One inherent characteristic of the relationship between nurses and physicians is that they care for patients both independently and together. With respect to gender and the historic origins and roots of each profession, most physicians were male and most nurses female. Thus, traditional gender expectations of the time became deeply associated with the physician and nurse roles and were strictly followed, both formally and informally, in the hospital setting.

Various wars, epidemics, and societal evolution expanded roles for women. The role of the nurse expanded as well, and the education of nurses moved out of the hospitals and into colleges. Nurses subsequently assumed administrative and teaching roles. Columbia University awarded the first master’s degree in the clinical specialty of nursing in 1956.⁹ The role of the “bedside nurse” became increasingly filled by personnel other than registered nurses (usually licensed practical nurses), and prompted the Surgeon General in the early 1960s to appoint a group of nurses to review nursing needs.¹⁰ The report, Toward Quality in Nursing, noted increased responsibilities of professional nurses, changing medical practices, and specified levels of preparation for professional nurses. The report contained a number of recommendations, one of which was to study the nursing education system with respect to nursing skills and responsibilities to provide for patient care of the highest quality. Another was to provide federal funding for student loans and scholarships toward advanced education for professional nurses. In addition, recommendations were also made to increase and improve the quality of education programs and to support an increase in nursing research.

The role of the advanced practice nurse evolved over time and increased the dialogue and legislative activity regarding collaboration between nurses and physicians.¹¹ The American Nurses Association (ANA) and the National League for Nursing (NLN) obtained funding for an independent study on nursing. The National Commission for the Study of Nursing and Nursing Education in the United States was formed in 1967 to assess the status of recommendations from the Surgeon General’s report. The commission’s work lasted several years and the final report, An Abstract for Action, was published in 1971.¹² One of the major recommendations of the report was to establish the National Joint Practice Commission between medicine and nursing “to discuss and make recommendations concerning the
congruent roles of the physician and the nurse in providing quality health care, with particular attention to the rise of the nurse master clinician; the introduction of the physician’s assistant; and the increased activity of other professions in areas long assumed to be the concern solely of the physician and/or the nurse.”¹³ The Commission’s director proposed that nursing and medicine work out their respective roles through joint discussions, and the term joint practice was born. Not initially well received, the term has evolved over time to collaborative practice.

The American Medical Association (AMA) recognized the need for discussion about collaborative practice and issued a position statement in 1970 regarding the role of the nurse in expanded practice.¹⁴ The ANA in 1980 defined collaboration as “a true partnership, in 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 both parties.”¹⁵

Rising costs of medical care and insurance, the nursing shortage of the 1980s, and the availability of advanced practice nursing degrees brought about further discussions regarding collaborative practice.¹⁶ Nursing practice continued to expand with advanced degrees such as certified nurse-midwifery, nurse-anesthetist, clinical nurse specialist, and nurse practitioner. In addition, doctoral degrees became available for an increased number of nurses in the United States. This posed an even larger debate between nurses and physicians, as the business of taking care of patients moved forward from physicians only to nurses and physicians both looking for how to deal with these changes. The AMA and the ANA conducted a series of hearings between 1993 and 1994 in an attempt to reach agreement on nurse–physician professional relationships and establish an acceptable definition of the term “collaboration.” They agreed on the following definition: “Collaboration is the process whereby physicians and nurses plan and practice together as colleagues, working interdependently within the boundaries of their scopes of practice with shared values and mutual acknowledgment and respect for each other’s contribution to care for individuals, their families, and their communities.” A study was published in 1996, where both physicians and nurses had the opportunity to evaluate services “delivered in collaborative obstetrics and gynecology practices to determine whether patients perceived a difference in the delivery of services in a variety of practice settings.”¹⁷ This study demonstrated that patients accepted a collaborative practice model and determined that it offered a number of positive outcomes. The authors also noted that the model of care based on partnership between physician and non-physician professionals was not new and that, “The creation of collaborative models of care in which professionals work within their scopes of practice to meet patients needs without duplication may improve efficiency and patient outcomes.”

Nurse–physician collaboration is a key factor in nurses’ job satisfaction, retention, and job valuation.^{18,19,20,21,22} Decreased risk-adjusted mortality and length of stay, fewer negative patient outcomes, and enhanced patient satisfaction have also been associated with better nurse–physician collaboration.^7,23,24

A number of instruments with published psychometrics have been used in research to measure nurse–physician collaboration.²⁵ These instruments include:

These instruments have been recommended for use because they have undergone initial reliability and validity testing. The ICU Nurse–Physician Questionnaire and the CSACD measure collaboration of the same construct dimensions for both nurses and physicians. The CPS measures different aspects of collaboration between 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 been used primarily to compare attitudes toward collaboration between countries and cultures.

Two themes have been identified with respect to this subject. First, registered nurses have initiated much of the research on collaboration and, second, ICUs have been the site of much of the research.

A number of factors may help explain these phenomena. A study by Kurtz suggested that physicians may prefer not to be interactive and would subsequently avoid group involvement.²⁶ Sexton and colleagues described a significant disparity in nurse and physician perceptions of teamwork and communication.²⁷ Larson identified a disparity in nurse and physician perceptions of current and ideal authority of nurses.²⁸ Others have described the inequity of power and authority between nurses and physicians.^29,30

The professional education of nurses and physicians does not generally include interdisciplinary experiences
in communication, planning, and decision-making.³¹ Nurses and physicians may practice professionally as they have been frequently taught, using primarily independent decision-making on the part of physicians and more interdependent decision-making with coordination and communication functions on the part of nurses.^32,

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