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CE Online and Journal Club Feature

Effect of a Multidisciplinary Intervention on Communication and Collaboration Among Physicians and Nurses

	Abstract

Top Abstract Methods Results Conclusion References

 
• Background Improving communication and collaboration among doctors and nurses can improve satisfaction among participants and improve patients’ satisfaction and quality of care.

• Objective To determine the impact of a multidisciplinary intervention on communication and collaboration among doctors and nurses on an acute inpatient medical unit.

• Methods During a 2-year period, an intervention unit was created that differed from the control unit by the addition of a nurse practitioner to each inpatient medical team, the appointment of a hospitalist medical director, and the institution of daily multidisciplinary rounds. Surveys about communication and collaboration were administered to personnel in both units. Physicians were surveyed at the completion of each rotation on the unit; nurses, biannually.

• Results Response rates for house staff (n = 111), attending physicians (n = 45), and nurses (n = 123) were 58%, 69%, and 91%, respectively. Physicians in the intervention group reported greater collaboration with nurses than did physicians in the control group (P < .001); the largest effect was among the residents. Physicians in the intervention group reported better collaboration with the nurse practitioners than with the staff nurses (P < .001). Physicians in the intervention group also reported better communication with fellow physicians than did physicians in the control group (P = .006). Nurses in both groups reported similar levels of communication (P = .59) and collaboration (P = .47) with physicians. Nurses in the intervention group reported better communication with nurse practitioners than with physicians (P < .001).

• Conclusions The multidisciplinary intervention resulted in better communication and collaboration among the participants.

Despite these findings, literature that describes controlled interventions to improve the relationship between doctors and nurses is sparse. The Cochrane Database includes a search for randomized trials that designed interventions to improve doctor-nurse collaboration⁵; only one such study⁶ had been done in the United States. In that study,⁶ the primary aim was to improve patients’ care by creating daily interdisciplinary rounds, and the main outcome measured was resource utilization. Additionally, the instruments used in the study surveys were not tested or validated as measures of providers’ satisfaction, and the results were not separated according to the type of provider.

The Multidisciplinary Doctor Nurse Practitioner Study was designed to compare the effectiveness of care management with a multidisciplinary team with the effectiveness of a conventional approach for acutely ill general medicine inpatients on the basis of organizational and patients’ outcomes. In this article, we describe changes in communication and collaboration between physicians and nurses associated with the study. We hypothesized that the structure of the intervention would promote improved communication and collaboration between healthcare providers.

Improving collaboration between nurses and physicians may enhance satisfaction among nurses, physicians, and patients, increase the quality of care, and reduce costs.

 

	Methods

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Study Site and Sample
The study was conducted on a medical inpatient unit in a tertiary care hospital at the University of California, Los Angeles, over a 2-year period. One wing served as the intervention unit; the other provided usual care and served as the control unit. The distribution of diagnosis-related groups did not differ significantly between the 2 units. Attending physicians (n = 45) and house staff (residents and interns, n = 111) were randomized to the intervention unit or the control unit and remained in their designated group for the duration of the study, with few exceptions. Nurses (n = 123) also did not change from one unit to the other during the study. The usual staffing structure was 3 registered nurses and 2.5 care partners for every 15 beds. At baseline, the following characteristics of the nurses did not differ significantly between the intervention unit and the control unit, respectively: mean age (35 years vs 37 years), mean years employed at the hospital (4 vs 5), mean years of experience as a registered nurse (10 vs 11), percentage of nurses who exceeded expectations in performance evaluations (23 vs 23), sex (92% vs 90% female), and education (49% vs 45% with baccalaureate degrees and 4% vs 3% with master’s degrees).

The attending physicians were randomized within strata (such as researcher, administrator, clinician-educator) to provide educational equivalence for the house staff. A total of 2 general medicine teams staffed the intervention unit, and 2 teams staffed the control unit. Each medicine team consisted of an attending physician whose rotation changed every 2 weeks, and 2 residents and 3 interns whose rotations changed each month with a 1-week period of overlap.

Intervention
The intervention consisted of adding a nurse practitioner to each of the intervention teams, appointing a hospitalist medical director, and having daily multidisciplinary rounds on weekdays. The nurse practitioners worked from 7:30 AM to 4:30 PM on weekdays, excluding holidays. In order not to violate the autonomy of the residents and interns, the nurse practitioners did not admit patients on their own or write orders without the consent of a resident or an intern. The nurse practitioners accompanied the house staff in the morning on "work rounds" and attending physicians on teaching rounds.

The nurse practitioners promoted the use of disease-specific pathways. They also provided concurrent inpatient and discharge education for patients during the study, recorded twice weekly in each patient’s chart a list of medications being used, and called patients weekly for the first 4 weeks after the patients’ discharge from the hospital. Home visits were offered to patients, but less than 12% of eligible patients received home visits.

The hospitalist medical director oversaw the nurse practitioners and the attending physicians in the intervention group, wrote the disease-specific pathways, and assembled and orchestrated the daily multidisciplinary team. The director also worked closely with the nurse manager on the intervention unit. The daily multidisciplinary rounds for the intervention teams lasted 15 minutes per team. The control unit provided its usual staffing, including once weekly, 90-minute-long multidisciplinary rounds.

The Survey
Surveys were administered to the physicians and nurses to assess the degree of communication and collaboration on the 2 units. The physicians were surveyed immediately after they completed a given rotation, starting at the onset of the intervention. Physicians could staff the medical teams more than once during the study period and thus be surveyed multiple times on their designated unit. Nurses were surveyed biannually. Correlation of observations due to repeated sampling was taken into account during statistical analysis.

Physicians rated communication and collaboration with nurses. For physicians on the intervention unit, collaboration with nurse practitioners was also measured. Additionally, physicians were surveyed about communication among the physicians themselves. Nurses rated collaboration and communication with physicians. For nurses on the intervention unit, collaboration and communication with nurse practitioners was also measured.

The collaboration scales consisted of 4 questionnaire items:

1. Did nurses and doctors share in decision making?
   
2. Did nurses and doctors cooperate in decisions?
   
3. Did nurses and doctors plan together before making decisions?
   
4. Was there open communication between doctors and nurses in making decisions? The scale for communication among physicians included 5 questionnaire items:
   

1. received complete information,
   
2. had good communication,
   
3. felt certain about accuracy of information,
   
4. enjoyed working together, and
   
5. had easy access to high-quality ancillary staff.
   

The nurse version of this scale had parallel questions except question 1 asked about receiving correct information, question 4 referred to enjoyed collaborating with doctors/nurse practitioners, and question 5 referred to whether it was easy to ask questions of the attending physician/nurse practitioner.

The general perceptions of communication scale administered to physicians had 3 questionnaire items:

1. got relevant information on the status of patients,
   
2. no delays in relaying information, and
   
3. nurses called in a timely manner.
   

Nurses completed a version of the survey that omitted item 1.

Physicians’ surveys for communication among physicians and perceptions of communication of information had 4 response options, ranging from never to always. All other items administered had 5 possible response options, ranging from strongly agree to strongly disagree (Likert rating scale) or from none of the time to all of the time. Responses to items in the scale were scored in the same direction, and the sum was transformed linearly to a possible range of 0 to 100. Scores were compared by using 2-tailed t tests and paired t tests. Internal consistency reliability for the multi-item scales ranged from 0.64 to 0.91, with a median reliability of 0.84.

Communication using a multidisciplinary team, including a nurse practitioner, a hospitalist medical director, and multidisciplinary rounds, was compared with a conventional approach.

 

	Results

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Response rates were calculated by dividing the number of surveys for which we received responses by the number of surveys administered. The rates were 58% (264/456) for house staff, 69% (114/165) for attending physicians, and 91% (325/358) for nurses. Because the same person could fill out more than a single survey, the analysis was controlled for repeat responders.

Physicians’ Perceptions of Collaboration With Nurses and Nurse Practitioners
Physicians on the intervention unit reported significantly higher collaboration with nurses than did physicians on the control unit (P < .001; Table 1). Both house staff (P=.002) and attending physicians (P= .05) on the intervention unit had significantly higher collaboration scores than did their counterparts on the control unit. The house staff on the intervention unit reported the highest collaboration (mean score 66.9) of all the groups; the attending physicians on the intervention unit and the house staff on the control unit had the same mean scores (54.1); and the attending physicians on the control unit had the lowest mean scores (47.7). Physicians on the intervention unit reported greater collaboration with nurse practitioners than with nurses (P < .001; Table 1).

Physicians on the intervention teams reported more collaboration with nurses than did physicians in the control group, but nurses’ perceptions of collaboration with physicians was the same in both groups.

 

Nurses’ Perceptions of Communication Among Healthcare Providers
The scores of the nurses on the intervention unit did not differ significantly from the scores of nurses on the control unit for communication with physicians (score 60.8 vs 59.7, P = .59) and general communication among healthcare providers (score 63.2 vs 61.3, P<.39). Nurses in the intervention group reported significantly better communication with nurse practitioners than with physicians (score 70.0 vs 60.8, P< .001).

Physicians and nurses share the common goal of maximizing the health and comfort of their patients.⁷ Yet, the traditional doctor-nurse relationship was not created on a collaborative platform. Traditional patterns of behavior have been that of "physician dominance and nurse deference,"⁸ classically referred to as "the doctor-nurse game."⁹

Nurses in the intervention group reported better communication with nurse practitioners than with physicians.

 

In our study, we measured physicians’ and nurses’ perceptions of communication and collaboration after 3 interventions: institution of daily multidisciplinary rounds, addition of nurse practitioners, and appointment of a hospitalist medical director. The intervention had a positive effect on collaboration and communication. The effect was the strongest among the house staff, who reported significant increases in collaborative efforts with nurses. This finding is consistent with the hypothesis that the early training period is the most effective time to set the groundwork for collaborative practice, for that period is when experienced nurses can assist inexperienced interns.¹⁰

Because neither physicians nor nurses were allowed to "cross over" between the interventional unit and the control unit, a smaller pool of physicians could work with a smaller pool of nurses. As in the study of Prescott and Brown⁸ in the 1980s, we hoped that a stable nursing work force would promote familiarity and foster improved communication.

The difference between physicians and nurses in their reports of a collaborative effort is striking. Physicians may define or view collaboration in a different light than do nurses. We did not specifically define collaboration for the survey, but it was distinct from communication on the survey. Perhaps the physicians thought that collaboration implied cooperation and follow-through with respect to following orders rather than mutual participation in decision making. Although communication is a necessary component, it alone is not sufficient to allow collaboration.¹¹ Possibly, communication styles differ between nurses and house staff, so that physicians perceive collaboration whereas nurses feel they (ie, the nurses) are being ordered to do something. A second possibility is that nurses did not feel comfortable "challenging" physicians by giving a different point of view. Or, possibly the input the nurses gave was not valued or acted upon, and thus the interaction was not perceived by nurses as collaboration. Regardless, we would have preferred that both physicians and staff nurses report improvement in their perceptions, because unilateral improvement cannot be deemed a total success. However, the addition of the nurse practitioners was positive for both physicians and staff nurses.

Both physicians and nurses on the intervention unit reported higher collaboration with the nurse practitioners than between physicians and nurses. The nurse practitioners made daily rounds with the physicians, so the physicians had more interaction with the nurse practitioners than with the staff nurses. Although the staff nurses were invited to join house staff on their daily work rounds, all but one nurse declined, because the time of the rounds was perceived as too close to the change of shift. This lack of direct contact and opportunity to have discussions about patients at the bedside most likely did not help foster a collaborative environment. Additionally, the nurse practitioners attended daily multidisciplinary rounds with the house staff and rounds with the attending physicians and thus were intimately involved in the patients’ diagnoses and medical plan of care. The charge nurse rather than staff nurses attended the multidisciplinary rounds, again because of issues of coordination and time constraints.

The job description of nurse practitioners supports collaborative practice because these healthcare providers perform some common functions of physicians and seek consultation with physicians when appropriate. Moser and Armer¹² found that the most significant barrier in a primary care setting to collaborative practice from the physicians’ standpoint was the lack of knowledge about the role of nurse practitioners. Confusion about the role of nurse practitioners was also apparent in our study. Before this study, the medical center had not employed a nurse practitioner for internal medicine in the inpatient setting. Additionally, the director of the residency program was vehemently opposed to having nurses "take over" clinical duties of the house staff, concerned that having nurse practitioners would harm the educative process. To better define the role of nurse practitioners and promote collaboration, we created a checklist of duties for the nurse practitioners (including both their research and clinical functions) and provided an in-service program to the house staff before each rotation on the intervention unit.

Likewise, the staff nurses had more interaction with the nurse practitioners than the physicians did. The nurse practitioners spent the preponderance of their day on the intervention unit, whereas the physicians on the unit could have patients, conferences, and clinics on other units. Therefore, the nurse practitioners had more face-to-face contact with the nursing staff than with the physicians. Like the findings on collaboration, the nurses did not report improved communication with the physicians as a result of the intervention. However, the nurses did report better communication with the nurse practitioners.

Physicians on the intervention unit reported better communication among themselves than did physicians on the control unit. Both the control unit and the intervention unit had identical admitting cycles and daily rounds by attending physicians; thus both groups theoretically had equal time to communicate. Perhaps because of the presence of the nurse practitioner and structured daily multidisciplinary rounds, communication increased in aggregate and "trickled down" to the physicians themselves on the intervention unit. Additionally, by performing some tasks normally done by the house staff, the nurse practitioners could have freed up time for the house staff to communicate and collaborate among themselves.

In contrast to the positive change reported by physicians on the intervention unit, nurses on both the intervention unit and the control unit reported similar and lower levels of communication with physicians. Nurses were neutral to agreeable about the statement "It was sometimes necessary for me to go back and check the accuracy of information I received from doctors on this unit." The negative response from the staff nurses may be due to the teaching/academic nature of the hospital, where an intern’s plans can change as a result of input from residents, attending physicians, patients, and ancillary staff.

A second response of the nurses has less to do with an academic milieu. The nurses were neutral to agreeable about the statement "There were unnecessary delays in relaying information regarding patient care." Physicians, especially those in training, can fail to inform patients or nurses about changes in plans. Communication with a patient’s nurse would be especially useful, because the nurse is the one who is at the bedside and on the front line with the patient and the patient’s family. Stein et al¹³ noted that more open communication better uses nurses’ observational and intellectual skills, enhances job satisfaction, and improves the nurses’ ability to contribute to patients’ care.

Other effects of the intervention included a significant decrease in length of stay and cost for patients treated in the intervention unit, without an increase in readmission rate and without reductions in health-related quality of life and satisfaction (M. Cowan, M. F. Shapiro, R. D. Hays, A. Afifi, S. Vazirani, S. L. Ettner, unpublished data, 2004). As discussed earlier, collaboration and communication on the whole were improved on the intervention unit. Although we cannot isolate the effects reported by Cowan et al (unpublished data, 2004) from our primary findings, we speculate that increases in communication and collaboration among the physicians and nurses may have mediated these other effects.

	Conclusion

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As medical care becomes more complex, collaborative efforts between physicians and nurses become more important for achieving positive outcomes for patients.¹⁰ After the intervention, physicians reported improved collaboration with nurses, but nurses did not report improved collaboration with physicians. However, both nurses and physicians reported better collaboration with the nurse practitioners. In this time of a shortage of nurses, interventions to improve physician-nurse collaboration are needed, because such collaboration is advantageous for physicians, nurses, and patients. We hope that future investigators will devise interventions to improve communication and collaboration between doctors and nurses.

Although collaboration and communication on the whole were improved in the intervention unit, differences in physicians’ and nurses’ perceptions of collaboration may reflect different definitions of collaboration.

 

	ACKNOWLEDGMENTS

 
We are grateful to our nurse practitioners, Sue Won and Kristin Beck; our project director, Jo-Ann Eastwood; our data collectors, Chiayi Chen, Martha Harmon, Gina Moody, and Daria Zandi; our statistician, Jenny Kotlerman; the clinical director of nursing at the University of California, Los Angeles (UCLA), Cathy Ward; the medical nurses and care partners on the fifth floor of the Center for Health Sciences; the nurse managers, Beki Heffler and Tina Iu; UCLA attending physicians and internal medicine house staff; and the members of our Data Safety Monitoring Board. This study was supported by a grant from the Agency for Health Care Policy and Research (1 RO1 HS 10734) to Marie Cowan. Ron D. Hays was supported in part by funding from the UCLA/DREW Project EXPORT, National Institutes of Health, National Center on Minority Health and Health Disparities (P20-MD00148-01), and the UCLA Center for Health Improvement in Minority Elders/Resource Centers for Minority Aging Research, National Institutes of Health, National Institute of Aging (AG-02-004).

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Commentary by Mary Jo Grap (see shaded boxes).

	REFERENCES

Top Abstract Methods Results Conclusion References

 

1. Weiss SJ, Davis HP. Validity and reliability of the Collaborative Practice Scales. Nurs Res. 1985;34:299–305.[Medline]
2. Devereux PM. Essential elements of nurse-physician collaboration. J Nurs Adm. May 1981;11:19–23.[Medline]
3. Kuhn R. Nurse and physician collaboration: how to strengthen the team. Heart Lung. 1985;14:18A–21A.[Medline]
4. Koerner BL, Cohen JR, Armstrong DM. Professional behavior in collaborative practice. J Nurs Adm. October 1986;16:39–43.[Medline]
5. Zwarenstein M, Bryant W. Interventions to promote collaborations between doctors and nurses. Cochrane Database Syst Rev. 2000:(2) CD000072.
6. Curley C, McEachern JE, Speroff T. A firm trial of interdisciplinary rounds on the inpatient medical wards: an intervention designed using continuous quality improvement. Med Care. 1998;36(8 suppl):AS4–AS12.[Medline]
7. Pike AW, McHugh M, Canney KC, Miller NE, Reiley P, Seibert CP. A new architecture for quality assurance: nurse-physician collaboration. J Nurs Care Qual. April 1993;7:1–8.[Medline]
8. Prescott PA, Bowen SA. Physician-nurse relationships. Ann Intern Med. 1985;103:127–133.[Medline]
9. Stein LI. The doctor-nurse game. Arch Gen Psychiatry. 1967;16:699–703.[Medline]
10. Mechanic D, Aiken LH. A cooperative agenda for medicine and nursing [Sounding Board]. N Engl J Med. 1982;307:747–750.[Medline]
11. Baggs JG, Schmitt MH. Collaboration between nurses and physicians. Image J Nurs Sch. 1988;20:145–149.[Medline]
12. Moser SS, Armer JM. An inside view: NP/MD perceptions of collaborative practice. Nurs Health Care Perspect. 2000;21:29–33.[Medline]
13. Stein LI, Watts DT, Howell T. The doctor-nurse game revisited. N Engl J Med. 1990;322:536–549.

Journal Club Article Discussion Points

When critically appraising this issue’s AJCC journal club article, "Effect of a Multidisciplinary Intervention on Communication and Collaboration Among Physicians and Nurses," consider the questions and discussion points listed below.

Study Synopsis: Communication among healthcare providers is an important component of providing care to patients. This study sought to assess the impact of a multidisciplinary intervention on communication and collaboration among doctors and nurses on an acute inpatient medical unit during a 2-year period. The study used an experimental design to compare usual care with an intervention consisting of the use of nurse practitioners (NPs) to participate in multidisciplinary rounds and patient care management. The NPs rounded with the team, promoted the use of disease-specific pathways, provided education and discharge instructions to study patients, and conducted weekly telephone follow-up for the first 4 weeks after discharge. Communication and collaboration were assessed with the use of surveys that were completed by 111 residents, 45 attending physicians, and 123 nurses. Findings revealed a beneficial impact of the intervention, with physicians in the intervention group reporting greater collaboration with nurses than did physicians in the control group. In addition, nurses in the intervention group reported better communication with NPs than with physicians. In this study, the participation of NPs on a multidisciplinary team resulted in better communication and collaboration among doctors, nurses, and NPs.

1. Description of the Study
   • What was the purpose of the research?
     
   • Why are communication and collaboration significant in healthcare?
     
   
   
2. Literature Evaluation
   • How much research has been conducted in this area?
     
   
   
3. Sample
   • What type of staff were involved in the study?
     
   
   
4. Methods and Design
   • Describe the study intervention
     
   • What were the roles of the nurse practitioners on the intervention unit?
     
   • When and how were data on perceptions of communication and collaboration collected?
     
   
   
5. Results
   • What were the findings of the research?
     
   • What were the differences in communication and collaboration between the control and intervention units? In what areas did they not differ significantly?
     
   
   
6. Clinical Significance
   • What are the implications of the study?
     
   • What are other related areas of research that could be conducted?
     
   
   

Information From the Authors: Sondra Vazirani, lead author of this journal club article, provided additional information about the study. Vazirani explained that the study was conducted on an acute care medical unit and that the patients in the control and intervention groups did not differ with respect to diagnoses or age. She shared, "The predominant admitting diagnoses were esophagitis/gastritis, cellulitis, pneumonia, kidney/urinary infections, nutrition/failure to thrive, gastrointestinal hemorrhage, renal failure, syncope, circulatory disorders, other digestive diseases, and chronic obstructive disease/asthma. The ages ranged from 18 to 29 years (11%) to more than 85 years (6%), with the average age being 55 years old." Vazirani explained that while the patients did not differ on disease-specific characteristics or age, they did differ with respect to length of stay. She reported, "The average length of stay was significantly lower for the patients in the experimental unit (5 days) versus those in the control group (6.01 days)." This highlights another impact of the intervention in reducing length of stay.

In outlining the intervention, Vazirani explained that the study involved 2 NPs and in addition to rounding, a checklist was created to identify specific NP interventions. These interventions included reinforcement of established protocols and pathways; monitoring patient medications; providing discharge instructions; conducting postdischarge follow-up phone calls; and, if patients requested, home visits for patient follow-up.

Implications for Practice: According to the study results, the intervention had a significant impact on communication and collaboration. Vazirani said that the study results have several implications for nursing practice. She shared, "The readers should take away 2 things: More studies are needed to find interventions to improve nurses’ perceptions of communication and collaboration, and NPs are a good addition to healthcare teams to foster communication and collaboration." This study adds to the body of nursing knowledge in further demonstrating the impact of NP care on collaboration and communication.

Journal Club feature commentary is provided by Ruth Kleinpell.

This article has been cited by other articles:

				M. Rosenzweig, M. Hravnak, K. Magdic, M. Beach, M. Clifton, and R. Arnold Patient Communication Simulation Laboratory for Students in an Acute Care Nurse Practitioner Program Am. J. Crit. Care., July 1, 2008; 17(4): 364 - 372. [Abstract] [Full Text] [PDF]

				A. P. Gurses and Y. Xiao A Systematic Review of the Literature on Multidisciplinary Rounds to Design Information Technology J. Am. Med. Inform. Assoc., May 1, 2006; 13(3): 267 - 276. [Abstract] [Full Text] [PDF]

				R. M. Kleinpell Acute Care Nurse Practitioner Practice: Results of a 5-Year Longitudinal Study Am. J. Crit. Care., May 1, 2005; 14(3): 211 - 219. [Abstract] [Full Text] [PDF]

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