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Perceptions that affect physician-nurse collaboration in the perioperative setting

AORN Journal, July, 2007 by L. Suzanne Sterchi

Today's surgical setting is a complex, often tense arena. Factors such as efficient patient throughput, OR suite turnover times, varying patient acuity levels, timely preoperative patient preparation, surgeons' conflicting schedules, and increasingly complex technology and surgical instrumentation create a state of constant pressure and tension. (1) Collaboration is vital if these competing demands are to be incorporated into safe, high-quality surgical care. Collaboration requires tremendous effort among a diverse team of health care providers, including surgeons, perioperative nurses, anesthesia care providers, surgical technologists, surgical assistants, and support staff members. Each team member has a unique skill set that contributes to positive outcomes for surgical patients.

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By its very nature, the physician-nurse relationship is stressful. Both perceived and real differences in power and status between physicians and nurses can lead to problems when these health care providers do not agree on a patient's plan of care. Traditionally, the profession of medicine has emphasized expertise, autonomy, and responsibility more than interdependence, deliberation, or dialogue. Nursing, on the other hand, has emphasized hierarchy and bureaucracy, though emphasis on these has diminished along with deference to physicians. (2) Although in the past, nurses were used to following orders and not giving them, they have learned to adapt their approaches with physicians to accomplish their patient care goals. The different emphases that physicians and nurses have toward patient care may lead to strained physician-nurse relationships, which may in turn com promise patient safety, (3) unless the physicians and nurses develop collaborative relationships.

The purpose of this study was to examine physicians' and nurses' perceptions and attitudes toward collaboration in the perioperative setting. Results of this study may be helpful in improving the understanding of the physician-nurse relationship in the perioperative setting.

COLLABORATION

Collaboration is defined by Disch et al (4) as the process of joint decision-making among independent parties, involving joint ownership of decisions and collective responsibility for outcomes. Lockhart-Wood (5) defined collaboration as a process whereby two or more people come together to discuss a common problem. Each participant has the self-confidence to share knowledge and information on an equal basis, and mutual respect is given to each opinion. The focus remains on the needs of the patient, and negotiations result in a plan of care. (5,6) Drivers of success in physician-nurse collaboration have been identified as the valuing of nursing and the integration of service across the continuum. (7) Liedtka and Whitten (8) observed that real collaboration is not a result of the structure of the organization but must instead originate in the mind of the collaborator. Perceptions, therefore, are important in attempting to understand and improve collaboration.

Teamwork and collaboration between physicians and nurses is crucial for patient care and morale. (9) According to Benner, (9) each team member has his or her own perspective regarding assessment and plan of care for a patient, and only through collaboration and an exchange of information can appropriate treatment plans be made. In addition, physician-nurse collaboration and positive relationships have been identified as major factors contributing to positive patient outcomes and quality patient care. (10-12)

Noncollaborative relationships and negative interactions between physicians and nurses can adversely affect patient care. The importance of collaboration in the perioperative arena was shown in a study by Espin and Lingard, (13) who found through observations of errors during surgical procedures that multiple errors were related to poor-quality interpersonal relationships in the perioperative setting. Results from a 2003 survey conducted by the Institute for Safe Medication Practices showed that patient safety is at risk as a result of antagonistic work environments in which nurses or pharmacists who question medication orders are the recipients of intimidating behaviors from physicians or prescribers. (14) In a 2003 AORN Workplace Safety Task Force survey, verbal and physical abuse by physicians, lack of respect, and the absence of a code of conduct were reported as factors of concern by perioperative nurses. (15) Efforts to improve the safety and quality of surgical patient care are dependent on teamwork and are jeopardized by barriers in communication and collaboration between physicians and nurses. (3)

REVIEW OF THE LITERATURE

The physician-nurse relationship and collaboration has drawn the interest of researchers since the 1960s. Initially, the nurse's role was characterized by implicit trust in physicians, with nurses rarely questioning physicians' orders even if the nurse's professional judgment ran counter to the physician's. (16) In 1967, Stein (17) reported that nurses' relationships with physicians were based on a "game-playing" model, in which nurses gave recommendations regarding care without appearing to direct or disagree with the physician.

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Perceptions that affect physician-nurse collaboration in the perioperative setting

AORN Journal, July, 2007 by L. Suzanne Sterchi

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