t Relationships do matter: Understanding how nurse-physician relationships can impact patient care outcomes Sandra L. Siedlecki PhD RN CNS

Problem The professional practice environment has been implicated as a factor that affects nurse retention and recruitment, as well as patient outcomes.

Problem It has been posited that those organizations with a positive professional practice environment are able to recruit and retain the best nurses and that this coupled with the communication, respect, and collaboration between nurses and physicians at these organization contributes to an environment that results in fewer untoward patient problems.

Problem However, previous studies have limited their investigations to the impact of various negative aspects of the professional practice environment on nurse satisfaction, nurse retention, nurse recruitment, and patient outcomes

Problem No studies have examined the impact of a positive professional practice environment on these or other variables

Problem Understanding factors, other than simply the presence or absence of negative physician behaviors, that impact the professional practice environment is essential for developing a plan to improve the professional practice environment and for monitoring the impact of these plans. The absence of negative behaviors does not equal a positive professional practice environment

Specific Aims 1.Assess nurses and physicians perceptions of the professional practice environment where they practiced 2.Determine the extent to which physician behavior or attitude affects nursing practice decisions

Specific Aim 1 Positive Professional Practice Environment Scale

Specific Aim 1 To assess nurses and physicians perceptions of the professional practice environment we examined total scores on the Professional Practice Environment Assessment Scale (PPEAS). The PPEAS (Siedlecki & Hixson, 2011) is a 13-item scale developed by the researchers that examines the presence of positive physician and nurse characteristics, collaborative decision- making and beliefs in the impact of nurse-physician relationships on patient outcomes

Specific Aim 1 To assess nurses and physicians perceptions of the professional practice environment we examined total scores on the Professional Practice Environment Assessment Scale (PPEAS). Each of the items on the PPEAS is rated from 1 to 10 with higher scores indicting more positive perceptions of the professional practice environment. Total Scores can range from 13 to 130 Reliability of the instrument for this study was.86

Theoretical Framework Development of the Professional Practice Environment Assessment Scale (PPEAS) was based upon the following assumptions The Professional Practice Environment is a product of history and is therefore impacted by the educational and historical development of the nursing and medical professions

Theoretical Framework Development of the Professional Practice Environment Assessment Scale (PPEAS) was based upon the following assumptions: The professional practice environment is a product of societal norms and thus differs by culture of individuals within an organization as well as by the prevailing culture relative to the geographical location of the organization

Theoretical Framework Development of the Professional Practice Environment Assessment Scale (PPEAS) was based upon the following assumptions; A positive professional practice environment is more than and different from the absence of negative, abusive or disrespectful behaviors by physicians

Theoretical Framework Development of the Professional Practice Environment Assessment Scale (PPEAS) was based upon the following assumptions; A positive professional practice environment impacts patient outcomes as well as nurse and physician satisfaction

Theoretical Framework Development of the Professional Practice Environment Assessment Scale (PPEAS) was based upon the following assumptions; A positive professional practice environment is characterized by mutual respect, understanding of roles, beliefs in the importance of nurse-physician relationships on patient outcomes, effective communication, and collaborative decision-making.

Theoretical Framework Positive Professional Practice Environment Mutual Respect: Nurse for physician and physician for nurse Mutual understanding and appreciation of the role of both the nurse and the physician as it relates to patient care Quality of collaboration and evidence of collaborative decision-making Quality of Communication Mutual beliefs in the value of a positive professional practice environment and its impact on patient care and outcomes HISTORYHISTORY SOCIETALNORMSSOCIETALNORMS

Component 1 Component 1: Positive Physician Characteristics Physicians demonstrate respect for nurses in area where I work.846 Physicians understand the role of the nurse.810 Physicians demonstrate respect for nurses in facility where I work.778 Quality of physician nurse communication on a general day.729 Quality of physician nurse collaboration on a general day.673

Component 2 Component 2: Positive Nurse Characteristics Nurses demonstrate respect for physicians in area where I work.830 Nurses demonstrate respect for physicians in facility where I work.803 Nurses understand the role of the physician.793

Component 3 Component 3: Collaborative Decision Making Nurses and physicians routinely discuss patient care decisions with each other in the facility where I work.858 Nurses and physicians routinely discuss patient care decisions with each other in the area where I work.752

Component 4 Component 4: Positive Beliefs in Value of Relationship Amount of physician nurse communication impacts patient outcomes.911 Level of physician nurse collaboration impacts patient outcomes.908 Degree of physician nurse respect impacts patient outcomes.830

Specific Aim 2 Impact on Nursing Practice Decisions

To determine if behaviors and attitudes of individual physicians might impact nursing practice decisions, by affecting communication between nurses and physicians a single question was posed to the nurse respondents. This single forced-choice (yes/no) item asked nurses if a physician’s negative behavior or attitude affects how they ask a question or if it makes them reluctant to report changes in a patient’s clinical condition.

Methods Design & Analysis

Sampling A convenience sample (N = 1372) of nurses (n = 825) and physicians (n = 547) at a large Midwest healthcare facility was recruited for this study. A list of nurse and physician s was used to identify the target population. Invitations to physicians and nurses to participate in this survey were distributed via .

Data Collection Data collection lasted for 30 days and the research team sent out reminders each Monday for the four weeks of the study. The estimated return rate for this survey was 34%. The low return rate was attributed in part to nurses and physicians not checking their on a regular basis.

Sample Characteristics More nurses (n = 809) than physicians (n = 539) participated in the survey, but this was consistent with percentages of each group employed at the facility.

Sample Characteristics The average age for the nurse group was 44.2 (SD = 10) and the average age of the physician group was 43.3 (SD = 11). This difference was not significant

Sample Characteristics The majority of respondents were female (n = 893; 66%), with 732 (90%) of the nurses being female and 161 (30%) of the physicians being female.

Sample Characteristics The physician group consisted of residents (n = 88; 16%), fellows (n = 46; 8%) and staff physicians (n = 409; 75%).

Sample Characteristics The nurse group consisted of staff nurses (n = 479; 59%), nurse managers (n = 174; 22%), and advance practice nurses (n = 155; 19%).

Sample Characteristics Both groups had considerable experience in their profession, with the nurse group having an average of 19 (SD = 11) years experience and the physician group having an average of 16 (SD = 11) years experience. This difference was not significant

PPEAS The combined average score on the PPEAS was 89 (SD = 13) With nurses (mean = 87.8; SD = 14) scoring the professional practice environment lower than physicians (mean = 90.7; SD = 12) This difference was statistically significant [F(1,1175) = ; p = <.001].

PPEAS PPEAS demonstrates a normal distribution Findings indicates room for improvement

Impact on Nursing Practice To determine if a physicians negative behavior or attitude affected how a nurse asked a questions or if it made them reluctant to report changes in a patient’s clinical condition, we examined frequency data for this single question.

Impact on Nursing Practice Findings from this study found that 59% (n = 478) of nurses responded yes to this question, indicating that a physicians behaviors and attitudes does affect nursing practice decisions.

Impact on Nursing Practice To determine if this variable was affected by other factors we performed exploratory analysis and found that scores on the PPEAS did not differ between those who answered yes and those who answered no to this question But there was a significant difference related to age, with nurses who responded yes being younger than those who responded no (F(1,783) = 11.83, p =.001). A similar finding related to years experience was also noted, with nurses who responded no having more nursing experience than those who responded yes. In addition, clinical nurse specialists (86%) were more likely to respond no than nurse practitioners (59%), nurse managers (49%), or staff nurses (36%).

Discussion This study adds to the knowledge about the professional practice environment, factors that impact it, and how it may potentially impact patient outcomes.

Discussion Our finding that younger nurses, nurses with less experience and staff nurses are most intimidated by physician behaviors and attitudes may provide insight into how the professional practice environment impacts patient outcomes.

Implications for Practice The professional practice environment can and should be measured in positive terms, rather than just the presence or absence of negative behaviors Using the total score, organizations can examine the current status of their professional practice environment and examine changes in the environment over time; and subscale analysis can identify specific characteristics in need of facilitation.

Implications for Practice Improving the professional practice environment requires not only zero tolerance for abusive and disrespectful behaviors but also policies, procedures and processes that encourage nurses and physicians to better understand each others roles, to communicate effectively, and to collaborate when making patient care decisions.

Implication for Research Professional Practice Environment More research is needed on our instrument Sensitivity to change over time Structure when used with different organizations or in different cultures More research is needed related to the impact of a positive professional practice environment on: Patient outcomes Patient and family satisfaction with care Nurse and physicians job satisfaction Nurse recruitment and retention

Implications for Education Our finding that younger nurses, nurses with less experience and staff nurses are most intimidated by physician behaviors and attitudes suggests a need to better prepare nurses for their role in the real world. What can educators do?

Questions