFORMATION

Formation of Central Ostrobothnia Central Hospital

The

Hospital

District

of

Central

Ostrobothnia

(Keski-Pohjanmaan

erikoisairaanhoito- ja peruspalvelukuntayhtym) was founded in 1969 with 258

beds. It received a new building with an additional 50 beds in 1990. The
psychiatric ward began in 1993 with 32 beds. It also established three mental
health outpatient centres across the District of Central Ostrobothnia and a clinic for
intellectually disabled people to cater for the needs of the disabled. The hospital
district is composed of a joint municipal authority, established by 13 local
authorities. The joint authority board is chosen by a 25 member council headed by
a chairman. The boards responsibilities are administrative, preparatory and
executive in nature. The hospital as at 31st of December 2006 oversaw 77 372
inhabitants, of which 85 per cent were Finnish speaking and 15 per cent Swedish
speaking.

Management and Organisation of Central Ostrobothnia Central Hospital

The hospital has a management group which is headed by the Director. Other
members of the management group include the Medical Director, Nursing Director,
Director of Finance, two Consultants and an Assistant Consultant. Also in the
group are the Planning Director, the representative of staff and the deputy
member. The Hospital District of Central Ostrobothnia is divided into six areas;
these areas are further divided into different units. They include the operative area,
conservative area, psychiatric area, diagnostic services and pharmacy as well as
supporting services. Each area, excepting the supporting services which are
headed by the Hospital Director, is headed by an Area Director, who is a Medical
Doctor and a Head Nurse. Under each area are different units and wards headed
by Ward head doctors and Ward head nurses.
Statistics in 2007 revealed that hospital days were 70 185; discharges were
15 420; the average duration of hospital care was 4,6 days; the number of

APPENDIX 4/2
outpatient visits in the somatic area was 89 169, while the number of outpatient
visits in the mental health clinics was 23 709. The staff strength as at 2007 stood
at 987, with nurses being the highest with 501, doctors were 120, other ward
personnel were 115, other personnel were 146, while administrative, kitchen,
technical and cafe personnel were 105.