1. November-December 2012 • Vol. 21/No. 6 343
Sherita Johnson, MSN, RN, is Staff Nurse, Coronary Care Unit, Forsyth Medical Center,
Winston-Salem, NC.
Daria Kring, PhD, RN, is Director, Nursing Research, Forsyth Medical Center, Winston-Salem,
NC.
Nurses’ Perceptions of Nurse-Physician
Relationships: Medical-Surgical vs.
Intensive Care
Sherita Johnson
Daria Kring
“C
ollaboration has been
described as a process
that allows the inter-
action of colleagues
within a flat hierarchy to make deci-
sions both independently and as part
of a team” (Burchell, Thomas, &
Smith, as cited in Taylor-Seehafer,
1998, p. 387). It is a complex process
that requires intentional knowledge
sharing and joint responsibility for
patient care. “Interprofessional col-
laboration refers to collaboration of
two or more professionals working
jointly toward mutual goals with
shared responsibility” (Johanson,
2008, p. 29).
In the current, complex health
care environment, the collaboration
of professionals affected by complex
health care issues warrants attention
as a strategy for the problem-solving
team (Stein-Parbury & Liaschenko,
2007).
Collaboration between nurses
and physicians is essential in facili-
tating improved patient care out-
comes and patient care satisfaction.
The benefits of effective nurse/physi-
cian relationships include decreased
cost, better patient care, and
decreased patient morbidity and
mortality (Nelson, King, & Brodine,
2008). Additional benefits are
improved communication among
health care workers, improved effi-
ciency, improved understanding of
the nursing role, and decreased
patient length of stay (Dailey, Loeb,
& Peterman, 2007).
Implications
Historically, the doctor-nurse rela-
tionship has been an unequal one
characterized by the dominance of
the doctor, with the nurse assuming a
position of lower status and depend-
ence on the physician (Qolhole,
Research for PracticeResearch for Practice
Effective collaboration between nurses and physicians (RN-MD) is
essential in facilitating improved patient care outcomes. A pilot
study was conducted among nurses on medical-surgical and inten-
sive care units to identify differences in nurses’ perceptions of RN-
MD collaborative efforts.
Introduction
Collaboration between nurses and physicians is essential in fostering interdisci-
plinary relationships. Specialty practice may influence the quality of this collabora-
tion. Effective communication and collegial RN-MD relationships are critical to
improved patient outcomes.
Purpose
The purpose of this study was to identify differences in nurses’ perceptions of
collaborative efforts between nurses and physicians in medical-surgical (MSUs)
units versus intensive care units (ICUs).
Results
A descriptive survey methodology was employed. Nurses in three ICUs and
eight MSUs within a 975-bed Magnet®
hospital completed a 25-item Nurse-
Physician Relationship survey, used in previous studies on RN-MD communication.
The sample (N=170) consisted of 54% medical-surgical nurses and 46% ICU
nurses. No statistically significant differences were found in the demographic vari-
ables between the MSU and ICU nurses except for educational degree. A greater
percentage of ICU nurses held a bachelor’s degree. This study found that although
some differences existed in ICU and MSU nurses’ perceptions of RN-MD collabo-
ration, there are more similarities between the two areas. Overall, nurses were sat-
isfied with RN-MD relationships, with 75% of ICU and 65% of MSU nurses report-
ing satisfaction (p=0.110). MSU nurses were less likely to participate in interdisci-
plinary rounds than ICU nurses (p<0.001). ICU nurses were more likely than MSU
nurses to report that physicians treat nurses as handmaidens (p=0.056) and that
physicians displayed unprofessional behavior (p=0.019).
Conclusions
Certain nursing specialty areas are not immune to problems with RN-MD rela-
tionships. Rather, all clinical service lines should be concerned with fostering colle-
giality between nurses and their physician partners.

2. November-December 2012 • Vol. 21/No. 6344
Conradie, Ogunbanjo, & Malete,
2006). Nurses who work closely with
physicians and participate in shared
decision making experience less
burnout and decreased turnover.
Conversely, disruptive physician
behavior has been cited as a contribu-
tor to the nursing shortage (Nelson et
al., 2008). However, additional
research cites the benefits of mutual
respect and collaboration (Dailey et
al., 2007).
A great deal of progress remains to
be made. A study by Sirota (2008)
found 43% of nurses were dissatis-
fied with their overall relationships
with physicians and 68% doubted
physicians understood nursing
responsibilities. Respondents in this
study indicated a belief physicians
are more likely to respect and appre-
ciate nurses’ knowledge and skills
when they work closely with nurses
and get to know them. Interestingly,
over 57% indicated they had better
working relationships with younger
physicians than older ones.
Although evidence supports col-
laborative nurse/physician relation-
ships, true partnership rarely exists
in acute care facilities. Power dis-
tance and ineffective communica-
tion remain huge barriers to achiev-
ing collaboration. Factors contribut-
ing to ineffective collaboration must
be identified if real progress is to be
made. One factor yet to be explored
is clinical specialty. Different special-
ties often require different levels of
interaction between nurses and
physicians (Sirota, 2008).
Intensive care unit (ICU) nurses
have limited patient assignments
due to high acuity and often work
closely with one or two intensivists.
Medical-surgical nurses often care for
more patients and have shorter
interactions with many different
physicians. These two specialties
may experience differences in the
level of nurse/physician collabora-
tions (Sirota, 2008). Understanding
these possible differences may assist
nurses and physicians to focus
efforts on collaboration and team-
work according to specialty area. The
purpose of this study was to explore
perceived nurse/physician collabora-
tion between ICU and medical-surgi-
cal nurses.
Methods
A quasi-experimental design was
used to measure the perceptions of
nurse-physician collaboration with-
in a convenience sample of nurses
working either in an intensive care
unit or medical-surgical setting. This
study was conducted in an urban
975-bed hospital in the southeast
region of the United States. The
study population consisted of regis-
tered nurses who work on eight
medical-surgical units and three
intensive care units randomly select-
ed to participate. To participate in
this study, ICUs had to contain at
least eight beds and medical-surgical
units contained at least 12 beds.
Prior to data collection, the study
was approved by the hospital’s insti-
tutional review board and the nurs-
ing research council. A convenience
sample of all nurses working in those
units were invited to participate in
the study. Potential nurse partici-
pants had to meet the following
requirements: employment on a
medical-surgical unit or intensive
care unit for at least 6 months, and
work at least one 8-hour shift per
week. Nurses were informed about
the study in writing, and face-to-face
data collection sessions were con-
ducted with the principal investiga-
tor. Light refreshments were served
during the data collection sessions.
No incentives for participating were
offered.
Return of the surveys served as
implied consent. No identifying
information, such as name, employ-
ee identification number, or date of
birth, was collected. All surveys were
kept in a locked cabinet in the office
of nursing research. Computer files
were password protected.
Instrument
A 25-item survey used by Sirota
(2007) which uses a varying response
scale (Likert response as well as
“yes/no” response) was selected to
collect information regarding nurse/
physician collaboration. Computer
files were password protected. Per-
mission was obtained to use
Lippincott Williams & Wilkins Nurse-
Physician Relationships Survey Tool.
Questions for this tool, which has
been used in national studies regard-
ing nurse-physician relationships,
were similar to those posted in a
nurse-physician survey that drew
1,100 respondents in 1990 and near-
ly 900 in 2007 (Sirota, 2008). The sur-
vey evaluates collaborative efforts
between nurses and physicians, pro-
fessionalism and disruptive behavior,
and managerial and administrative
support. Sample questions include,
“Do you think physicians under-
stand the nursing profession and
your role as a nurse?” “Do physicians
speak to you in an unprofessional
tone?” “Do nurses routinely make
rounds with physicians?”
Data Collection
A trained research nurse adminis-
tered the surveys and ensured
requirements for participation were
enforced strictly. Recruitment fliers
were posted on the selected units
and nurses were notified 2 weeks
prior to the study initiation that a
nurse researcher would be conduct-
ing information data collection ses-
sions in the unit. Participants had 1
week to complete the survey.
Results
The sample was analyzed by
descriptive statistics (SPSS 16). The t-
test was used to compare means, and
findings with a p value less than 0.05
were deemed statistically significant.
Study participants included 170 nurs-
es, with 54% (n=89) of respondents
being medical-surgical nurses and
46% (n=77) ICU nurses. Approxi-
mately half the participants held a
bachelor’s degree in nursing (n=83),
had 5 or less years of nursing experi-
ence (n=80), and worked day shift
(n=85). Most participants were
direct-care nurses (n=138, 86%) and
worked full time (n=151, 93%). No
statistically significant differences
existed in the demographic variables
between the medical-surgical and
intensive care nurses except for edu-
cational degree. A greater percentage
of ICU nurses held a bachelor’s
degree compared to the medical-sur-
gical nurses (p=0.015) (see Table 1).
Each of the items on the survey was
Research for Practice

3. November-December 2012 • Vol. 21/No. 6 345
Nurses’ Perceptions of Nurse-Physician Relationships: Medical-Surgical vs. Intensive Care
analyzed collectively, as well as
according to work area (ICU or med-
ical-surgical) (see Table 2). Of the 21
questions with defined response sets,
only three showed a statistically sig-
nificant difference between the
groups (p≤0.05).
In general, nurses were satisfied
with RN-MD relationships. As many
as 75% (n=74) of ICU nurses and
65% (n=84) of medical-surgical nurs-
es reported satisfaction with the
nurse-physician relationships. In
addition, 78% (n=87) of medical-sur-
gical nurses and 76% (n=75) of ICU
nurses believed physicians respected
nurses’ decisions. However, one par-
ticipant stated, “Most physicians are
professional, but a few are rude and
disrespectful.” Another participant
noted, “Overall, I am satisfied with
nurse-physician relationships; on
the contrary, some physicians are
hateful and don’t return pages.”
While both ICU and medical-sur-
gical nurses indicated they had wit-
nessed disruptive behavior by physi-
cians (57%, n=94), only a minority
noted they had reported disruptive
behavior (26%, n=43). ICU nurses
were more likely to report physicians
displayed unprofessional behavior
than their medical-surgical counter-
parts (p=0.019); 80% (n=41) of ICU
nurses reported unprofessional phy-
sician behavior compared to 58%
(n=50) of medical-surgical nurses.
Similarly, ICU nurses were more like-
ly than medical-surgical nurses to
report physicians treat nurses as
handmaidens (p=0.056). One partic-
ipant stated, “Some physicians won’t
listen to what I say, but will give
orders in an exasperated tone.”
Another participant commented,
“Some physicians don’t take the
time to listen to what we are asking
or listen to our concerns.”
A statistically significant differ-
ence was detected between ICU and
medical-surgical nurses regarding
interdisciplinary rounds, with 75%
(n=71) of intensive care nurses and
33% (n=80) of medical-surgical nurs-
es reporting they participate in inter-
disciplinary rounds with physicians
(p<0.001). One participant indicated
she needed to make a greater attempt
to talk with physicians during inter-
disciplinary rounds. Another partici-
pant stated physicians do not include
nurses in the patient’s plan of care.
Only 53% (n=80) of nurses at the
study hospital reported they partici-
pate in interdisciplinary rounds.
Regardless of whether nurses were
satisfied with their RN-MD relation-
ships, very few ICU and medical-sur-
gical nurses reported having collegial
relationships with their physician
counterparts (32%, n=51). One par-
ticipant stated, “I think it depends
on the nurse and the physician and
how much knowledge the nurse
displays regarding the patient.”
Another participant suggested colle-
giality varies according to the physi-
cian service line.
A majority 62% (n=100) of the
nurses perceived they were subordi-
nate to physicians. In addition, about
half the respondents perceived physi-
cians do not really understand what
nurses do. Interestingly, half the
respondents reported having a better
relationship with younger physi-
cians. How nurses and physicians
addressed each other also may con-
tribute to perceptions of collegiality.
The majority of nurses 62% (n=97)
reported physicians addressed nurses
by their first names. However, nurses
almost never 2% (n=160) addressed
physicians by their first names.
Discussion
This study found that although
TABLE 1.
Demographic Information
Medical-Surgical ICU Total
Job Title (p=0.152)
Staff RN 83% 89% 86%
Team leader 1% 0 1%
Advanced practice nurse 0 1% 0.6%
Charge nurse 10% 9% 9%
Nurse manager 5% 0 3%
Employment (p=0.144)
Part time 2% 9% 6%
Full time 95% 89% 93%
PRN 2% 1% 2%
Shift (p=0.418)
7 a.m. – 7 p.m. 49% 56% 53%
7 p.m. – 7 a.m. 44% 42% 44%
7 a.m. – 3 p.m. 1% 0 0.6%
Other 5% 1% 3%
Education (p=0.015)
Diploma 16% 3% 10%
Associate’s Degree 34% 28% 32%
Bachelor’s Degree 43% 61% 51%
Master’s Degree 7% 8% 7%
Experience (p=0.099)
6 months-2 years 22% 36% 28%
3-5 years 17% 25% 21%
6-10 years 21% 12% 17%
11-15 years 11% 8% 10%
More than 15 years 26% 20% 24%
Note: p value is statistically significant if p<0.05.

4. November-December 2012 • Vol. 21/No. 6346
some differences exist between ICU
and medical-surgical nurses’ percep-
tions of RN-MD collaboration, in
general there are more similarities.
Overall, nurses were satisfied with
RN-MD relationships. Nevertheless,
both ICU and medical-surgical nurs-
es had witnessed disruptive behavior
by physicians. Surprisingly, only a
small minority of nurses had report-
ed disruptive behavior. Nurses may
not be aware of processes in place for
dealing with disruptive physician
behavior, or they may not believe
the process is effective. Additionally,
nurses may not know how to use
their chain of command effectively,
or they may feel uncomfortable ini-
tiating the process.
ICU nurses were more likely to
report disruptive behavior by physi-
cians than were medical-surgical
nurses, and ICU nurses were more
likely to perceive physicians treated
them as handmaidens. This finding
was worthy of note, particularly
because 75% (n=71) of ICU nurses
participated in interdisciplinary
rounds with physicians. Perhaps
medical-surgical nurses have a more
distant relationship with their physi-
cian colleagues and are less invested
in the quality of that relationship.
Medical-surgical nurses may be
unable to participate in interdiscipli-
nary rounds due to their patient care
assignments and higher nurse-to-
patient ratios.
In this study, some nurses stated
physicians do not understand the
role of a nurse. This may explain
why some nurses, particularly ICU
nurses, perceived they were treated
as handmaidens. As for collegiality,
most nurses perceived they were sub-
ordinate to physicians and very few
nurses reported having collegial rela-
tionships with their physician coun-
terparts. A possible influence on this
perception is the belief by a majority
of nurse respondents that physicians
do not understand the significance of
a nurse’s job role and responsibility.
A great deal of work remains to
promote and facilitate better colle-
gial relationships between nurses
and physicians. One way to establish
collegiality between nurses and
physicians is to facilitate a mentor-
ing relationship. For instance, nurses
and physicians could follow each
other to get a better understanding
of the other’s role and responsibili-
ties. Participating in joint activities is
another way to promote collegial
relationships. For example, quarterly
luncheons or an annual field day
between nurses and physicians may
facilitate teamwork and relationship
building.
Nurses and physicians need posi-
tive, respectful relationships to
ensure quality patient care. In-
creasing opportunities for nurses and
physicians to interact with each
other also increases the likelihood of
developing collaborative, interactive
relationships. Likewise, nurses and
Research for Practice
TABLE 2.
Lippincott Williams & Wilkins Nurse-Physician Relationships Survey by Nursing Unit
Question Medical-Surgical ICU Total p
Nurses are satisfied with professional relationships. 65% 75% 70% 0.110
Physicians understand what nurses do. 50% 57% 54% 0.701
Physicians respect nurses’ decisions. 78% 76% 77 0.550
Nurses have better relationships with younger MDs. 50% 50% 51% 0.561
Physicians address nurses by first name. 60% 64% 62% 0.465
Nurses address physicians by first name. 3% 1% 2% 0.358
Nurses perceive they are subordinate to physicians. 62% 61% 62% 0.963
Nurses have a collegial relationship with physicians. 30% 32% 32% 0.963
Nurses make rounds with physicians. 25% 34% 30% 0.330
Nurses have seen disruptive behavior by physicians. 56% 57% 57% 0.513
Nurses are aware of process for disruptive behavior. 88% 78% 84% 0.231
Nurses report disruptive physician behavior. 31% 19% 26% 0.140
Physicians display unprofessional behavior. 58% 80% 68% 0.019*
Physicians don’t understand the nurses’ role. 34% 51% 42% 0.074
Physicians don’t listen to nurses about patients. 42% 48% 42% 0.332
Physicians don’t communicate with nurses. 54% 43% 50% 0.227
Physicians treat nurses like handmaidens. 21% 39% 30% 0.056
Nurses participate in team conferences. 25% 32% 29% 0.189
Nurses participate in interdisciplinary rounds. 33% 75% 53% 0.000*
Nurses use practice protocols. 33% 42% 38% 0.182
Nurses use communication tools, like SBAR. 91% 84% 88% 0.161
* p value <0.05

5. November-December 2012 • Vol. 21/No. 6 347
physicians must engage with each
other away from the bedside. With
increased exposure comes the associ-
ation of names with faces rather
than just room numbers with scrub
colors (Dailey et al., 2007).
Concerning interdisciplinary
rounds, although unforeseen cir-
cumstances can occur, having
rounds on specific days and times
can help ensure members of each
discipline can be available. This
would be very helpful on medical-
surgical units, where only 33%
(n=80) of nurses reported participa-
tion in interdisciplinary rounds with
physicians. Moreover, nurses would
have a better understanding of the
patient’s medical plan of care and
physicians could discuss aspects of
patient care with nurses.
One interesting finding in this
study was more ICU nurses held a
bachelor’s degree (61%, n=76) com-
pared to medical-surgical nurses
(43%, n=87). Within the study set-
ting, 40% (n=788) of staff nurses
held a bachelor’s degree in nursing.
According to the North Carolina
Board of Nursing (2010), 32% of
nurses in the state have a bachelor’s
degree. The ICU nurses in this study
not only had more education than
their medical-surgical colleagues,
but also more than many nurses in
the state. This educational differ-
ence may have contributed to a
greater desire by ICU nurses to be
equals with their physician col-
leagues; they may have been more
concerned when they were treated
disrespectfully, or felt less appreciat-
ed for what they contributed to
patient plans of care.
Future Research
A great deal of research still is
needed on the topic of RN and MD
collegiality. This study should be
replicated in other settings with
greater numbers of nurses. While
this study was undertaken using an
established survey for understanding
RN-MD relationships, it was not
based on a conceptual model of
these relationships. Thus, the instru-
ment’s questions only could be ana-
lyzed individually. Creating an
instrument built on subscales of
the concept of RN-MD collegiality
would provide researchers with a
stronger tool. Such an instrument
would allow creation of a conceptu-
al framework delineating antecedent
and causal relationships impacting
collegiality, as well as testing of inter-
ventions to improve collegial rela-
tionships.
How nurses and physicians ad-
dress each other needs to be ex-
plored. Using last names to address
colleagues is a sign of formality and
respect, whereas using first names
among colleagues is a sign of famil-
iarity and comfort. However, a mis-
matched form of address often sig-
nals power distance and inequality
(Hofstede, Hofstede, & Minkov,
2010). This mismatch often is seen
with children and adults, students
and teachers, and as evidenced here,
nurses and physicians. Using first
names may be a future development
as collegial relationships mature, or
it may be that using first names at
the onset of a relationship fosters
collegiality more quickly.
Given many of the findings of
concern in this study, it is interesting
that nurses are satisfied with RN-MD
relationships overall. This result is
quite encouraging and provides a
firm foundation for making further
improvements. It may be that a few
disruptive physicians drive the nega-
tive perceptions held by some nurses
toward their physician colleagues.
Because the study site was a Magnet-
designated hospital, these results
may be higher than what might be
seen at non-Magnet hospitals, as one
of the Forces of Magnetism is posi-
tive interdisciplinary relationships
(American Nurses Credentialing
Center, 2008).
Conclusion
Faulty communication between
nurses and physicians can affect
patient outcomes adversely. Nurses
promote patient safety in part by
communicating with physicians
(Monojlovich, Antonakos, & Ronis,
2009). Effective collaborative efforts
and clear communication improves
the quality of patient care in the
work environment (Nelson et al.,
2008). Poor communication between
physicians and nurses leads to mis-
understandings, errors, and ongoing
conflict between nurses and physi-
cians (Sirota, 2007). Ultimately, qual-
ity patient care is jeopardized. For
these reasons, collaborative efforts
and positive relationships between
physicians and nurses must be
assessed and improved continuously.
This study found certain nursing spe-
cialty areas are not immune to prob-
lems with RN-MD relationships.
Rather, all clinical service lines
should be concerned with fostering
collegiality between nurses and their
physician partners.
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