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JONAVolume 35, Number 5, pp 244-253C©2005, Lippincott Williams & Wilkins, Inc.

A Review of Instruments MeasuringNurse-Physician Collaboration

Mary B. Dougherty, MBA, MA, RNElaine Larson, PhD, RN, FAAN, CIC

Objective: To review instruments used to mea-sure nurse-physician collaboration and compare thestrengths and potential opportunities of each instru-ment.Background: Nurse-physician collaboration hasbeen studied using a variety of instruments. The abil-ity to generalize the outcomes of studies and buildon the findings is predicated on acceptable validityand reliability metrics of these instruments.Methods: A literature search using PubMed® andHealth and Psychological Instruments databaseswas conducted for articles published between 1990and May 2004 to identify instruments measuringstaff nurse–physician collaboration. After the instru-ments were identified, a second search was con-ducted to identify at least one peer-reviewed articledescribing the psychometrics of the instrument. Ar-ticles identified were then entered into the ISI Webof Science® Citation Index to identify the instru-ments that had been used in at least 2 other studies.These selected instruments were then reviewed forthe following information: background for the de-velopment of the tool, description of the tool, initialpsychometric testing, and strengths and potential ap-plications for each instrument.Results: Five instruments met study criteria: the Col-laborative Practice Scale, Collaboration and Satis-faction About Care Decisions, ICU Nurse-PhysicianQuestionnaire, Nurses Opinion Questionnaire, andthe Jefferson Scale of Attitudes Toward PhysicianNurse Collaboration.Conclusions: The identified instruments have under-gone initial reliability and validity testing and arerecommended for future research on nurse-physiciancollaboration.

Nurse-physician collaboration is a key factor innurse job satisfaction, retention, and job valua-tion.1-3 Decreased risk-adjusted mortality and lengthof stay, fewer negative patient outcomes, and en-

hanced patient satisfaction have also been associ-ated with better nurse-physician collaboration.4-6 Anumber of instruments have been used to measurecollaboration.

The word collaboration is derived from Latinwords col, meaning with or together, and laborare,meaning work.7-9 The base meaning of this word isto work together. The American Nurses Associationin Nursing: A Social Policy Statement describes col-laboration as “a true partnership, which the poweron both sides is valued by both, with recognitionand acceptance of separate and combined practicespheres of activity and responsibility, mutual safe-guarding of the legitimate interests of each party,and a commonality of goals that is recognized byeach party.”10(p7) Collaboration has been describedas laboring together, sharing communication anddecision-making, and willing cooperation on the ba-sis of shared power and authority.11

Methodology

A search of the literature was conducted to identifyinstruments used to measure nurse-physician collab-oration and examine their psychometric properties.To be included in this review, an instrument had tomeet the following criteria:

1. Cited and published in English between 1990 andMay 2004 in a peer-reviewed journal.

2. Identified by key words “nurse-physician collab-oration” for PubMed® and “collaboration” forHealth and Psychological Instruments (HaPI).

Authors’ affiliation: Vice President (Ms Dougherty), PatientCare Services, Orange Regional Medical Center, Middletown,NY; Doctoral Student (Ms Dougherty); Associate Dean and Pro-fessor of Pharmaceutical and Therapeutic Nursing (Dr Larson),Columbia University School of Nursing, New York.

Corresponding author: Ms Dougherty, Orange Regional Med-ical Center, 60 Prospect Ave, Middletown, NY 10960 ([email protected]).

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3. Used in at least one study on staff nurse–physiciancollaboration.

4. At least one separate peer-reviewed article assess-ing the psychometrics of the instrument published.

5. The psychometric article cited in at least 2 refer-ences in the ISI Web of Science® Index Expanded(http://wos.mimas.ac.uk).

6. Copies of the instrument readily available to theresearcher.

Initially, PubMed (http://www.nlm.nih.gov.)and HaP databases were searched to identifyarticles describing instruments used to measurenurse-physician collaboration. After the instru-ments were identified, a search was conductedof the same databases for at least one separatepeer-reviewed article reporting psychometric testingof the instrument. These psychometric articles werethen entered into the ISI Web of Science CitationIndex, beginning with the year of initial publicationof each article to May 2004. Those instrumentsfor which the psychometric article was cited atleast twice and which were readily obtained to theresearcher were included in this review.

The nurse-physician collaboration instrumentsthat met these criteria were then reviewed for thefollowing information: background for developmentof tool, description of tool, initial psychometric test-ing, and strengths and potential applications for eachinstrument.

Results

In the database search, 293 articles from PubMedand 32 articles from HaPI related to nurse-physiciancollaboration were identified. Fifteen (5%) of the293 citations from PubMed and 3 (9%) fromHaPI met the inclusion criteria. Five instruments re-sulted from this review: the Collaborative Practice

Table 1. Major Dimensions Measured in the 5 Instruments Assessing Nurse-Physician Collaboration

Collaborative Collaboration and The Jefferson Scale of AttitudesPractice Scale Satisfaction about Care Toward Physician-Nurse Nurses’ Opinion ICU MD/RN(CPS) Decisions (CSACD) Collaboration Questionnaire (NOS) Questionnaire

Assertion Assertion Collaborative relationship Leadership LeadershipCooperation Cooperation Caring as opposed to curing Professional practice Team cohesion

Planning Planning Professional relationships Conflictmanagement

Communication Communication Nursing influence CommunicationShared decision-making Shared decision-making Physical environment Perceived unit

effectivenessSatisfaction Shared education Satisfaction CoordinationCoordination Nurse autonomy Nursing Influence Culture

Physician authority

Scale (CPS),12 Collaboration and Satisfaction aboutCare Decisions (CSACD),13 ICU Nurse-PhysicianQuestionnaire,14 Nurses’ Opinion Questionnaire(NOQ),15 and the Jefferson Scale of Attitudes To-ward Physician Nurse Collaboration.16

Table 1 lists the major dimensions reported ineach instrument. Table 2 displays examples of stud-ies that have used the instrument. Figure 1 providesa description of validity and reliability measures.Figure 2 summarizes the psychometrics measured ineach instrument. Each instrument is reviewed below.

Review of Instruments

Collaborative Practice ScaleBackgroundThe CPS is rooted in the work of Blake andMouton,17 Thomas,18 and Thomas and Kilman.19

Their work focused on the interaction methods usedto solve problems or resolve conflict: assertion andcooperation. The definition of collaboration used byWeiss and Davis in developing this tool was “inter-actions between nurse and physician that enable theknowledge and skills of both professionals to syner-gistically influence the patient care provided.”12(p299)

Description of InstrumentThe instrument consists of 2 separate scales, one forphysicians and the other for nurses.12 There are 9items in the nurse scale and 10 items in the physicianscale.12 The items are measured on a 6-point Likert-type scale, ranging from never to always, with higherscores indicating more collaborative practice.12

PsychometricsPsychometric properties were tested in one study of200 physicians and 200 nurses who were randomlyselected from the rosters of health professionals

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Table 2. Examples of Research Using Nurse-Physician Collaboration Instruments

Articles Reporting ResearchInstrument Psychometric Article Using Instrument Objective of Research

CollaborativePractice Scale(CPS)

Weiss S, Davis H. Validity andreliability of thecollaborative practicescales. Nurs Res.1985;34:299–304.

Krairiksh M, Anthony M. Benefitsand outcomes of staff nurses’participation in decision-making.J Nurs Adm. 2001;31(1):16f-23f.

Wells N, Johnson R, Salyer S.Interdisciplinary collaboration.Clin Nurse Spec. 1998;12(4):161-168.

To investigate the relations among staffnurse participation in phases ofdecision-making process related todecisions in nursing practice,competencies of nurse managerleadership and nurse physiciancollaboration.

To investigate interdisciplinarycollaboration over a 16 monthperiod on units using differentcollaborative practice strategies.

Collaboration andSatisfaction withCare Decisions(CSACD)

Baggs JG. Development of anInstrument to measurecollaboration andsatisfaction about caredecisions. J Adv Nurs.1994;20:176-182

Bratt M, Broome M, Kelber S,Lostoco L. Influence of stress andnursing leadership on jobsatisfaction of pediatric intensivecare nurses. Am J Crit Care.2000;9(5):307-317.

Dechario-Marino A, Jordan-MarshM, Traiger G, Saulo M. Nursephysician collaboration: actionresearch and the lessons learned.J Nurs Adm. 2001;31(5):223-232.

To explore the influence of nurseattributes, unit characteristics, andelements of the work environmenton the job satisfaction of nurses inpediatric critical care units and todetermine stressors that are uniqueto nurses in pediatric critical care.

To utilize an action research model tomeasure collaboration innurse-physician led interdisciplinaryteams to improve the interventionand the approach to outcomemeasurement.

The Jefferson Scaleof Attitudestoward PhysicianNurseCollaboration

Hojat M, Fields S, Veloski J,Griffiths M, Cohen M,Plumb J. Psychometricproperties of an attitudescale measuring physiciannurse collaboration. EvalHealth Prof. 1999;22(2):208-220.

Hojat M, Nasca T, Cohen M, et al.Attitudes toward physician nursecollaboration in the UnitedStates and Mexico. Nurs Res.2001;50(2):123-128.

Hojat M, Gonnella, Nasca T, et al.Comparison of American, Israeli,Italian and Mexican physiciansand nurses on the total andfactor scores of the JeffersonScale of Attitudes towardphysician-nurse collaborativerelationships. Int J Nurs Stud.2003;40:427-435.

To test 3 research hypothesisconcerning attitudes towardphysician nurse collaboration acrossgenders, disciplines and cultures.

To compare the attitudes of physiciansand nurses toward physician nursecollaboration in the United States,Israel, Italy and Mexico.

Collaboration withMedical StaffScale (CMSS) ofthe NursesOpinionQuestionnaire(NOQ)

Adams A, Bond S, Arber S.Development andvalidation of scales tomeasure organizationalfeatures of acute hospitalwards. Intl J Nurs Stud.1995;32((6):612-627.

Chaboyer W, Najman J, Dunn S.Factors influencing jobvaluation: a comparative studyof critical care and non-criticalcare nurses. Int J Nurs Stud.2001;38:153-161.

Chaboyer W, Patterson E.Australian hospital generalistand critical care nurses’perception of doctor-nursecollaboration. Nurs Health Sci.2001;3:73-79.

To identify the relationship betweenthree predictor variables, perceivedcollaboration with medical staff,autonomy and independent actionsand an outcome, the value nursesplaced on their work.

To identify the influence of the area ofwork on nurses’ perceptions ofcollaboration with the medical staff.

ICU RN-MDQuestionnaire

Shortell S, Rousseau D, GilliesR, Devers K, Simons T.Organizational assessmentin intensive care units(ICUs): constructdevelopment, reliability andvalidity of the ICU nursephysician questionnaire.Med Care. 1991;29:709-723.

Miller P. Nurse physiciancollaboration in an intensive careunit. Am J Crit Care.2001;10(5):341-350.

Hansen H, Biros M, Delaney N,Schug V. Research Utilizationand InterdisciplinaryCollaboration in EmergencyCare. Acad Emerg Med.1999;6(4):271-279.

To examine perspectives of nurses andphysicians on collaborativeinteraction in an intensive care unit;to examine differences betweengroups in perceptions ofcollaborative interaction in the unit;to compare his unit with unitsexamined in a national study.

To examine perceptions ofnurse-physician collaboration andresearch utilization in a medicalcenter with emergency medicineresidency program; to assessdifferences among nurses, residentsand attending physicians; to explorethe relationship betweencollaboration and researchutilization

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Type Definition

Validity Measures the extent to which an instrument measures what it intended to measure.Concurrent Correlation between result obtained with this tool and the results of a know gold standard, when

applied to the same group.Construct Establishes the ability of the instrument to measure an abstract concept or construct.√

Factor analysis is used to establish construct validity.√The concept of factor analysis is based on the idea that a construct contains one or moredimensions.

Content Establishes the adequacy with which the universe is sampled by the test.Convergent Indicates that the 2 measures believed to reflect the same underlying phenomena will yield similar

results or correlate higher.Criterion Indicates that the outcomes of one, the target test, can be used as a substitute measure for an

established gold standard test.Predictive Establishes that the interpretation of a measurement is appropriate for determining effective

intervention.Discriminant Indicates that different results, or low correlations, are expected from measures that assess

different characteristics.Reliability The extent to which a measurement is consistent and stable.

Internal consistency Measures the extent to which items measure various aspects of the same characteristic andnothing else.

Cronbach’s alpha is the statistic most often used to measure internal consistency. It equals themean of all possible split-half coefficients in a data set.

Test Retest Establishes that an instrument is capable of measuring a variable consistently over time.Interrater Measures the extent to which 2 or more independent raters of the same event have the same

results.

Figure 1. Definitions of types of validity and reliability.

affiliated with a single health sciences center in awestern metropolitan area.12

Construct validity: In a factor analysis, orthogo-nal and oblique rotations confirmed the 2 constructfactors in each survey.

Collaboration andCollaborative Satisfaction with Care The Jefferson Nurses Opinion ICU MD/RN

Practice Scale Decisions (CSACD) Scale Survey (NOS) Questionnaire

ValidityConcurrent

√Construct

√ √ √ √ √Content

√ √ √ √Convergent

√Criterion

√ √Predictive

√Discriminant

√

ReliabilityInternal

√ √ √ √ √consistency

Cronbach’s RN = .83 MD = .85 .95 .85 .86 Scale range from .61 to .88alpha

Test Retest√ √

Figure 2. Psychometric testing of instruments designed to measure nurse-physician collaboration.

Concurrent validity: The separate nurse andphysician CPS scores were compared to 2 otherinstruments: Management of Differences Exercise(MODE) and the Health Role Expectation Index(HREI). A statistically significant correlation

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(Spearman correlation: 0.25, P < .01) between thenurse CPS scores and the HREI was found, but therewas no correlation with the MODE instrument.Conversely, the physicians’ scores on the CPS werenot correlated with the HREI scores, but weresignificantly associated with the MODE instrumentscores (Spearman correlation = 0. 25, P < .05).12

Predictive validity was assessed by comparingpeer review of interprofessional practice by nursesfor physicians and physicians for nurses with theCPS scores. The Spearman coefficient was 0.42(P < .02)12 for the total CPS scores of physicians andtheir nurse peer evaluators, but there was no signif-icant correlation between the nurses’ scores on theCPS and scores of their physician peer evaluators.12

Reliability: Test-retest measure yielded a coeffi-cient of 0.83 for the nurse’s scale and 0.85 for thephysician scale.12

Citations for the Psychometric ArticleThe psychometric article was cited 15 times in theISI Web of Science Citation Index.

Strengths and Potential ApplicationsThe scale is easy to administer and takes approx-imately 5 minutes to complete. Each professionreports on a different aspect of collaboration: nursesreport on their perception of assertiveness, whilephysicians report on their perception of collabora-tion. To compensate for this, Weiss and Davis sug-gest that additional items may need to be added tothis instrument “to examine consensus developmentand negotiation behavior of nurses and active as-sertive contribution by physicians.”12(p304)

This tool was one of the first instruments devel-oped to measure nurse and physician perception ofcollaboration. Given that this instrument was devel-oped in the mid 1980s and additional instrumentswith a more comprehensive definition of collabora-tion have been developed, the researcher may con-sider the need to update this instrument prior to usefor current research.13-16 This instrument has beenused in studies to determine the perceptions of physi-cians and nurses on the assertion versus cooperationcomponents of collaboration.

Collaboration and Satisfaction about Care DecisionsBackgroundThe CSACD measures nurse-physician collabora-tion and satisfaction with care decisions in inten-sive care units (ICUs). Baggs and Schmitt20 used areview of the literature, the conflict resolution the-orem of Thomas,13,19 and the coordination theo-rem of Thompson for complex organizations13,21

to expand the collaboration attributes beyond co-

operation and assertiveness. They identified 4 addi-tional attributes: shared responsibility for planning,shared decision-making, open communication, andcoordination.13 The definition of collaboration usedin the development of this instrument is, “ICU nursesand physicians cooperatively working together, shar-ing responsibility for problem solving and decision-making, to formulate and carry out plans for pa-tient care.”13(p177),20 The tool was constructed usinga combination of the CPS,12 Index of Work ForceSatisfaction (IWS),22 and the Decision about Trans-fer Scale.23 Validity and reliability metrics have beenestablished for these tools.

Description of InstrumentThe CSACD consists of 9 questions measured on a7-point Likert-type scale, ranging from 1 (stronglydisagree) to 7 (strongly agree).13 Six questions mea-sure the critical attributes of collaboration and onemeasures the perceived global amount of collabora-tion in the ICU.13 Two questions measure the sat-isfaction with the decision-making process and thedecision itself.13,23

PsychometricsThe CSACD was pilot-tested on a convenience sam-ple of 32 neonatal intensive care unit (NICU) nursesand 26 pediatric residents who had recently workedin the NICU of a northeastern teaching hospital.13

Content validity: Questions were developedfrom a review of the literature with a theoreticalbase13 and were then reviewed by 12 nursing andmedical experts in collaborative practice.13 In addi-tion, 7 mobile intensive care unit (MICU) nurses,2 attending physicians, and 2 resident physiciansbased in the MICU agreed that the questions mea-sured collaboration as defined.13

Criterion validity: The global collaborationquestion correlated with the 6 critical attribute itemswith a correlation coefficient of 0.87.13

Construct validity: A factor analysis was con-ducted, and a single factor explained 75% of thevariation in collaboration. The Eigenvalue for thefactor was 4.5. Factor loading for the 6 items rangedfrom 0.82 to 0.93.13

Reliability: Cronbach’s alpha for internal con-sistency of the 6 critical attributes of collaboration13

was .93.


Strengths and Potential ApplicationsThe survey is short and easy to complete in a high-intensity environment (ICU). Measurement of the

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critical attributes of collaboration makes it possibleto correlate individual items with the global col-laboration question.13 Both physicians and nursesuse the same instrument. Since this instrument wasdeveloped to measure collaboration and satisfac-tion with decision-making in the ICU, additionalpsychometric studies would be necessary in otherpractice settings.

ICU Nurse-Physician QuestionnaireBackgroundA team- and achievement-oriented culture andleaders who set high standards are hypothesizedto provide more open, accurate, and timelycommunication; effective coordination with otherunits; and more open collaborative problem-solvingapproaches.14 These relationship components con-tribute to a team approach to care, resulting in thedelivery of more effective patient care.14 This instru-ment measures organizational climate, with a focuson unit culture, leadership, communication, coordi-nation, problem-solving/conflict management, unitcohesiveness, and perceived unit effectiveness.14

Description of InstrumentThe original instrument for which published psy-chometrics is available has a 48-item Likert-typescale measured from 1 to 5. The 48 items are de-rived from the Organizational Culture Inventory(OCI).14,24-26 The OCI has demonstrated reliabilityand validity14,27 and stable factor solutions acrosssamples.14,24,26 The ICU Nurse-Physician Question-naire yields 3 factors: team orientation factor, peoplesecurity factor, and a task security orientation.14,24,25

Subconstructs measure leadership, communication,coordination, problem-solving, conflict manage-ment, unit cohesiveness, and unit effectiveness.14

There are separate surveys for physicians andnurses, with separate discipline-specific questionswritten for each.14 Two components of the in-strument (workplace and facility safety scales andculture) were not included in the survey avail-able from the authors because they are copyrightedby Human Synergistics, Plymouth, Mich28 (http://www.humansyn.com). There was a high intercorre-lation between the scales on the original instrument.The instrument has been revised and shortened sothat it takes 20 minutes to complete. The authorsfelt that using the shortened version enabled the easeof administration and thus better survey compliancewithout compromising the validity and reliability.28

PsychometricsThe psychometrics reported is based on the long ver-sion. The original survey was administered to a na-

tional sample of staff in 42 medical surgical ICUs (40hospitals). A total of 1418 questionnaires were com-pleted by nurses (78% return), 790 by physicians(65% return), 111 by ward clerks (65% return), and221 (85%) by members of the top management teamfor an overall completion rate of 73%.14

Content validity: In a factor analysis,14 3 identi-fied factors loaded at 0.40 or above, with an Eigen-value well above 1.0.

Reliability: Cronbach’s alphas for 21 of thescales were greater21 than .70, and were greaterthan .60 for the following scales: timeliness of com-munication, within-shift communication, satisfac-tion with nurse communication, and within- andbetween-group forcing conflict management.14


Strengths and Potential ApplicationsReliability and validity testing was conducted in alarge national sample.14 This instrument is designedto measure collaboration at the unit level and to mea-sure organizational components that facilitate a col-laborative clinical interaction. However, it is longand takes 45 minutes to complete. Since separatevalidity and reliability studies have not been com-pleted for the short version, testing criterion-relatedvalidity using the 2 instruments is indicated. Thisinstrument may be used to compare collaborationbetween units, among units and institutions, as wellas reporting on organizational variables, which maysupport collaboration. The instrument has been usedfor research of ICU nurse-physician collaborationand interdisciplinary collaboration in emergencydepartments.

Nurses’ Opinion QuestionnaireBackgroundThe NOQ is based on the rationale that the or-ganizational structure, role behavior, and commu-nication patterns and methods between caregivers(physicians and nurses) affect patient outcomes andnurse satisfaction.1,2,4,5,15,29-33 The NOQ was devel-oped in the United Kingdom (UK) to measure phys-ical and social aspects of acute hospital wards.15

Description of InstrumentThe NOQ consists of 98 items within 6 scales:physical environment of ward, professional nursingpractice, ward leadership, professional working re-lationships, nursing influence, and job satisfaction.The scale measuring professional working relation-ships has been used as a separate instrument under

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the name Collaboration with Medical Staff Scale(CMSS). The CMSS component consists of 9 state-ments rated on a 4-point scale. Negatively wordeditems are reverse scored so that higher scale valuesindicate more positive views on interactions.15

PsychometricsInitial psychometric testing of the NOQ was com-pleted in the United Kingdom with 1499 nurses from119 wards in 17 hospitals.15

Content validity: Items were developed fromqualitative interviews and literature review.15 Factoranalyses were completed using maximum likelihoodextraction to test the correlation between items onthe NOQ. Common factor solutions were achievedwith orthogonal and oblique rotations. Factors wereretained if they had with an Eigenvalue15 greater orequal to 1.

Criterion validity: Scale scores from staff work-ing on 6 wards who had taken part in the surveywere compared to observational assessments of theward characteristics by independent assessors usinga rating schedule.15 Thirty-three of 48 paired rat-ings were identical or differed by only one point ofmagnitude.15

Construct validity: There was consistency be-tween extracted factors and the a priori groupingof items for the NOQ.15 Split-half tests were com-pleted, and the resulting factor structures of the2 halves were reported to be almost identical.15

Items within scales15 were significantly correlated,P < .001. Chaboyer and Patterson conducted addi-tional construct validity testing of the CMSS. Factoranalyses with oblique rotation yielded a 2-factor so-lution: consideration of nurses and valuing nurse’sinput.34

Reliability: Cronbach’s alpha for the NOQ was.81 and the test-retest correlation coefficient was0.77. The Cronbach’s alpha for the CMSS subscalewas .86 and a test-retest Pearson correlation coeffi-cient was 0.83.3,15

Citations for the Psychometric ArticleThe psychometric article was cited 9 times in the ISIWeb of Science Citation Index.

Strengths and Potential ApplicationsComprehensive qualitative interviews provided thebasis for item construction in the scales. The scaleswere not tested against similar tools, because a simi-lar instrument had not been developed in the UnitedKingdom. Additional criterion-related validity test-ing is indicated. Cultural and semantic differencesbetween the United States and United Kingdom maynecessitate additional psychometric testing for usein the United States. The large sample size and the

national scope of the initial study lend strength tothe reliability and validity results. However, ini-tial psychometric testing of this instrument occurredonly with nurses. Further psychometric testing withphysicians is necessary should physicians be includedin studies. The CMSS component of the NOQ hasbeen used in research comparing nurses’ perceptionsof collaboration between ICU and non-ICU nurses.

Jefferson Scale of Attitudes TowardPhysician-Nurse CollaborationBackgroundJefferson Scale of Attitudes Toward Physician-NurseCollaboration was based on the rationale that inter-professional collaboration is a joint venture, withshared authority and responsibility, open commu-nication, and shared decision-making. The educa-tion of professionals within a collaborative envi-ronment would also affect the attitude of nursesand doctors toward each other and the concept ofcollaboration.16,35-37

Description of InstrumentThe instrument measures physician and nurseattitudes toward authority, autonomy, and re-sponsibility for patient-monitoring, collaborativedecision-making, role expectations, and collabora-tive education.16 There are 15 questions that are an-swered on a 4-point Likert-type scale.

PsychometricsThe instrument was administered to 208 first-yearmedical students and 86 nursing students in anupper-division baccalaureate program, 93% of theirtotal classes.16

Content validity: In a factor analysis with or-thogonal varimax rotation, 6 extracted factors hadEigenvalues greater than 1.16

Construct validity: There was consistency of ex-tracted factors with discussions of collaboration inthe literature.

Reliability: Cronbach’s alpha was .84 for medi-cal students and .85 for nursing students. The itemtotal score correlations for the combined groupranged from 0.65 to 0.40 with a median correlationof 0.61.16

Citations for the Psychometric ArticleThe psychometric article was cited twice in the ISIWeb of Science Citation Index.

Strengths and Potential ApplicationsThe same instrument can be used for both physi-cians and nurses. Additional criterion-related valid-ity testing is indicated. This instrument was tested onfirst-year medical and upper-division baccalaureate

250 JONA • Vol. 35, No. 5 • May 2005


nursing students. The use of students with limitedpractice experience to test the validity and relia-bility of the instrument may limit its utilizationwith practicing nurses and physicians. Additionalpsychometric testing may be required to use this in-strument in studies with practicing nurses and physi-cians. The instrument has been used primarily tomeasure the attitude of nurses and physicians in dif-ferent countries toward the concept of collaboration.

Discussion

These instruments are recommended for use becausethey have undergone initial reliability and valid-ity testing, and, therefore, represent a good startingplace for future research regarding nurse-physiciancollaboration. Despite the fact that these instrumentshave undergone some validity and reliability testing,it would be imperative to conduct additional psy-chometric testing when an instrument is used witha new population or study. Of the instruments re-viewed, the ICU Nurse-Physician Questionnaire andthe CSACD measure collaboration of the same con-struct dimensions on both nurses and physicians.The CPS measures different aspects of collaborationof nurses and physicians. The CMSS component ofthe NOQ measures nurse perception of collabora-tion but physicians were not included in the initialsurvey development. The Jefferson Scale has primar-ily been used to compare attitudes toward collabo-ration between countries and cultures.

Two themes have emerged from this review:(a) RNs have initiated much of the research on col-laboration and (b) ICUs have been the site of muchof the research.

Why Is Most Research on Collaboration Conductedby Nurses?Fagin noted that there is minimal interest on the partof physicians in interprofessional relationships.37 Astudy by Kurtz suggested that physicians would pre-fer not to be interactive and would avoid groupinvolvement.38 Sexton et al described a significantdisparity between nurse and physician perceptionof teamwork and communication.39 Larson identi-fied a disparity in nurse and physician perceptionsof current and ideal authority of nurses.40 Severalothers41,42 have described the inequity in power andauthority between nurses and physicians.

The professional education of nurses and physi-cians does not generally include interdisciplinary ex-periences in communication, planning, and decision-making.37 Nurses and physicians may practice pro-fessionally as they have been frequently taught: pri-marily independent decision-making on the part

of physicians and more interdependent decision-making with coordinating and communication func-tions on the part of nursing.2,7,37,44,45 Thus, nursesand physicians perceive the value and need for col-laboration differently, and this affects their interestin research on collaboration.2,37

Why Is Most Research in CollaborationConducted in ICUs?Knauss et al4 demonstrated the importance of com-munication and coordination in the achievement ofpositive patient and fiscal outcomes in ICUs. This ledto additional studies conducted in ICUs, probablybecause of the higher rates of patient acuity, mor-tality, and clinical practice errors that occur in thatsetting. The critical care setting requires immediatemedical and nursing intervention, active dialogue,and communication to respond to rapidly chang-ing physiological parameters of the patients. Lowstaffing ratios, smaller units, the presence of expe-rienced and specialized nurses, and close proximityamong staff members are factors that facilitate col-laboration in ICUs.

Summary and Recommendations

In this article, we have described several instrumentswith published psychometrics that have been used inresearch to measure nurse-physician collaboration.These studies have shown a correlation betweennurse-physician collaboration and positive patient,fiscal, and staff satisfaction outcomes. Since there isnow a considerable body of descriptive research onthis topic, we suggest that a natural evolution is indi-cated in the study of nurse-physician collaboration.

Many professional organizations, including theNational Patient Safety Foundation of the Ameri-can Medical Association, the Joint Commission onAccreditation of Health Care Organizations, the In-stitute of Medicine, and the Agency for Health CareResearch and Quality, have encouraged changes incommunication and the adoption of approachesused in other disciplines, such as aviation and nu-clear power to enhance patient safety.43,46-48 Col-laboration is one of the key communication strate-gies to minimize errors. Instrument development andresearch may be necessary to describe or test or-ganizational and cultural changes that support col-laborative practice. It is also important to examineinterpersonal communication and shared decision-making among nurses and physicians that contributeto a decrease in error or morbidity for patients.

We have reviewed several instruments to assessnurse-physician collaboration. The continued devel-opment and testing of these and other instruments

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will support additional research on collaboration.The study of collaboration within the construct ofpatient safety may provide an added impetus forchange in nurse-physician collaboration that tran-

scends historical and sociological constraints. Thischange in nurse-physician collaboration may ulti-mately lead to better clinician communications andpatient outcomes.

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Nursing Administration Research Conference

The Nursing Administration Research Conference (NARC), FromNursing Science to the Nursing Workplace: Creating New Pathways, will beheld October 5–8, 2005, at the Marriott Star Pass Resort in Tucson,Arizona. The conference purpose is to disseminate current research onnursing administration and nursing systems topics. Specific objectives are to:

• Identify promising research findings on nursing administration andworkforce issues.

• Evaluate our readiness to use the results of nursing research to improvequality and cost outcomes in nursing care settings.

• Analyze barriers and supports for translating research into meaningfulsolutions.

For further information, contact [email protected]

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