Perspectives and experiences of Iranian nurses regarding nurse–physician communication: A content analysis study

Authors


Mahvash Salsali, Faculty of Nursing and Midwifery, Tehran University of Medical Sciences, Eastern-Nosrat Street, Touhid Square, Tehran, Iran. Email: m_salsali@hotmail.com

Abstract

Background:  Nurse–physician communication in the healthcare setting is an important subject that requires international attention because of its relationship with nurses' job satisfaction, turnover, patient safety, and above all, the quality of care. The importance of conducting studies on communication in different cultures and contexts in order to increase nurses' knowledge regarding nurse–physician communication cannot be overemphasized.

Aim:  The purpose of this study was to explore the perspectives and experiences of Iranian nurses regarding nurse–physician communication.

Methods:  A qualitative study, using the content analysis approach, was conducted. Semistructured interviews were held with 22 female nurses with a Bachelor's degree who were working in two teaching hospitals in an urban area of Iran.

Results:  During the data analysis, three main themes emerged: “no independence in decision-making”, “lack of acknowledgment of nurses' capabilities”, and “unequal support by the healthcare system”.

Conclusion:  Healthcare team members and administrators should listen to nurses' perspectives and try to address the problematic areas of nurse–physician communication if they are improving the quality of nursing care that is expected.

INTRODUCTION

Communication, in any form, is an integral part of daily life and, within the realm of health care, can mean the difference between life and death (Weeks, 2004). Communication with physicians is a significant part of nurses' activities. The professional model of nursing conceives nurse–physician communication as interactions between two professions, each with its own areas of expertise and responsibilities (Rothstein & Hannum, 2007). The coordination of actions between the physician and the nurse obviously is supported by oral communication, but the written forms of communication are also important in this regard (Beuscart-Zéphir, Pelayo, Anceaux, Maxwell, & Guerlinger, 2007).

Complex healthcare organizations, characterized by uncertainty, unpredictability, and instability, have created new challenges to the nurse–physician relationship (Hendel, Fish, & Berger, 2007). In addition, the complexity and rapidity of change in patients' status make interdisciplinary collaboration a necessity (Schmalenberg et al., 2005). This implies that physicians need support from other healthcare professionals, such as the nursing staff, because decision-making about today's healthcare problems is multifaceted (Puntillo & McAdam, 2006). According to the American Nurses Association (1980), interprofessional collaboration is a cooperative venture that is based on shared authority and responsibility, requiring open communication and shared decision-making as the means of improving the quality of care (American Nurses Association, 1980).

In today's complex healthcare organizations, conflict between physicians and nurses occurs daily and it has grown into a major subfield of organizational behavior (Hendel et al., 2007). When a variety of individuals and professions is brought together in one area, it is virtually impossible to have consistent and flawless communication patterns (Weeks, 2005). A healthcare system's communication patterns rest on nurse–physician collaboration (Brandi, 2000). Interprofessional relationships tend to be complementary in societies where physicians and nurses share the power and are viewed to have complementary roles and responsibilities in patient care (Hojat et al., 2003). It is known that the combination of the nursing approach to the patient's environment, needs of the patient's family, and disease education is complementary to the disease-focused approach of the physician (Greenfield, 1999).

Improving the knowledge of nurses and physicians regarding the process of nurse–physician communication will enable them to be collaborative in the healthcare system, where patient care is the main goal (Weeks, 2005). Although other healthcare professionals are involved in quality patient initiatives, making the entire communication issue complex, nurses' contribution to communication in the nurse–physician dyad has not been understood fully (Manojlovich & DeCicco, 2007).

Conducting studies on nurse–patient communication is of utmost importance because it is hoped that, once the common barriers are clearly identified and the strategies to overcome these barriers are used, successful collaboration will occur, leading to improved patient outcomes (Clarin, 2007). It has been suggested that the errors that are related to communication problems might result from a lack of guidelines for clinician-to-clinician communication and a lack of a shared framework and approach to communication (Beyea, 2004). It is worth noting that the available studies in the international literature mainly describe the components in, and influences of, the nurse–physician work relationship. If they validly capture the daily aspects of nurses' interaction with other healthcare team members, such as physicians, they also might enable health-services researchers to more realistically investigate the actual patient and provider outcomes, which can be correlated with various practise patterns (Corser, 2000).

As a starting point, nurses as research subjects are suitable for acquiring information about their perception of communication (Nelson & Venhaus, 2005). Furthermore, designing and using a professional nursing model that is based on such data might help nurses to develop the necessary skills in order to improve nurse–physician communication and to provide patient-centered care (Lawson, 2002; Manojlovich & DeCicco, 2007). Above all, conducting multiple studies in different cultures and contexts is recommended, as values are embedded in cultures (Hojat et al., 2001; Schmalenberg et al., 2005; Sterchi, 2007). Therefore, such studies will result in the development of beneficial communication patterns and enhanced understanding within the context of workplace situations (Weeks, 2004).

Importance of nurse–physician communication

A vital partnership exists between healthcare professionals that can be either negatively or positively affected by interprofessional communication (Weeks, 2004). Clearly, a link between the nurse–physician relationship and patient outcomes exists, regardless of geographic boundaries (Hojat et al., 2003). If nurses and physicians disagree on the dynamics of interprofessional communication, potentially detrimental patterns will continue (Weeks, 2005). Studies have suggested that collaboration is one of the factors that positively influences patient outcomes (Hendel et al., 2007).

Healthy or unhealthy nurse–physician communication influences both nurses and patient care. Unhealthy nurse–physician relationships can contribute to the loss of some of the best and brightest nurses (Nelson & Venhaus, 2005). Studies have shown that nurses are more satisfied with open, accurate, and understanding communication (Manojlovich & Antonakos, 2008). Nurses who are unhappy with their career decision are at risk of potential attrition from the profession (Boswell, Lowry, & Wilhoit, 2004). In other words, the resulting frustration is likely to compromise the work environment atmosphere and contribute to nurses' burnout and turnover (Oweis & Mousa Diabat, 2005). In addition, the greatest source of stress has been recognized to be nurse–physician interpersonal conflict (Anderson, 1996). Nurse–physician communication has been mentioned as a significant mediating variable in nurses' job satisfaction (Manojlovich, 2005). When nurses experience strong collaborative relationships with physicians, they enjoy a high level of job satisfaction (Sterchi, 2007). The development of effective partnerships between nurse and physician leaders can result in creating an environment that enhances collaboration, productivity, and morale for all caregivers (Sterchi, 2007). A possible consequence of better communication and collaboration is an increased probability that an evidence-based decision is actually carried out (Zwarenstein & Reeves, 2006). Such collaboration is increasingly viewed as necessary to contain costs and to sustain the quality of care. It also results in cost savings through positive patient outcomes and increased staff retention rates (Hojat et al., 2001; 2003; Weeks, 2004).

The role of nurses as a communicator between patients and their treating physicians can impact the diagnostic and treatment process. Accurate and adequate communication between the nurse and the physician is important because nurses are accountable for the outcomes of their professional actions (van Niekerk & Martin, 2002). Poor nurse–physician communication leads to a polarization of the efforts to care for patients (Greenfield, 1999). Conversely, collaboration has been shown to be effective in improving patient care (Brancato, 2005). Collaboration is vital if these competing demands are to be incorporated into safe and high-quality care (Sterchi, 2007). Interdisciplinary communication and teamwork can be improved in order to promote a safer care environment (Simpson, James, & Knox, 2006). Patient safety is predicated on trust, open communication, and effective interdisciplinary teamwork (Simpson et al., 2006). In addition, it has a strong link with the communication between nurses and physicians (Nelson & Venhaus, 2005). Nurse–physician communication is a predictive factor for nurse-assessed medication errors. It might be the most significant factor to be associated with excess hospital mortality in critical-care settings (Manojlovich & DeCicco, 2007). The more collaboration that is noted by the nurse, the less the predicted risk of a negative outcome for the patient (Puntillo & McAdam, 2006). It has been stated that the positive outcomes resulting from nurse–physician communication decrease the mortality rate, shorten the length of stay, decrease the amount of adverse patient complications, and improve the quality of care (Narasimhan, Eisen, Mahoney, Acerra, & Rosen, 2006; Schmalenberg et al., 2005). Above all, increased collaboration and communication can result in more appropriate care, as well as increased satisfaction of the physician, nurse, patient, and patient's family (Puntillo & McAdam, 2006). Thus, clinicians must work together to prevent the injuries that result from ineffective or incomplete communication and develop strategies to ascertain that communication is effective and timely (Beyea, 2004).

In summary, the current healthcare environment, with higher patient acuity, shorter hospital stays, and more frequent interdisciplinary patient care planning, has prompted a closer examination of the work relationships among nurses and physicians (Corser, 2000). In addition, there is a growing belief among policy-makers that interprofessional relationships are important and must be improved (Zwarenstein & Reeves, 2006).

Background in Iran

Those who want to pursue a nursing career in Iran are expected to successfully pass the Iranian Universities National Examination as a precondition to being granted permission to choose and enter one of the 40 schools of nursing in the country. A Bachelor's degree in nursing is the minimum requirement for employing nurses in both public and private healthcare settings and consists of the successful completion of theoretical and practical courses (93 and 37 units, respectively) over 4 years. In addition, Master's and PhD degrees in nursing are available to those nurses who are interested in supplementary studies.

As mentioned before, nurse–physician communication is an important subject, considering its impact on patient safety and the quality of care. Unfortunately, this important subject has not been considered to be a priority in Iranian studies. Thus, the authors sought to find the answer to the following question: How do nurses describe their perspectives and experiences regarding nurse–physician communication in Iranian healthcare settings?

Therefore, the purpose of this study, as the first Iranian research on the subject, was to explore the perspectives and experiences of Iranian nurses regarding nurse–physician communication.

METHODS

Design

A qualitative design, based on the content analysis approach, was used for the data collection and analysis of the perspectives and experiences of Iranian nurses. Qualitative studies are intended to enhance one's understanding and to describe the world of human experience (Myers, 2000). Qualitative research findings contain information about the subtleties and complexities of the human responses that are essential to the construction of effective and developmentally and culturally sensitive interventions (Sandelowski & Barroso, 2003). Through content analysis, it is possible to distill words into fewer content-related categories. The aim is to attain a condensed and broad description of a phenomenon and the analysis outcome is the concepts or categories that describe the phenomenon (Elo & Kyngas, 2008). In addition, content analysis is used in order to produce findings that are closer to the data as given, or “data-near”. It is defined as entailing a commitment to studying a phenomenon in a manner as free of artifice as possible in the artifice-laden enterprise that is known as “conducting research” (Sandelowski, 2010).

Participants

In this study, 22 female nurses with a Bachelor's degree were chosen by using the purposeful-sampling strategy. They worked in the medical and surgical wards of two teaching hospitals in an urban area of Iran. They were recruited by using maximum-variation sampling for the number of years of nursing experience. The study's participants ranged from 1 to 21 years in their number of years of nursing experience, with a mean of 10.17 years (standard deviation = 5.98 years).

Data collection

Face-to-face, semistructured interviews, lasting 20–45 min on average, were held in quiet locations in the nursing wards that were convenient to the participants. The data were audio-recorded and gathered by using an interview guide. The interviews were conducted in the Persian language by the first author and they were translated later into English. The second author, as a bilingual translator, supervised the translation process. The major foci of the questions in the interviews were: What is your perspective about nurse–physician communication? Would you please share with us your experiences regarding your communication with physicians in this healthcare setting? The interviews covered the nurses' perspectives and experiences regarding nurse–physician communication. In addition, probing questions were asked to follow the participants' thoughts and to bring clarification to their responses during the interview. The data collection and analysis proceeded concurrently in order to develop themes that were related to nurse–physician communication. Once the themes were identified and data saturation was achieved, the interviews were discontinued. The data were gathered in 2010.

Data analysis

Content analysis was conducted to identify the themes and categories. The following steps were taken to analyze the collected data (Graneheim & Lundman, 2004):

  • 1Transcribing the interviews verbatim and reading through several times in order to obtain the sense of the whole.
  • 2Dividing the text into meaning units that were condensed.
  • 3Abstracting the condensed meaning units and labeling them with codes.
  • 4Sorting the codes into subcategories and categories, based on comparisons regarding their similarities and differences.
  • 5Formulating themes as the expression of the latent content of the text.

Trustworthiness

Trustworthiness was established in accordance with Graneheim and Lundman (2004). Maximum variation of the sampling enhanced the confirmability and credibility of the data. The researchers ensured the depth of the content and its authenticity by thoroughly identifying diverse and novel data. The data were analyzed independently by the researchers in order to identify and categorize the initial codes. Then, the codes and themes were compared. The credibility of the data was established through peer-checking and member-checking. A summary of the interviews was returned to the participants and it was confirmed by them that the researchers were representing their perspectives and experiences. Peer-checking was done by the authors and two doctoral nursing students, which resulted in similar findings.

Ethical considerations

The study was approved by the appropriate university, which corroborated its ethical considerations. All the participants were informed about the study's purpose and method. They were informed that participation in the study was voluntary and that they could refuse to participate or withdraw from the study at any time. Moreover, they were assured that their responses would be kept confidential and that their identity would not be revealed at any stage of the study. Lastly, written consent was obtained from those nurses who willingly accepted to participate in the study.

RESULTS

The data analysis resulted in three main themes: “no independence in decision-making”, “lack of acknowledgment of the nurses' capabilities”, and “unequal support by the healthcare system”. The themes summarized the perspectives and experiences of the Iranian nurses regarding nurse–physician communication. It should be stated that what has been presented below shows the real context of nurse–physician communication in Iranian healthcare settings.

No independence in decision-making

The study's participants declared that, during communication with the physicians, they were considered to be the physicians' subordinates who were expected to only carry out orders. They were not given any independence to make decisions according to their own reasoning. The nurses also were expected to inform the physicians about the patients' condition and to not take any kind of action without getting permission from them:

We are not allowed to intervene without physician permission (nurse with 15 years of nursing experience).

We should always check with doctors before doing anything. We can do nothing without their orders (nurse with 2 years of nursing experience).

I am not expected to decide for my interventions. It is a routine here that you are given orders and then you intervene (nurse with 21 years of experience).

Obeying doctors' orders encompassed all kinds of nursing interventions, even the least-important ones, such as pain medication. It was stated that the patients suffered from pain and that the nurses could do nothing because of having no order and, at the same time, no independence to intervene on their behalf:

Patients may suffer from pain for a couple of hours until I find the doctor because I have not been given any order to administer painkillers (nurse with 13 years of nursing experience).

The majority of the participants accepted their present conditions. They had been convinced that “having no independence” in nursing practise was an undeniable fact of the healthcare setting. They did not complain very much about receiving orders from the attending physicians. However, passing on the authority of decision-making to medical residents was unacceptable. In summary, they preferred to communicate and work with the attending physicians and not with the medical residents:

Attending physicians are very expert. We have got no problem with them. They make decisions very fast and without mistake (nurse with 7 years of nursing experience).

We have got no problem with attending physicians. We receive orders from them without any delay, but medical residents are not committed to their work. We are forced to find them and ask them to rectify their orders. Sometimes, the delay endangers patients' health (nurse with 11 years of nursing experience).

Lack of acknowledgment of the nurses' capabilities

The nurses were dissatisfied with the physicians' inattention to the nurses' point of view, comments, and suggestions during communication about patient care. For example, the nurses criticized the physicians regarding their approach toward patient care, but no attention was paid to their words at all. From the participants' perspective, the physicians did not believe in the nurses' knowledge and skills:

I have the experience of working in the intensive care unit. I know many things regarding patient oxygenation. In the surgery unit, I recommended the physician to change the oxygen gauge and I brought him the reasons for my suggestion, but he did not pay attention to my words. He did not believe in my knowledge (nurse with 15 years of nursing experience).

Physicians think that we are not knowledgeable and do not know anything regarding patient care (nurse with 12 years of nursing experience).

The medical resident did not follow sterile rules during . . . the procedure. I objected to him, but he did not care at all (nurse with 11 years of nursing experience).

It was mentioned that the physicians adopted a sense of grandiosity and superiority in their communication with the nurses, which hindered the physicians' acknowledgment of the nurses' knowledge and skills. According to the participants' narrations, the physicians behaved in this manner in order to show their superiority to the nurses. The physicians' behavior resulted in the nurses' dissatisfaction with their workplace. Sadness and resentfulness were evident in the nurses' narrations of the physicians' behavior:

The physician was so proud. He knew that I was right and my point of view regarding patient care was more correct than his, but he did not confess to it (nurse with 13.5 years of nursing experience).

They do not confess that they are wrong. Their pride hinders the confession (nurse with 19 years of nursing experience).

Some of them believe that they are better than [the] other healthcare team members and others should respect them unilaterally (nurse with 19 years of nursing experience).

The study's participants declared that they paid tribute to the physicians and, likewise, they expected to be respected as healthcare team members. They considered themselves to be the physicians' eyes and ears, recording changes in the patients' condition in the physicians' absence. Therefore, their knowledge and skills deserved to be treated respectfully:

I should report to the physician what has happened to the patient in the last 24 h. If not, the result is clear (nurse with 21 years of nursing experience).

The physicians stay with patients for a few minutes, but we are in touch with patients day-and-night. Therefore, our perspectives about [the] patients' condition should be considered seriously (nurse with 13 years of nursing experience).

The nurses suggested a number of strategies that should be used by the physicians in their communication in order to show their acknowledgment of the nurses' participation in patient care. “Being trusted by the physicians”, “being invited to actively take part in rounds”, and “reading nurses' documentation” were among the suggested strategies:

We and physicians work together. There is a close cooperation between us. Therefore, we should be trusted by physicians. Some kind of trust-based communication should be available between us (nurse with 13 years of nursing experience).

Nurses should be asked to actively participate in ward rounds. We should be asked one-by-one to speak and announce our perspectives regarding the patients' care (nurse with 13 years of nursing experience).

Nurses' documentation should be read by physicians. They should care about what nurses write in patients' files (nurse with 15 years of nursing experience).

Unequal support by the healthcare system

This theme is related to a suggested cause for the problems that were experienced by the nurses regarding nurse–physician communication. The participants reported that the healthcare system was dominated by physicians. Such dominance gave the physicians enough assurance and ability to practise independently and to ignore the nurses in their communication. Therefore, no one in the system supported the nurses. This is important regarding nurse–physician communication because the nurses experienced some kind of position inequality with the physicians in the healthcare team:

The healthcare system is physician-dominated. You must follow whatever they prefer. You [nurses] are nothing in the system (nurse with 15 years of nursing experience).

Physicians are defended without any precondition in the system. They do whatever they like and no one asks why (nurse with 7 years of nursing experience).

It was thought that the medical residents were considered to be superior to the experienced nurses:

A first-year medical resident is respected much more than an experienced nurse in the system (nurse with 12 years of nursing experience).

The unconditional support for the physicians resulted in a decreased level of accountability among the medical residents, who did not answer nurses' phone calls or pay attention to the nurses' alerts. When the patients were hurt or they complained about the quality of the services in the healthcare system, the medical residents shifted the blame and responsibility to the nurses and no one defended the nurses. Therefore, the nurses were always reproached for what was not in their domain of practise:

The medical resident did not do his job. He was expected to assess the patient carefully and remind us about the patient's eyesight problem. The patient fell off his bed and was hurt. The medical resident did his best and showed us [as] guilty. No one defended us (nurse with 15 years of nursing experience).

I called the medical resident, that the patient needed . . . emergency care. She did not come at all. The patient was hurt. She reported to the head nurse that “No one had called me.” As usual, her words were believed, not mine (nurse with 13 years of nursing experience).

The nurses claimed that their reports to the administrators about the physicians' or medical residents' negligence or mistakes did not result in any action by the system:

It was the medical resident's negligence. He was expected to come and visit the patient in the emergency room. He did not come and the patient was hurt. We [nurses] reported it to . . . , but nothing happened and no one [was] prosecuted (nurse with 7 years of nursing experience).

The medical residents were assigned to conduct some invasive procedures or dressing changes, which were beyond the nurses' description of duties. Sometimes, they refused to do the procedures and the nurses were forced to take the role. If the nurses refused to do so, they were blamed for not fulfilling the patents' care:

In here, it is [the] medical residents' duty to insert the urinary catheter. When they evade their duties, I do it myself to escape blame (nurse with 11 years of nursing experience).

The nurses were not supported and were not considered as one of the pivotal members of the healthcare team because the physicians did not possess the correct image of nursing and nurses' duties, roles, and job descriptions. From the participants' perspective, it resulted in nurse–physician communication problems:

Unfortunately, they think that nurses are employed to do primary jobs and they know nothing of specialized care (nurse with 7 years of nursing experience).

They should not expect us to do beyond our job descriptions . . . Some work, asked to be done by nurses, should be conducted by other healthcare team members (nurse with 13.5 years of nursing experience).

DISCUSSION

The present study provided the opportunity to explore the perspectives and experiences of Iranian nurses regarding nurse–physician communication. In this regard, the context and dynamics of nurse–physician communication were described. The first theme indicated that the participants had no independence to practise that was based on their own reasoning. The physicians expected the nurses to get permission for taking any kind of action. Historically, a hierarchical relationship has existed between nurses and physicians in the healthcare arena. Physicians often were viewed as subordinates or followers (Brancato, 2005). Nurses' willingness to practise independently and to follow their own reasoning are commonly seen in other countries. For example, in a study by Simpson et al. (2006) in the USA, the nurses were willing to observe a fetal heart rate pattern with unreassuring characteristics for some time without intervening or notifying the physicians (Simpson et al., 2006). In another study in the USA, the expert nurses expressed satisfaction regarding their autonomous role and their ability to make clinical decisions (James, Simpson, & Knox, 2003). However, having no independence in decision-making seems to be something that is more specific to an Eastern nursing culture. For example, Canadian nurses believed that they make their own personal decisions because they are independent practitioners; however, Korean nurses usually accept that they do not make the decision and accept the physicians' recommendations (Malloy et al., 2009). It should be noted that autonomy is one of the elements that nurses have identified as being essential to the quality of patient care and professional job satisfaction (Schmalenberg et al., 2005). In fact, a significant barrier to nursing autonomy is related to the attitudes of healthcare practitioners (Sterchi, 2007). There are certainly areas where nurses can be granted some independence in decision-making, such as advancing diets and administering analgesics for mild aches and pains (Greenfield, 1999).

The Iranian nurses accepted the fact that having no independence in nursing practise was an undeniable fact of the healthcare setting. However, they preferred to work with the attending physicians rather than the medical residents. According to Manojlovich and Antonakos (2008), nurses are more satisfied with understanding, open, and accurate communication, especially with attending-level physicians. In a similar study, the level of the physician was reported to be a significant contributor to communication satisfaction. The association between all the communication subscales and the amount of time that was spent in communication with the attending-level physicians was significantly positive, whereas the amount of time that was spent communicating with the first-year residents was significantly negative (Manojlovich & Antonakos, 2008). It has been reported that, if residents do not respond appropriately to nurses' reports or to their promptings, the nurses feel comfortable calling the attending physician directly (Schmalenberg et al., 2005).

The second theme indicated that the study's participants were resentful that the physicians did not acknowledge the nurses' knowledge and skills. According to the international literature, looking at the interactions that take place in the patient's room clearly shows that the direction of communicative actions is physician-focused. The typical ward round is a dyadic interaction between the patients and the physicians, with only minor contributions from the nurses (Weber, Stöckli, Nübling, & Langewitz, 2007). It means that nurses do not contribute substantially to the content of what is said during ward rounds (Weber et al., 2007). Alternatively, it has been shown that doctor–nurse communications are rare and that their shared knowledge about the patient is weakened (Beuscart-Zéphir et al., 2007). In a study by Puntillo and McAdam (2006) in the USA, 30% of the study's nurses reported being excluded by physicians from the patient-care decisions. These nurses thought that this was a major or extreme obstacle to the delivery of optimum care. Similarly, in the study of Malloy et al. (2009), the nurses from Canada, Ireland, and Korea mentioned that there was a sense of the physicians having a disregard for the advice and recommendations that were given by the nurses.

According to the participants, the physicians adopted a sense of grandiosity and superiority in their communication with the nurses. Much of the conflict between the nurses and the physicians is rooted in the historically dominant role of physicians and the subservient role of nurses that was envisioned by Florence Nightingale (Greenfield, 1999). Nurses and physicians traditionally have operated under the paradigm of physician dominance and nurse deference, in which the physician's position prevails regarding patient-care issues (Hendel et al., 2007). As another possible explanation, the typical conditions of salary, prestige, and a toughening-up mind-set that are found in much of medical education contrast sharply with the more altruistic values that are conveyed to nursing students, who are less likely to embrace the orientation to power or money that is ascribed to medical students (Corser, 2000). Unfortunately, educational programs offer little or no education about communicating with other clinicians (Beyea, 2004). It is suggested that physicians should learn how to communicate in a way that is satisfying to nurses (Manojlovich & Antonakos, 2008). In other words, physicians should be oriented to the benefits of listening to, and working with, nurses (Schmalenberg et al., 2005).

This study's participants expected to be respected as healthcare team members. Nurses want more respect from physicians for their level of knowledge and skill (Nelson & Venhaus, 2005). Respect, trust, and collegiality are core values (Schmalenberg et al., 2005). Clearly, the lack of respect can be a barrier to effective collaboration (Clarin, 2007). What is implied here is that better communication between nurses and doctors will lead to more satisfaction and better outcomes for patients and their family (Puntillo & McAdam, 2006).

“Being trusted by physicians”, “being invited to actively take part in rounds”, and “reading nurses' documentation” were suggested in order to acknowledge nurses' capabilities. An increase in shared decision-making can result from a better understanding of, and respect for, the perspectives and burdens that are felt by other caregivers (Puntillo & McAdam, 2006). In an ideal situation, an analysis of the physician–nurse dialogues during medical rounds demonstrated that, in the synchronous situation, the nurses actively participated in the medication-ordering process (Beuscart-Zéphir et al., 2007). Nurses conceptualized “good” physicians as respecting what nurses do, asking their opinions, and trusting their judgment (Simpson et al., 2006). If nurses are confident, then they are likely to be providing quality care and the patients are likely to be satisfied (Boswell et al., 2004).

The third theme indicated that the participants believed that the Iranian healthcare system was dominated by physicians. The Iranian nurses experienced some kind of position inequality with physicians in the healthcare team. A critical factor in empowering nurses to practise independently within their legislated scope of practise is providing the organizational context that visibly supports their practise (Arford, 2005). Usually, the greater power of a professional is associated with more independence and more dependence is associated with less power (Hendel et al., 2007). Resistance from physicians, who are fearful of losing actual or perceived power, can challenge the discourse surrounding the importance of nurse–physician collaboration and the interprofessional communication pattern (Weeks, 2004). Studies have yielded some evidence that the change from traditional leadership models to the nurse–physician shared-leadership model might have advantages in the management of the healthcare system (Steinert, Goebel, & Rieger, 2006). As an undeniable fact, both the perceived and real differences in power and status between physicians and nurses can lead to problems when these healthcare providers do not agree on the patient care plan (Sterchi, 2007). Nurses report frustration with their lack of power, in contrast to the overwhelming power of physicians (Malloy et al., 2009).

In Iran, the experienced nurses were not paid attention in the healthcare system. Similarly, in the study by Rothstein and Hannum (2007) in the USA, the nurses were least-satisfied with the physicians' recognition of their other responsibilities besides the care of the physicians' patients. Physicians seldom observe those activities and have little awareness of their extent and subsequent time demands (Rothstein & Hannum, 2007). Nurses who do not receive support are less able to cope with job-related stresses (Boswell et al., 2004).

Above all, the poor amount of system-level support of the nurses resulted in a decreased degree of accountability among the medical residents. It has been proposed that those who are in a position of greater power are less likely to express a desire for a collaborative relationship (Hojat et al., 2003). Organizational and group conflicts also might be related to power differentials and to tendencies to differentiate rather than converge (Hendel et al., 2007). The disciplines that are involved in direct care cannot accomplish their work without the cooperation and task completion of each other (Arford, 2005).

According to the nurses, the nurses' reports regarding the physicians' negligence and mistakes were not heard in the healthcare system. Physicians assess and provide prescriptions, whereas nurses assess patients' status and serve as an advocate for patients by promoting an understanding of their existing problems among the healthcare team members (van Niekerk & Martin, 2002). It has been suggested that nurses' voices are silenced or are not expressed, in terms of ethical decision-making (Malloy et al., 2009). How well that nurses perform when at cross-purposes with physicians largely depends on how much support they receive from their supervisors (Brandi, 2000).

It was said that the medical residents sometimes refused to do the procedures that were attached to their job description and that the nurses were forced to take on their role. Generally, nurses do not like to be pressured to do something that they think is unnecessary or inappropriate (Simpson et al., 2006). Although nurses were used to following orders in the past, they have learned to adapt their approaches with physicians in order to accomplish their patient-care goals (Sterchi, 2007).

Finally, the study's participants mentioned the physicians' unfamiliarity with the nurses' roles and job descriptions in the healthcare team. A lack of knowledge of nurses' role and scope of practise is commonly stated in the international literature (Clarin, 2007). Conflicts between nurses and physicians also are related to the overlapping nature of their domains and a lack of clarification between their roles (Hendel et al., 2007). Most nurses and physicians indeed do possess varied expectations of each other as they attempt to adapt to the intense demands that are imposed on them in healthcare settings (Corser, 2000). Therefore, for both nurses and physicians, education concerning the role of nurses in the workplace will help to ensure that these conflicts do not arise (van Niekerk & Martin, 2002).

Limitations of the study and suggestions for future studies

This study focused on nurses' perspectives and experiences regarding nurse–physician communication in Iran. The perspectives of other healthcare team members, such as physicians, were not collected during the data-gathering process. However, the author believes that the results are innovative and noteworthy despite the limitation. Therefore, conducting studies on the perspectives of male nurses, nursing managers, and physicians is recommended in order to increase nurses' knowledge regarding nurse–physician communication. In addition, the relationship between nurses' independence in decision-making, the acknowledgment of nurses' capabilities, and healthcare system support for nurses and nurse–physician communication should be substantiated by conducting quantitative and qualitative studies.

CONCLUSION

Having independence and being respected, trusted, and supported in the workplace are prerequisites for improving the satisfaction level of healthcare providers with their job and, as a result, patients' satisfaction with the provided care. In other words, these are the minimum conditions that nurses need in order to improve the quality of nursing care. Healthcare team members and administrators should listen to nurses' perspectives and try to address the problematic areas of nurse–physician communication if an improvement in the quality of nursing care is expected.

ACKNOWLEDGMENTS

This study was supported financially by Tehran University of Medical Sciences, Tehran, Iran. The authors thank the willing participation of, and valuable contributions that were made by, our study nurses. Without their help and cooperation, this study could not have been conducted.

Ancillary