In 2003, the Board of Directors of the American Association of Critical-Care Nurses (AACN) embarked on a strategic planning initiative to identify the three most pressing issues in which AACN’s influence and voice could have the greatest impact on members. Consensus emerged that nurse staffing, healthy work environments, and end-of-life care were pivotal issues. Staffing and healthy work environments were seen as critical issues for nursing’s largest specialty organization because of evidence that strong and supportive environments contribute to lower patient mortality rates [7]. Healthy work environments are those in which professionals work as team members, respect each other, and display caring for patients and families as well as each other. In these environments, effective collaboration provides opportunities for shared problem solving and emergence of shared mental models that support new solutions [2]. Professionals are empowered to practice according to the standards of their professions, including making decisions about their practice. They are led by leaders with the skills and power to design and implement a vision for superb practice. This was the vision that motivated the AACN Board of Directors to charge a work group, led by past president Connie Barden to develop healthy work environment standards [8]. These standards, listed in Table 206.1, were designed to give a strong message that immediate change in current practice settings was needed. Research identifying factors foundational to healthy work environments support AACN’s decision to select these standards as the framework to drive widespread change.

There is evidence that nurses and physicians who work together differ significantly in their perceptions of collaborative decision making. In a large French study involving over 3,000 nurses and over 500 physicians, over 90% of the total sample agreed that decisions involving patients’ end-of-life care should be made collaboratively. In practice, however, physicians were nearly twice as likely as nurses to report that nurses were involved in decision making (50% vs. 27%) and were significantly more satisfied with decision processes (73% vs. 33%, p < 0.001). These uneven perceptions were paralleled by strong differences in reports of physician consultation with nurses in the decision making process (79% vs. 31%, p < 0.001). Nurses were much more likely to feel that their presence in the meeting with the family was important. They valued being there more than the physicians valued their presence (56% vs. 36%, p < 0.05). The importance of these findings to clinical practice was evident in that significant linkages were found between satisfaction with decision making, perception of the unit’s commitment to high ethical standards, and nurses’ involvement in achieving these standards (p < 0.0001) [9]. Understanding that providers have disparate views of successful collaboration provides insight into potential root causes of communication problems both in day-to-day practice and when providers and patients face tough decisions. Efforts to achieve an ethical solution to practice dilemmas using processes that respect and value the input of the entire healthcare team are needed to achieve truly healthy work environments.

Effective communication has been shown to affect prevention of adverse outcomes. In particular, timeliness of nurse–physician communication was related to decreased incidence of pressure ulcers in a critical-care patient population, and conversely, when nurses perceived variability in communication with physicians, ventilator associated pneumonia (VAP) rates were higher [10]. Given the importance of preventing adverse events, it is reasonable to consider changes in care processes to foster clear and effective communication. System changes such as use of multidisciplinary rounds, appointment of a hospitalist medical director, and addition of a nurse practitioner (NP) to support the care interface between staff nurses and physicians are becoming more common, particularly in tertiary care hospitals. In a setting with these values in place, when care in that environment was compared with standard practice on a similar acute medical care unit, it was found that attending physicians and house staff perceived nurse collaboration to be significantly better but both the physicians and nurses rated collaboration with the NPs to be significantly better than with each other. No differences were found between nurses’ perceived communication and collaboration with physicians on the model unit versus the standard practice unit. However, physicians on the model unit reported improved communication with each other. Improved patient outcomes included reduction in patient length of stay and care costs without reductions in quality of care or increased readmissions [11]. A possible explanation for the positive outcomes of physician/NP collaboration may lie in an appreciation of skills gained through NP versus MD education. It has been argued that NPs may be more adept at managing
patients through chronic care protocols in primary care. This is supported by their nursing background with its focus on patient education and use of communication skills [12]. Hence, the NP lives in both worlds and can easily translate and fill in gaps.

Why would physicians and nurses perceive care processes so differently? As was evident in Vazirani and colleagues’ study [11], staff nurses may have difficulty being freed from direct care responsibilities to be able to participate in patient rounds or may be uncomfortable presenting their data and recommendations and thus avoid participation. Clear expectation for each provider’s role in rounds, support for their participation through patient coverage, and providing adequate mentoring of young professionals in effective participation strategies are needed. Dialogue to ensure clarity about the characteristics of good collaboration and to develop respect and recognition of the value of each others’ contributions are important steps in achieving benefits for patients and providers. Without this preparation, physicians may view improved collaboration to mean simply receiving accurate patient information and nurses following through on physician orders versus actual sharing in the decision making process. Addition of an NP to the team may serve as a bridge between nurses and physicians, improving the flow of information but may have the unintended effect of predisposing the nurses to communicate with the NP at times when they otherwise may call a physician [11].

Nurse–physician communication difficulty may have its roots in disparate educational systems. In their basic education, nurses are expected to present a broad, comprehensive picture of the patient’s situation, in contrast to the targeted, specific problem focus that drives physician communication [13]. Nursing case summaries are graded highly if they thoroughly addressed the patient’s physical health problems, including supporting pathophysiology, emotional and coping reactions, family and community support systems, and the interrelationships between all of these, resulting in a comprehensive nursing care plan that also integrates the nurse’s support of the medical plan. Parsimonious, concise descriptions tend to be graded as missing key information and insights. Those training exercises, while designed to educate the nurses to view the patient holistically as a being with vast nursing needs beyond the medical illness, do not prepare them for a concise, problem-specific and action-driven health system, particularly as exists in critical-care settings. Thus, vastly different and ingrained way of thinking about patients’ problems coupled with hierarchical power differentials can lead to pervasive dysfunctional norms of communication. Fear of reprisal or ridicule blocks interjection of critical information into the dialogue. Reliance on vague, imprecise communication styles may exclude critical information or urgency in message delivery. Leonard and colleagues [13] refer to this as the “hint and hope” model—one that holds a strong potential to harm patients.