A Review of Instruments Measuring Nurse-Physician Collaboration

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JONA
Volume 35, Number 5, pp 244-253
C 2005, Lippincott Williams & Wilkins, Inc.
A Review of Instruments Measuring

Nurse-Physician Collaboration
Mary B. Dougherty, MBA, MA, RN
Elaine Larson, PhD, RN, FAAN, CIC
Objective: To review instruments used to measure nurse-physician collaboration and compare the
strengths and potential opportunities of each instrument.
Background: Nurse-physician collaboration has
been studied using a variety of instruments. The ability to generalize the outcomes of studies and build
on the findings is predicated on acceptable validity
and reliability metrics of these instruments.
Methods: A literature search using PubMed and
Health and Psychological Instruments databases
was conducted for articles published between 1990
and May 2004 to identify instruments measuring
staff nursephysician collaboration. After the instruments were identified, a second search was conducted to identify at least one peer-reviewed article
describing the psychometrics of the instrument. Articles identified were then entered into the ISI Web
of Science Citation Index to identify the instruments that had been used in at least 2 other studies.
These selected instruments were then reviewed for
the following information: background for the development of the tool, description of the tool, initial
psychometric testing, and strengths and potential applications for each instrument.
Results: Five instruments met study criteria: the Collaborative Practice Scale, Collaboration and Satisfaction About Care Decisions, ICU Nurse-Physician
Questionnaire, Nurses Opinion Questionnaire, and
the Jefferson Scale of Attitudes Toward Physician
Nurse Collaboration.
Conclusions: The identified instruments have undergone initial reliability and validity testing and are
recommended for future research on nurse-physician
collaboration.
Nurse-physician collaboration is a key factor in
nurse job satisfaction, retention, and job valuation.1-3 Decreased risk-adjusted mortality and length
of stay, fewer negative patient outcomes, and en-
244
hanced patient satisfaction have also been associated with better nurse-physician collaboration.4-6 A
number of instruments have been used to measure
collaboration.
The word collaboration is derived from Latin
words col, meaning with or together, and laborare,
meaning work.7-9 The base meaning of this word is
to work together. The American Nurses Association
in Nursing: A Social Policy Statement describes collaboration as a true partnership, which the power
on both sides is valued by both, with recognition
and acceptance of separate and combined practice
spheres of activity and responsibility, mutual safeguarding of the legitimate interests of each party,
and a commonality of goals that is recognized by
each party.10(p7) Collaboration has been described
as laboring together, sharing communication and
decision-making, and willing cooperation on the basis of shared power and authority.11
Methodology
A search of the literature was conducted to identify
instruments used to measure nurse-physician collaboration and examine their psychometric properties.
To be included in this review, an instrument had to
meet the following criteria:
1. Cited and published in English between 1990 and
May 2004 in a peer-reviewed journal.
2. Identified by key words nurse-physician collaboration for PubMed and collaboration for
Health and Psychological Instruments (HaPI).
Authors affiliation: Vice President (Ms Dougherty), Patient
Care Services, Orange Regional Medical Center, Middletown,
NY; Doctoral Student (Ms Dougherty); Associate Dean and Professor of Pharmaceutical and Therapeutic Nursing (Dr Larson),
Columbia University School of Nursing, New York.
Corresponding author: Ms Dougherty, Orange Regional Medical Center, 60 Prospect Ave, Middletown, NY 10960 (mbd16@
columbia.edu).
JONA Vol. 35, No. 5 May 2005
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3. Used in at least one study on staff nursephysician

collaboration.
4. At least one separate peer-reviewed article assessing the psychometrics of the instrument published.
5. The psychometric article cited in at least 2 references in the ISI Web of Science Index Expanded
(http://wos.mimas.ac.uk).
6. Copies of the instrument readily available to the
researcher.
Initially, PubMed (http://www.nlm.nih.gov.)
and HaP databases were searched to identify
articles describing instruments used to measure
nurse-physician collaboration. After the instruments were identified, a search was conducted
of the same databases for at least one separate
peer-reviewed article reporting psychometric testing
of the instrument. These psychometric articles were
then entered into the ISI Web of Science Citation
Index, beginning with the year of initial publication
of each article to May 2004. Those instruments
for which the psychometric article was cited at
least twice and which were readily obtained to the
researcher were included in this review.
The nurse-physician collaboration instruments
that met these criteria were then reviewed for the
following information: background for development
of tool, description of tool, initial psychometric testing, and strengths and potential applications for each
instrument.
Results
In the database search, 293 articles from PubMed
and 32 articles from HaPI related to nurse-physician
collaboration were identified. Fifteen (5%) of the
293 citations from PubMed and 3 (9%) from
HaPI met the inclusion criteria. Five instruments resulted from this review: the Collaborative Practice
Scale (CPS),12 Collaboration and Satisfaction about

Care Decisions (CSACD),13 ICU Nurse-Physician
Questionnaire,14 Nurses Opinion Questionnaire
(NOQ),15 and the Jefferson Scale of Attitudes Toward Physician Nurse Collaboration.16
Table 1 lists the major dimensions reported in
each instrument. Table 2 displays examples of studies that have used the instrument. Figure 1 provides
a description of validity and reliability measures.
Figure 2 summarizes the psychometrics measured in
each instrument. Each instrument is reviewed below.
Review of Instruments
Collaborative Practice Scale
Background
The CPS is rooted in the work of Blake and
Mouton,17 Thomas,18 and Thomas and Kilman.19
Their work focused on the interaction methods used
to solve problems or resolve conflict: assertion and
cooperation. The definition of collaboration used by
Weiss and Davis in developing this tool was interactions between nurse and physician that enable the
knowledge and skills of both professionals to synergistically influence the patient care provided.12(p299)
Description of Instrument
The instrument consists of 2 separate scales, one for
physicians and the other for nurses.12 There are 9
items in the nurse scale and 10 items in the physician
scale.12 The items are measured on a 6-point Likerttype scale, ranging from never to always, with higher
scores indicating more collaborative practice.12
Psychometrics
Psychometric properties were tested in one study of
200 physicians and 200 nurses who were randomly
selected from the rosters of health professionals
Table 1. Major Dimensions Measured in the 5 Instruments Assessing Nurse-Physician Collaboration

Collaborative
Practice Scale
(CPS)
Assertion
Cooperation
Collaboration and
Satisfaction about Care
Decisions (CSACD)
The Jefferson Scale of Attitudes

Toward Physician-Nurse
Collaboration
Nurses Opinion
Questionnaire (NOS)
ICU MD/RN
Questionnaire
Leadership
Team cohesion
Conflict
management
Communication
Perceived unit
effectiveness
Coordination
Culture
Assertion
Cooperation
Planning
Collaborative relationship
Caring as opposed to curing
Planning
Leadership
Professional practice
Professional relationships
Communication
Shared decision-making
Communication
Shared decision-making
Nursing influence
Physical environment
Satisfaction
Coordination
Shared education
Nurse autonomy
Physician authority
Satisfaction
Nursing Influence
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Table 2.
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Examples of Research Using Nurse-Physician Collaboration Instruments
Instrument
Psychometric Article
Articles Reporting Research

Using Instrument
Objective of Research
Collaborative
Practice Scale
(CPS)
Weiss S, Davis H. Validity and Krairiksh M, Anthony M. Benefits To investigate the relations among staff
reliability of the
and outcomes of staff nurses
nurse participation in phases of
collaborative practice
participation in decision-making.
decision-making process related to
scales. Nurs Res.
J Nurs Adm. 2001;31(1):16f-23f.
decisions in nursing practice,
1985;34:299304.
competencies of nurse manager
leadership and nurse physician
collaboration.
Wells N, Johnson R, Salyer S.
To investigate interdisciplinary
Interdisciplinary collaboration.
collaboration over a 16 month
Clin Nurse Spec. 1998;12(4):
period on units using different
161-168.
collaborative practice strategies.
Collaboration and Baggs JG. Development of an Bratt M, Broome M, Kelber S,
To explore the influence of nurse
Satisfaction with
Instrument to measure
Lostoco L. Influence of stress and
attributes, unit characteristics, and
Care Decisions
collaboration and
nursing leadership on job
elements of the work environment
(CSACD)
satisfaction about care
satisfaction of pediatric intensive
on the job satisfaction of nurses in
decisions. J Adv Nurs.
care nurses. Am J Crit Care.
pediatric critical care units and to
1994;20:176-182
2000;9(5):307-317.
determine stressors that are unique
to nurses in pediatric critical care.
Dechario-Marino A, Jordan-Marsh To utilize an action research model to
M, Traiger G, Saulo M. Nurse
measure collaboration in
physician collaboration: action
nurse-physician led interdisciplinary
research and the lessons learned.
teams to improve the intervention
J Nurs Adm. 2001;31(5):
and the approach to outcome
223-232.
measurement.
The Jefferson Scale Hojat M, Fields S, Veloski J,
Hojat M, Nasca T, Cohen M, et al. To test 3 research hypothesis
of Attitudes
Griffiths M, Cohen M,
Attitudes toward physician nurse
concerning attitudes toward
toward Physician
Plumb J. Psychometric
collaboration in the United
physician nurse collaboration across
Nurse
properties of an attitude
States and Mexico. Nurs Res.
genders, disciplines and cultures.
Collaboration
scale measuring physician
2001;50(2):123-128.
nurse collaboration. Eval
Hojat M, Gonnella, Nasca T, et al. To compare the attitudes of physicians
Health Prof. 1999;22(2):
Comparison of American, Israeli,
and nurses toward physician nurse
208-220.
Italian and Mexican physicians
collaboration in the United States,
and nurses on the total and
Israel, Italy and Mexico.
factor scores of the Jefferson
Scale of Attitudes toward
physician-nurse collaborative
relationships. Int J Nurs Stud.
2003;40:427-435.
Collaboration with Adams A, Bond S, Arber S.
Chaboyer W, Najman J, Dunn S.
To identify the relationship between
Medical Staff
Development and
Factors influencing job
three predictor variables, perceived
Scale (CMSS) of
validation of scales to
valuation: a comparative study
collaboration with medical staff,
the Nurses
measure organizational
of critical care and non-critical
autonomy and independent actions
Opinion
features of acute hospital
care nurses. Int J Nurs Stud.
and an outcome, the value nurses
Questionnaire
wards. Intl J Nurs Stud.
2001;38:153-161.
placed on their work.
(NOQ)
1995;32((6):612-627.
Chaboyer W, Patterson E.
To identify the influence of the area of
Australian hospital generalist
work on nurses perceptions of
and critical care nurses
collaboration with the medical staff.
perception of doctor-nurse
collaboration. Nurs Health Sci.
2001;3:73-79.
ICU RN-MD
Shortell S, Rousseau D, Gillies Miller P. Nurse physician
To examine perspectives of nurses and
Questionnaire
R, Devers K, Simons T.
collaboration in an intensive care
physicians on collaborative
Organizational assessment
unit. Am J Crit Care.
interaction in an intensive care unit;
in intensive care units
2001;10(5):341-350.
to examine differences between
(ICUs): construct
groups in perceptions of
development, reliability and
collaborative interaction in the unit;
validity of the ICU nurse
to compare his unit with units
physician questionnaire.
examined in a national study.
Med Care. 1991;
Hansen H, Biros M, Delaney N,
To examine perceptions of
29:709-723.
Schug V. Research Utilization
nurse-physician collaboration and
and Interdisciplinary
research utilization in a medical
Collaboration in Emergency
center with emergency medicine
Care. Acad Emerg Med.
residency program; to assess
1999;6(4):271-279.
differences among nurses, residents
and attending physicians; to explore
the relationship between
collaboration and research
utilization
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Type
Definition
Validity
Concurrent
Construct
Content
Convergent
Criterion
Predictive
Discriminant
Reliability
Internal consistency
Test Retest
Interrater
Measures the extent to which an instrument measures what it intended to measure.

Correlation between result obtained with this tool and the results of a know gold standard, when
applied to the same group.
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 more
dimensions.
Establishes the adequacy with which the universe is sampled by the test.
Indicates that the 2 measures believed to reflect the same underlying phenomena will yield similar
results or correlate higher.
Indicates that the outcomes of one, the target test, can be used as a substitute measure for an
established gold standard test.
Establishes that the interpretation of a measurement is appropriate for determining effective
intervention.
Indicates that different results, or low correlations, are expected from measures that assess
different characteristics.
The extent to which a measurement is consistent and stable.
Measures the extent to which items measure various aspects of the same characteristic and
nothing else.
Cronbachs alpha is the statistic most often used to measure internal consistency. It equals the
mean of all possible split-half coefficients in a data set.
Establishes that an instrument is capable of measuring a variable consistently over time.
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 a

western metropolitan area.12
Construct validity: In a factor analysis, orthogonal and oblique rotations confirmed the 2 construct
factors in each survey.
Collaborative
Practice Scale
Concurrent validity: The separate nurse and

physician CPS scores were compared to 2 other
instruments: Management of Differences Exercise
(MODE) and the Health Role Expectation Index
(HREI). A statistically significant correlation
Collaboration and
Satisfaction with Care The Jefferson Nurses Opinion
Decisions (CSACD)
Scale
Survey (NOS)
ICU MD/RN
Questionnaire
Validity
Concurrent
Construct
Content
Convergent
Criterion
Predictive
Discriminant
Reliability
Internal
consistency
Cronbachs
alpha
RN = .83 MD = .85
.95
.85
.86
Scale range from .61 to .88
Test Retest
Figure 2. Psychometric testing of instruments designed to measure nurse-physician collaboration.
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(Spearman correlation: 0.25, P < .01) between the

nurse CPS scores and the HREI was found, but there
was no correlation with the MODE instrument.
Conversely, the physicians scores on the CPS were
not correlated with the HREI scores, but were
significantly associated with the MODE instrument
scores (Spearman correlation = 0. 25, P < .05).12
Predictive validity was assessed by comparing
peer review of interprofessional practice by nurses
for physicians and physicians for nurses with the
CPS scores. The Spearman coefficient was 0.42
(P < .02)12 for the total CPS scores of physicians and
their nurse peer evaluators, but there was no significant correlation between the nurses scores on the
CPS and scores of their physician peer evaluators.12
Reliability: Test-retest measure yielded a coefficient of 0.83 for the nurses scale and 0.85 for the
physician scale.12
Citations for the Psychometric Article
The psychometric article was cited 15 times in the
ISI Web of Science Citation Index.
Strengths and Potential Applications
The scale is easy to administer and takes approximately 5 minutes to complete. Each profession
reports on a different aspect of collaboration: nurses
report on their perception of assertiveness, while
physicians report on their perception of collaboration. To compensate for this, Weiss and Davis suggest that additional items may need to be added to
this instrument to examine consensus development
and negotiation behavior of nurses and active assertive contribution by physicians.12(p304)
This tool was one of the first instruments developed to measure nurse and physician perception of
collaboration. Given that this instrument was developed in the mid 1980s and additional instruments
with a more comprehensive definition of collaboration have been developed, the researcher may consider the need to update this instrument prior to use
for current research.13-16 This instrument has been
used in studies to determine the perceptions of physicians and nurses on the assertion versus cooperation
components of collaboration.
Collaboration and Satisfaction about Care Decisions
Background
The CSACD measures nurse-physician collaboration and satisfaction with care decisions in intensive care units (ICUs). Baggs and Schmitt20 used a
review of the literature, the conflict resolution theorem of Thomas,13,19 and the coordination theorem of Thompson for complex organizations13,21
to expand the collaboration attributes beyond co-
248
operation and assertiveness. They identified 4 additional attributes: shared responsibility for planning,
shared decision-making, open communication, and
coordination.13 The definition of collaboration used
in the development of this instrument is, ICU nurses
and physicians cooperatively working together, sharing responsibility for problem solving and decisionmaking, to formulate and carry out plans for patient care.13(p177),20 The tool was constructed using
a combination of the CPS,12 Index of Work Force
Satisfaction (IWS),22 and the Decision about Transfer Scale.23 Validity and reliability metrics have been
established for these tools.
The CSACD consists of 9 questions measured on a
7-point Likert-type scale, ranging from 1 (strongly
disagree) to 7 (strongly agree).13 Six questions measure the critical attributes of collaboration and one
measures the perceived global amount of collaboration in the ICU.13 Two questions measure the satisfaction with the decision-making process and the
decision itself.13,23
Psychometrics
The CSACD was pilot-tested on a convenience sample of 32 neonatal intensive care unit (NICU) nurses
and 26 pediatric residents who had recently worked
in the NICU of a northeastern teaching hospital.13
Content validity: Questions were developed
from a review of the literature with a theoretical
base13 and were then reviewed by 12 nursing and
medical experts in collaborative practice.13 In addition, 7 mobile intensive care unit (MICU) nurses,
2 attending physicians, and 2 resident physicians
based in the MICU agreed that the questions measured collaboration as defined.13
Criterion validity: The global collaboration
question correlated with the 6 critical attribute items
with a correlation coefficient of 0.87.13
Construct validity: A factor analysis was conducted, and a single factor explained 75% of the
variation in collaboration. The Eigenvalue for the
factor was 4.5. Factor loading for the 6 items ranged
from 0.82 to 0.93.13
Reliability: Cronbachs alpha for internal consistency of the 6 critical attributes of collaboration13
was .93.
The survey is short and easy to complete in a highintensity environment (ICU). Measurement of the
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critical attributes of collaboration makes it possible

to correlate individual items with the global collaboration question.13 Both physicians and nurses
use the same instrument. Since this instrument was
developed to measure collaboration and satisfaction with decision-making in the ICU, additional
psychometric studies would be necessary in other
practice settings.
ICU Nurse-Physician Questionnaire
Background
A team- and achievement-oriented culture and
leaders who set high standards are hypothesized
to provide more open, accurate, and timely
communication; effective coordination with other
units; and more open collaborative problem-solving
approaches.14 These relationship components contribute to a team approach to care, resulting in the
delivery of more effective patient care.14 This instrument measures organizational climate, with a focus
on unit culture, leadership, communication, coordination, problem-solving/conflict management, unit
cohesiveness, and perceived unit effectiveness.14
The original instrument for which published psychometrics is available has a 48-item Likert-type
scale measured from 1 to 5. The 48 items are derived from the Organizational Culture Inventory
(OCI).14,24-26 The OCI has demonstrated reliability
and validity14,27 and stable factor solutions across
samples.14,24,26 The ICU Nurse-Physician Questionnaire yields 3 factors: team orientation factor, people
security factor, and a task security orientation.14,24,25
Subconstructs measure leadership, communication,
coordination, problem-solving, conflict management, unit cohesiveness, and unit effectiveness.14
There are separate surveys for physicians and
nurses, with separate discipline-specific questions
written for each.14 Two components of the instrument (workplace and facility safety scales and
culture) were not included in the survey available from the authors because they are copyrighted
by Human Synergistics, Plymouth, Mich28 (http://
www.humansyn.com). There was a high intercorrelation between the scales on the original instrument.
The instrument has been revised and shortened so
that it takes 20 minutes to complete. The authors
felt that using the shortened version enabled the ease
of administration and thus better survey compliance
without compromising the validity and reliability.28
Psychometrics
The psychometrics reported is based on the long version. The original survey was administered to a na-
tional sample of staff in 42 medical surgical ICUs (40

hospitals). A total of 1418 questionnaires were completed by nurses (78% return), 790 by physicians
(65% return), 111 by ward clerks (65% return), and
221 (85%) by members of the top management team
for an overall completion rate of 73%.14
Content validity: In a factor analysis,14 3 identified factors loaded at 0.40 or above, with an Eigenvalue well above 1.0.
Reliability: Cronbachs alphas for 21 of the
scales were greater21 than .70, and were greater
than .60 for the following scales: timeliness of communication, within-shift communication, satisfaction with nurse communication, and within- and
between-group forcing conflict management.14
Reliability and validity testing was conducted in a
large national sample.14 This instrument is designed
to measure collaboration at the unit level and to measure organizational components that facilitate a collaborative clinical interaction. However, it is long
and takes 45 minutes to complete. Since separate
validity and reliability studies have not been completed for the short version, testing criterion-related
validity using the 2 instruments is indicated. This
instrument may be used to compare collaboration
between units, among units and institutions, as well
as reporting on organizational variables, which may
support collaboration. The instrument has been used
for research of ICU nurse-physician collaboration
and interdisciplinary collaboration in emergency
departments.
Nurses Opinion Questionnaire
Background
The NOQ is based on the rationale that the organizational structure, role behavior, and communication patterns and methods between caregivers
(physicians and nurses) affect patient outcomes and
nurse satisfaction.1,2,4,5,15,29-33 The NOQ was developed in the United Kingdom (UK) to measure physical and social aspects of acute hospital wards.15
The NOQ consists of 98 items within 6 scales:
physical environment of ward, professional nursing
practice, ward leadership, professional working relationships, nursing influence, and job satisfaction.
The scale measuring professional working relationships 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 statements rated on a 4-point scale. Negatively worded
items are reverse scored so that higher scale values
indicate more positive views on interactions.15
Psychometrics
Initial psychometric testing of the NOQ was completed in the United Kingdom with 1499 nurses from
119 wards in 17 hospitals.15
Content validity: Items were developed from
qualitative interviews and literature review.15 Factor
analyses were completed using maximum likelihood
extraction to test the correlation between items on
the NOQ. Common factor solutions were achieved
with orthogonal and oblique rotations. Factors were
retained if they had with an Eigenvalue15 greater or
equal to 1.
Criterion validity: Scale scores from staff working on 6 wards who had taken part in the survey
were compared to observational assessments of the
ward characteristics by independent assessors using
a rating schedule.15 Thirty-three of 48 paired ratings were identical or differed by only one point of
magnitude.15
Construct validity: There was consistency between extracted factors and the a priori grouping
of items for the NOQ.15 Split-half tests were completed, and the resulting factor structures of the
2 halves were reported to be almost identical.15
Items within scales15 were significantly correlated,
P < .001. Chaboyer and Patterson conducted additional construct validity testing of the CMSS. Factor
analyses with oblique rotation yielded a 2-factor solution: consideration of nurses and valuing nurses
input.34
Reliability: Cronbachs alpha for the NOQ was
.81 and the test-retest correlation coefficient was
0.77. The Cronbachs alpha for the CMSS subscale
was .86 and a test-retest Pearson correlation coefficient was 0.83.3,15
The psychometric article was cited 9 times in the ISI
Web of Science Citation Index.
Comprehensive qualitative interviews provided the
basis for item construction in the scales. The scales
were not tested against similar tools, because a similar instrument had not been developed in the United
Kingdom. Additional criterion-related validity testing is indicated. Cultural and semantic differences
between the United States and United Kingdom may
necessitate additional psychometric testing for use
in the United States. The large sample size and the
250
national scope of the initial study lend strength to

the reliability and validity results. However, initial psychometric testing of this instrument occurred
only with nurses. Further psychometric testing with
physicians is necessary should physicians be included
in studies. The CMSS component of the NOQ has
been used in research comparing nurses perceptions
of collaboration between ICU and non-ICU nurses.
Jefferson Scale of Attitudes Toward
Physician-Nurse Collaboration
Background
Jefferson Scale of Attitudes Toward Physician-Nurse
Collaboration was based on the rationale that interprofessional collaboration is a joint venture, with
shared authority and responsibility, open communication, and shared decision-making. The education of professionals within a collaborative environment would also affect the attitude of nurses
and doctors toward each other and the concept of
collaboration.16,35-37
The instrument measures physician and nurse
attitudes toward authority, autonomy, and responsibility for patient-monitoring, collaborative
decision-making, role expectations, and collaborative education.16 There are 15 questions that are answered on a 4-point Likert-type scale.
Psychometrics
The instrument was administered to 208 first-year
medical students and 86 nursing students in an
upper-division baccalaureate program, 93% of their
total classes.16
Content validity: In a factor analysis with orthogonal varimax rotation, 6 extracted factors had
Eigenvalues greater than 1.16
Construct validity: There was consistency of extracted factors with discussions of collaboration in
the literature.
Reliability: Cronbachs alpha was .84 for medical students and .85 for nursing students. The item
total score correlations for the combined group
ranged from 0.65 to 0.40 with a median correlation
of 0.61.16
The psychometric article was cited twice in the ISI
Web of Science Citation Index.
The same instrument can be used for both physicians and nurses. Additional criterion-related validity testing is indicated. This instrument was tested on
first-year medical and upper-division baccalaureate
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nursing students. The use of students with limited

practice experience to test the validity and reliability of the instrument may limit its utilization
with practicing nurses and physicians. Additional
psychometric testing may be required to use this instrument in studies with practicing nurses and physicians. The instrument has been used primarily to
measure the attitude of nurses and physicians in different countries toward the concept of collaboration.
Discussion
These instruments are recommended for use because
they have undergone initial reliability and validity testing, and, therefore, represent a good starting
place for future research regarding nurse-physician
collaboration. Despite the fact that these instruments
have undergone some validity and reliability testing,
it would be imperative to conduct additional psychometric testing when an instrument is used with
a new population or study. Of the instruments reviewed, the ICU Nurse-Physician Questionnaire and
the CSACD measure collaboration of the same construct dimensions on both nurses and physicians.
The CPS measures different aspects of collaboration
of nurses and physicians. The CMSS component of
the NOQ measures nurse perception of collaboration but physicians were not included in the initial
survey development. The Jefferson Scale has primarily been used to compare attitudes toward collaboration between countries and cultures.
Two themes have emerged from this review:
(a) RNs have initiated much of the research on collaboration and (b) ICUs have been the site of much
of the research.
Why Is Most Research on Collaboration Conducted
by Nurses?
Fagin noted that there is minimal interest on the part
of physicians in interprofessional relationships.37 A
study by Kurtz suggested that physicians would prefer not to be interactive and would avoid group
involvement.38 Sexton et al described a significant
disparity between nurse and physician perception
of teamwork and communication.39 Larson identified a disparity in nurse and physician perceptions
of current and ideal authority of nurses.40 Several
others41,42 have described the inequity in power and
authority between nurses and physicians.
The professional education of nurses and physicians does not generally include interdisciplinary experiences in communication, planning, and decisionmaking.37 Nurses and physicians may practice professionally as they have been frequently taught: primarily independent decision-making on the part
of physicians and more interdependent decisionmaking with coordinating and communication functions on the part of nursing.2,7,37,44,45 Thus, nurses
and physicians perceive the value and need for collaboration differently, and this affects their interest
in research on collaboration.2,37
Why Is Most Research in Collaboration
Conducted in ICUs?
Knauss et al4 demonstrated the importance of communication and coordination in the achievement of
positive patient and fiscal outcomes in ICUs. This led
to additional studies conducted in ICUs, probably
because of the higher rates of patient acuity, mortality, and clinical practice errors that occur in that
setting. The critical care setting requires immediate
medical and nursing intervention, active dialogue,
and communication to respond to rapidly changing physiological parameters of the patients. Low
staffing ratios, smaller units, the presence of experienced and specialized nurses, and close proximity
among staff members are factors that facilitate collaboration in ICUs.
Summary and Recommendations

In this article, we have described several instruments
with published psychometrics that have been used in
research to measure nurse-physician collaboration.
These studies have shown a correlation between
nurse-physician collaboration and positive patient,
fiscal, and staff satisfaction outcomes. Since there is
now a considerable body of descriptive research on
this topic, we suggest that a natural evolution is indicated in the study of nurse-physician collaboration.
Many professional organizations, including the
National Patient Safety Foundation of the American Medical Association, the Joint Commission on
Accreditation of Health Care Organizations, the Institute of Medicine, and the Agency for Health Care
Research and Quality, have encouraged changes in
communication and the adoption of approaches
used in other disciplines, such as aviation and nuclear power to enhance patient safety.43,46-48 Collaboration is one of the key communication strategies to minimize errors. Instrument development and
research may be necessary to describe or test organizational and cultural changes that support collaborative practice. It is also important to examine
interpersonal communication and shared decisionmaking among nurses and physicians that contribute
to a decrease in error or morbidity for patients.
We have reviewed several instruments to assess
nurse-physician collaboration. The continued development and testing of these and other instruments
251
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will support additional research on collaboration.

The study of collaboration within the construct of
patient safety may provide an added impetus for
change in nurse-physician collaboration that tran-
scends historical and sociological constraints. This

change in nurse-physician collaboration may ultimately lead to better clinician communications and
patient outcomes.
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Nursing Administration Research Conference

The Nursing Administration Research Conference (NARC), From
Nursing Science to the Nursing Workplace: Creating New Pathways, will be
held October 58, 2005, at the Marriott Star Pass Resort in Tucson,
Arizona. The conference purpose is to disseminate current research on
nursing administration and nursing systems topics. Specific objectives are to:
Identify promising research findings on nursing administration and
workforce issues.
Evaluate our readiness to use the results of nursing research to improve
quality and cost outcomes in nursing care settings.
Analyze barriers and supports for translating research into meaningful
solutions.
For further information, contact jverran@nursing.arizona.edu
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