Asian Nursing Research 12 (2018) 166e174

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Asian Nursing Research

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Research Article

Physicians' Experience of Communication with Nurses related to

Patient Safety: A Phenomenological Study Using the Colaizzi Method
Kwang-Ok Park,1 Sung-Hee Park,2 Mi Yu3, *,*
1
Department of Nursing, College of Life Science and Natural Resources, Sunchon National University, Sunchon, Republic of Korea
2
Department of Nursing, Kyungmin University, Uijeongbu, Republic of Korea
3
College of Nursing, Institute of Health Sciences, Gyeongsang National University, Jinju, Republic of Korea

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: This study attempted to understand the core experiences of physicians related to communi-
Received 26 November 2017 cating with nurses in Korea.
Received in revised form Methods: Ten physicians who worked at four tertiary university hospitals were interviewed. Data were
29 May 2018
analyzed using the phenomenological method developed by Colaizzi.
Accepted 4 June 2018
Results: The following six categories of participants’ experience of communication with nurses were
extracted from the analysis: (a) “Complex situations and heavy roles that cannot afford safety,” (b)
Keywords:
“Forcing a superior position in an authoritative environment,” (c) “Different perspectives on patient care
communication
nurses
and difficulties in establishing relationships,” (d) “Communicating key clues and receiving feedback from
physicians each other,” (e) “Apathetic agreements rather than improvements,” and (f) “Gradually developing
qualitative research mutually complementary communication.”
safety Conclusion: The present findings revealed that physicians lacked an understanding about the roles and
tasks of nurses. The participants engaged in mutually complementary communication with experienced
nurses, obtaining desirable patient outcomes and perceived order filtering by nurses as a safety mech-
anism. It is important for managers to act as proactive change agents to improve communication.
Furthermore, the importance and different forms of complementary communication between physicians
and nurses need to be described and taught in depth with practical cases.
© 2018 Korean Society of Nursing Science, Published by Elsevier Korea LLC. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction communication have generally focused on medical accidents

Communication-related patient safety issues have become a
global concern, and therefore, these issues have been studied in the
United States [1], Iran [2], and Sweden [3]. Disruptive communi-
cation between nurses and physicians occurs with alarming fre-
quency [4]. A lack of effective communication between nurses and
physicians can lead to adverse effects such as hospital read-
missions, extended length of stay [5], preventable patient injury,
and death [6]. In contrast, one study showed that as the level of
communication between physicians and nurses increased, patient
mortality and medication error rates decreased [7]. However, there
is limited research on the communication between physicians and
nurses. Previous studies examining health professionals’
* Correspondence to: Yu Mi, PhD, College of Nursing, Gyeongsang National Uni-
versity, 816-15, Jinju-daero, Jinju-si, 52828, Republic of Korea.
E-mail address: yumi825@gnu.ac.kr
*
ORCID: https://orcid.org/0000-0002-7947-0923
related to duties [8], obstacles or factors related to communication
delivery [9], developing a standardized handover tool [10], and
communication styles [11]. However, although researchers have
recognized the importance of patient safety [1], studies examining
patient safety content are insufficient and limited.
Communication is influenced by contextual factors such as ed-
ucation, culture, language, gender relations, and health-care sys-
tems, and it is typically examined based on individual interactions.
Nurses and physicians have been trained to communicate in very
different ways [12], but very little nursing and medical education
has addressed interprofessional communication [13]. Furthermore,
communication regarding patient safety has not been discussed
actively by medical educators in Korea [14], unlike those in the USA
[15]. In addition, a cultural environment emphasizing hierarchy
creates peer conflict and hinders effective and constructive
communication within the institution [16]. Japanese physicians'
style of communication with nurses was identified as

https://doi.org/10.1016/j.anr.2018.06.002
p1976-1317 e2093-7482/© 2018 Korean Society of Nursing Science, Published by Elsevier Korea LLC. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
 K.-O. Park et al. / Asian Nursing Research 12 (2018) 166e174
“individualistic” at one end and “collaborative” at the other [11].
Ruhnke et al [17] suggested that the communication styles of
American and Japanese physicians differ, but it remains unclear how
they differ. In the Korean culture, refraining from revealing one's
emotional state is considered a virtue. Problems that involve
emotional expression and communication are closely associated
with the need to “save face” and to authority variables that are
peculiar to the patriarchal culture of Korea. Furthermore, these
characteristics exist among individuals as well as groups [18].
In addition, in Korea, technical solutions such as e-Healthcare,
up-to-date equipment, and the promotion of clinical practice
guidelines are being used to reduce medical malpractice related to
patient safety issues [19]. Nevertheless, there is no report that such
technological advances improve the quality of communication be-
tween physicians and nurses. Furthermore, there is a lack of
comprehensive qualitative examination of the experiences of
physicianenurse communication from the perspective of
physicians to determine appropriate resolutions for communica-
tion problems and to prevent latent errors.
Previous research implies that cooperation between physicians
and nurses is not achieved easily, and conflicts between the two
parties have been observed since long. Furthermore, it has been
reported that nurses, rather than physicians, thought negatively
about communication and cooperation, and therefore, it is impor-
tant to improve this attitude [20]. In addition, it has been reported
that nurses' communication with physicians is unidirectional [21].
However, there is a paucity of studies investigating how nurses or
physicians communicate with each other in the clinical setting,
where they are practical counterparts. Communication represents a
continuum of activities, as one behavior in a larger cluster of be-
haviors [22]. To better understand the differing perceptions of in-
formation needs and communication patterns of health-care
professionals with reference to patient safety, we need to under-
stand how physicians’ communication with nurses can promote
patient safety or can lead to errors.
Aim and research questions
To understand the core experiences of physicians in communi-
cating with nurses, interview data were analyzed using the method
proposed by Colaizzi [23].
This study aimed to understand the core of the experience of
communication concerning patient safety between physicians and
nurses in hospitals based on the perspectives of physicians in Korea.
The study involved listening to descriptions of communication
experiences and analyzing cases, with the goal of providing infor-
mation to develop ways to improve patient safety in clinical prac-
tice. The following research question was explored: “What do
physicians experience while communicating with nurses con-
cerning patient safety?”
Methods
Study design
In this qualitative study, physicians were interviewed in depth
about their experiences regarding communicating with nurses
about patient safety. Data were collected in hospitals, and they
were analyzed based on the phenomenological methodology sug-
gested by Colaizzi [23]. In phenomenology, we try to understand
the subjective experiences of participants by returning to the sit-
uation itself. In other words, the researcher uses discontinuities
such as bracketing to describe participants' experience world
without bias or prejudice. In the phenomenological approach, the
situation itself refers to the subjective feelings, perceptions, and
167
reactions experienced by the participants in a specific life scene.
Thus, the aim of a phenomenological study is to understand the
meaning and essence of participants' experiences in a specific sit-
uation [24]. In the present study, Colaizzi's method [23] of
phenomenological analysis was applied.
Characteristics of the participants
The participants in the present study were 10 physicians from
four tertiary university hospitals in S and J city in Korea. An initial
purposive sampling was conducted to identify “good informants,”
that is, those who had experienced the phenomenon under
study and were reflective and willing to share their experiences [25].
The inclusion criteria were “being a physician with 2 or more years
of clinical experience and of working in the same department,” as
this is the amount of time it takes for physicians to be able to explain
their own duties; “having performed conventional duties such as
prescription and ordering” [26]; and “having experienced the phe-
nomenon under study and being reflective and willing to share one's
experiences [25] regarding physicianenurse communication.”
Data collection
Researchers' training and preparation
The present researchers had varying experiences as nurses and
nurse managers in the general ward, operating room, intensive care
unit (ICU), and nursing administration department, and they took
qualitative research courses in graduate schools. In addition, they
had recently published qualitative studies in journals. Therefore, it
was deemed that they were capable of understanding the partici-
pants’ communication experiences in the hospital.
All interviews were conducted in person, at a participant-chosen
time and location, including small hospital conference rooms or a
quiet spot near the participant's workplace from December 2014 to
January 2015. Interviews usually took about 90e120 minutes, and
the authors conducted in-depth interviews using the same interview
guidelines to reduce variation or errors in the data collection process.
All interviews were audio recorded with the participants' permis-
sion. The main question that the participants were required to
answer was “What is your experience of physicianenurse commu-
nication concerning patient safety?” Interviews began with open-
ended questions such as “In your workplace, how is the communi-
cation with nurses regarding patient safety issues such as prescrip-
tion including verbal order and discussion about patient condition?”
To elicit rich descriptions from the interviewees and/or to under-
stand their descriptions clearly, auxiliary open-ended questions such
as “Could you describe some successful experiences or difficulties in
communicating with nurses regarding different types of communica-
tion or the background?”, “Have you ever experienced accidents or close
calls due to communication?”, “Which aspect of communication im-
pedes patient safety?”, and “What strategies do you use to improve
communication?” were used. During each interview, significant dialogs
were recorded in a memo, which were used for the subsequent inter-
view and analysis. Data collection and analysis were performed
simultaneously. After each interview, the analyst listened to the recor-
ded data, reviewed the transcript, and then coded the data. Newly
collected data were compared to the preanalyzed categories in terms of
similarities and differences. Transcribed data were coded indepen-
dently by the three authors, and the results of their analyses were dis-
cussed to reach complete agreement among the study's authors.
Data analysis
For the data analysis, the recorded data were first transcribed
word for word. It took 8e10 hours to transcribe each participant's
168 K.-O. Park et al. / Asian Nursing Research 12 (2018) 166e174
interview. Subsequently, the researcher listened to the recordings
to improve the accuracy and reliability of the data. The data were
analyzed using the method described by Colaizzi [23], with data
collection and analysis taking place in a circular fashion. In the first
stage of the analysis, the researcher read the transcribed data
several times, focusing on the context of the data and participant
responses, and selected significant statements. Then, similar ex-
pressions were grouped and organized among the extracted
statements, and they were reconstructed in a more abstract
fashion. This was followed by the extraction of a theme by grouping
similar content in significant statements, and similar themes were
grouped and categorized into themes with high abstractness. Data
collection and analysis were performed simultaneously. Interviews
were conducted till theoretical saturation was achieved such that
no new contents appeared in the interviews and the same type of
concepts and themes emerged in the data analysis.
Establishing rigor of the data
To ensure rigor in this qualitative study, we followed Sande-
lowski's method [27] following four standards: 1) to maintain
credibility, we began with open-ended questions and allowed
participants to talk about their experiences freely in their own
language. We used bracketing to maintain neutrality excluding
researcher's thoughts, experiences and emotions, and the same
question was asked in different forms to allow repeated identifi-
cation during interviews and analysis. In addition, we tried to
improve the credibility of the research results by confirming with
the participants via email if the results coincided with their expe-
riences. 2) Fittingness is established based on in-depth data
collection until saturation. In this study, investigators extracted
significant ideas from participants' descriptions of specific and
vivid experiences. 3) Auditability confirms that insights and data
are not contradictory and that a possible conclusion can be drawn
[26]. In this study, we received feedback from coauthors on the
results of the study, and we carefully discussed the analysis and
interpretation through ongoing discussions. Because the authors
have different academic and clinical backgrounds and interests,
reading and discussing each other's interpretations of the data
helped identify implicit preconceptions. 4) Conformability in-
dicates whether a neutral position is maintained and results are
obtained without investigator participation. In this study, we cited
the participants' comments so that the reader could verify the
interpretation and analysis of the data. For this purpose, we sepa-
rately recorded the researchers' preconceptions, assumptions, and
ideas on the topic during the entire research process. This was done
by consciously comparing and analyzing the present interview data
and the results of previous studies. Thus, the present findings
reflect the experiences and opinions of research participants as
much as possible, minimizing the prejudices of the researchers.
Finally, two study participants reviewed the summary of the study
results to verify if they captured the essence of their experiences.
Ethical considerations
Ethical approval was obtained from the Institutional Review
Board of Sunchon National University (Approval no. 1040173-
201411-HR 008-02). Before the interviews, anonymity, confidenti-
ality, the right to withdraw at any time without any penalty, and the
purpose of the study were explained to the participants, and then
each participant provided written informed consent. During data
analysis, each transcript was anonymized to make sure that the
participants could not be identified.
Results
Participants
The present participants included six female and four male
physicians. The mean age of the physicians was 33.70 years (range:
26e41 years). The mean length of clinical experience was
3.91 years. Regarding academic background, three physicians had a
bachelor's degree and seven had a master's degree or higher. In
terms of specialty or department, three, five, and two physicians
belonged to the departments of internal medicine, surgery
(including obstetrics & gynecology, urology), and anesthesiology,
respectively (Table 1).
Physicians’ experience of communication
In this study, 45 significant statements were extracted from the
interview data, which were then categorized into 13 themes.
Finally, six categories were formed by merging similar themes
(Table 2).
Category 1: Complex situations and heavy roles that cannot afford
safety
Assignment of excessive workload. The participants viewed their
workload as overwhelming. They felt that they had an acute
shortage of time and that they were working 24 hours a day. As
attending physicians, they were responsible not only for the hos-
pital wards and ICUs but also for surgery and outpatient tasks. As
such, they were forced to leave the patients assigned to them. They
also expressed difficulties in identifying their patients as too many
patients were assigned to them. Too much work disturbed the
physicians, which made it difficult for them to communicate
effectively. Physicians thought that they were extremely busy with
excessive duties, and therefore, they could not fully understand the
patients’ conditions.
“I receive hundreds of text messages every day. I often forget nurses
who notify me and the details of the same. Generally, when I am
about to do something after being notified, I need to go to another
place because someone calls me, and then I forget what I was
about to do just before the call. In such situations, nurses say, ‘Why
do you not do anything even after you just said you would?’ I have
a lot of work, and I have no choice but to ignore patient safety.”
(Physician 8).
Facing complex situations that are burdensome for beginners.
As the participants began to work as a training physician or medical
resident, they felt that they lacked the knowledge and experience
necessary for fully understanding and executing their workload. As
such, they felt that they needed expertise in a diverse range of
clinical situations, from emergency situations to attending to ICU
patients. However, participants had generally failed to understand
basic tasks at the hospital at least until a year into their experience
as training physicians or medical residents, and they expressed that
they lacked patient identification skills.
“One night, I was the only medical resident on the ward. It was just
me. I got calls every 30 minutes to see patients. I told the nurse to
give morphine to one patient. However, if a patient's condition
deteriorates, immediate correction is needed. But the new nurse
and I weren't able to react appropriately. Six hours later, she called
me to come quickly. My heart started beating very fast as I ran to
the patient.” (Physician 2)
 K.-O. Park et al. / Asian Nursing Research 12 (2018) 166e174 169

Table 1 The Sample of Interviewed Physicians’ Experience of Communicating with Nurses.

Interviewee Gender Age (yrs) Position status Specialty Clinical experiences Educational background Duration of interview

Interviewee 1 Woman 31 Clinical fellow Internal medicine 6 yrs 9 months Master's degree 2 hrs
Interviewee 2 Man 41 Resident Urology 4 yrs Master's degree 2 hrs
Interviewee 3 Woman 26 Resident Internal medicine 2 yrs Bachelor's degree 1 hr 30 mins
Interviewee 4 Woman 29 Resident Obstetrics & Gynecology 3 yrs 11 months Master's degree 2 hrs
Interviewee 5 Woman 38 Resident Obstetrics & Gynecology 3 yrs 11 months Master's degree 2 hrs
Interviewee 6 Man 40 Resident Internal medicine 3 yrs Master's degree 1 hr 45 mins
Interviewee 7 Man 33 Resident General surgery 4 yrs Bachelor's degree 2 hrs
Interviewee 8 Man 37 Clinical fellow Vascular surgery 5 yr 11 months Master's degree 2 hrs
Interviewee 9 Woman 29 Resident Anesthesiology 3 yrs 8 months Bachelor's degree 1 hr 45 mins
Interviewee 10 Woman 33 Resident Anesthesiology 2 yrs Master's degree 2 hrs

Note. hrs ¼ hours; mins ¼ minutes; yrs ¼ years.

Category 2: Forcing a superior position in an authoritative
environment
Holding a superior position as compared to nurses. The participants
felt that, given the nature of their jobs, the relationship between
physicians and nurses was not equal in a hospital. They felt that
they were in a superior position as someone providing orders to
nurses and that they had a sense of authority.
“When nurses say, ‘Why do you prescribe so? I have not seen other
physicians doing so,’ I say, ‘You just follow the order’.” (Physician 5).
“Why does a nurse retort when a physician says something? It may
be a stereotyped idea. In this way, the dialog between doctors and
nurses does not occur from equal positions.” (Physician 2)
Strong hierarchical atmosphere. The participants felt that the hos-
pital atmosphere was hierarchical to the point that intern physi-
cians or residents with fewer years of experience could not pose
questions to professors. Furthermore, the participants reported that
nurses with more experience tended to act high-handedly, and
they felt that they were controlled by experienced nurses as
training physicians or residents with less experience. This experi-
ence of strict hierarchy between nurses and physicians influenced
their work. For example, new nurses tended to prefer reporting to
an attending physician instead of handing over the responsibility to
senior nurses because despite being scolded by attending physi-
cians, the new nurses felt more at ease with physicians than with
experienced nurses.
“Acting high-handedly or taming? It's worst during March … for
new residents and interns because the nurses' attitude is like, ‘what
do you know?’ They look down on new physicians on rotations.
They don't respect a new physician, and it's like they're challenging
authority. Flexible and mutually complementary communication in
patient care is not easy in this atmosphere” (Physician 9)
Category 3: Different perspectives on patient care and difficulties in
establishing relationships
Difference in interests, perspectives, and work priorities between
physicians and nurses. Although the participants worked closely
with nurses in hospitals, they did not know each other well and
showed differences in interests, perspectives, and work priorities.
The participants placed importance on surgeries or treatment and
did not care much about patient safety related to falls as much as
nurses did. The participants wished that nurses would be consid-
erate in a work setting; however, given frequent movements in
their assigned locations, it was difficult to cultivate a stronger
relationship with nurses. For example, interns switched their work
locations every month, and residents, depending on their major,
worked in a specific ward and had to switch between surgery
rooms, outpatient wards, ICUs, treatment, and testing rooms.
Therefore, they experienced difficulties in forming cooperative re-
lationships with nurses.
“I do not know what kind of education nurses have received and
what exactly they do here. I think that many physicians would not
know either. I think nurses look at us in the same way. They might
think ‘Physicians just come over for a short period, give orders and
submit progress records.’ In that sense, I think we basically have no
understanding of each other. So, it is difficult for nurses and doctors
to form cooperative relationships in patient care.” (Physician 4)
“There are 30 to 40 nurses in a ward. There would be even more if
all sorts of medical staff are counted. If we had a staff dinner and
more time to meet by chance, we might be able to understand each
other and establish trust. However, we have no time for it. More-
over, every physician has a different working style and staff is al-
ways being replaced.” (Physician 8)
Expecting consideration from nurses in a professional setting.
The participants wanted the other party, including nurses, to be
considerate with them in their communication. The participants
wanted nurses to be considerate of their harsh daily routines. For
example, they wanted nurses to refrain from calling or ordering
requests early in the morning, to organize group work requests or
reports on patients, and to use a tone of voice useful for suggestions
or discussions.
“I have not experienced something as difficult as this, I rarely sleep.
I'm so tired, but nurses do not experience what I am doing. To be
honest, the most important thing, I think, is to be courteous to each
other.” (Physician 5 and 6)
Category 4: Communicating key clues and receiving feedback from
each other
Providing clear orders. The participants agreed that the basic part of
communication for patient safety involves providing accurate or-
ders. The clear delivery of orders included providing justification for
prescriptions, completeness of prescriptions, providing additional
explanations about the reason for prescription, suggestion of spe-
cific guidelines, and prudent clinical decision-making. The partici-
pants perceived that the absolute authority and responsibility of the
order was with the physician. However, interns and residents lacked
time and patient information to provide valid orders based on
clinical decisions. The participants agreed that clear orders are very
important as they directly influenced nurses’ work.
“Every single line in an order is meaningful. So physicians need to
pay attention to details rather than copy and paste. When nurses
report to physicians, it would be better for physicians to explain the
context sufficiently so that nurses would understand the meaning
of each task they conduct.” (Physician 3)
“If we don't know the plan, we refer to the lab reports. If there's
nothing about fasting, and the patient eats meals, then we're done
for. The 8-hour surgery gets delayed, the patient gets worse…
Sometimes, the doctor cares a lot about patient fasting, but if
they're too busy to do that, someone comes and says oops, the
170 K.-O. Park et al. / Asian Nursing Research 12 (2018) 166e174
Table 2 Categories and Themes of Physicians’ Experience of Communication with
Nurses related to Patient Safety.
Categories Themes Significant statements
Complex situations and Assignment of excessive  Working 24 hours a day
heavy roles that workload  Complete lack of time
cannot afford safety  Outpatient and surgery
room management
aside from wards
 Many assigned patients
Facing complex  Beginners (interns and
situations that are first-year residents) are
burdensome for always present
beginners  Lack of knowledge in
basic work and patient
identification
 Lacking experience and
knowledge
 Lacking competency
Forcing a superior Holding a superior  Sense of authority as
position in an position as compared to the physician
authoritative nurses  Superior role (order
environment giver)
Strong hierarchical  Hierarchical structure
atmosphere between physicians
(interns, residents, and
professors)
 Hierarchy between
nurses
 Acting high-handedly
Different perspectives on Difference in interests,  Ignorance toward the
patient care and perspectives, and work other party's work
difficulties in priorities between  Differences in work
establishing physicians and nurses importance and priority
relationships  Doctors value surgery
and treatment and do
not care about safety
issues such as fall
 Short-term assignment
due to rotations
 Lack of opportunities to
build relationships
Expecting consideration  Want nurses to
from nurses in a consider their busy
professional setting schedule
 Refraining from calls
during early mornings
 Notifications sent in
groups
 Wants tone of voice
that allows for
suggestions and
discussion
Communicating key Providing clear orders  Valid reasons for orders
clues and receiving  Additional explanations
feedback from each if required
other  Provide important
guidelines
Filtering orders for each  Order filtering between
other physicians (interns and
residents/senior and
junior residents/
residents and
professors)
 Order filtering between
physicians and nurses
experienced nurses
filtering for new nurses
 Confirming missing or
lack of orders
 Enabling feedback for
incomplete orders
Communicating from an  Identify key evidence in
overall context using key the patient clinical file
clues  Exchange patient
information from an
overall treatment
perspective
Table 2 (continued )
Categories Themes Significant statements
 Wants key evidence
and notifications with
suggestions
 Wants discussions on
patient file
Apathetic agreements Inevitable agreements  Ignoring
rather than  Remaining silent
improvements  Does not wish for bad
relationships
Apathetic responses  Asking for help from
higher managers (head
nurses, chief, and
professors) as objective
mediator in times of
conflict
 No route to open
problem-solving
 No signs of
improvement
 Wants backup from
experienced nurses
Gradually developing Achieving effective  Communication grows
mutually communication through more effectively with
complementary long-term efforts more years of
communication experience
 Acquire
communication skills
through experiencing
different cases
Engaging in mutually  Gradually trust nurses
complementary and understand their
communication with points of view
nurses  Acquiring from
experienced and
skilled nurses
 Asking for nurses'
advice
patient had meals… oh no! We have plans in our heads telling us
that this patient has to enter surgery, but it doesn't get passed
along. Meals are very problematic.” (Physician 4)
Filtering orders for each other. Physicians believed that receiving
feedback from colleagues on prescriptions was important for pa-
tient safety. Omissions and incomplete transcriptions were checked
and corrected via feedback. Specifically, physicians felt that nurses
could filter out risk factors because nurses keep an eye on assigned
patients, whereas physicians do not. The participants emphasized
that the orders received by new nurses should be filtered by
experienced nurses. This order filtering was perceived as a mech-
anism to ensure patient safety. The participants asserted that these
functions make up for missing orders, nonexistence of orders that
should exist, and incomplete orders. They believed that such
feedback ensures patient safety.
“As an internal medicine resident, I prescribed dopamine to reduce
blood pressure. In such cases, experienced nurses would ask for
different doses for patients in the neurosurgical wards. Likewise,
nurses filter prescriptions to reduce any potential risk.” (Physician 6)
Communicating from an overall context using key clues. The partic-
ipants felt that it was important to exchange patient information to
ensure patient safety. The clarified that in the clinical scene, in
which complex events occur in short intervals, it was important to
accurately extract significant evidence from the clinical data of
numerous patients, which should then be exchanged between
physicians and nurses from an overall treatment perspective.
 K.-O. Park et al. / Asian Nursing Research 12 (2018) 166e174
In the same context, physicians wanted nurses to identify key
clues, summarize a theme when reporting, and discuss the patient's
status together. Similarly, nurses participated in physicians' rounds,
as much as they could, to obtain accurate information. To achieve
this objective, the participants asserted that they need serious
discussions with nurses. In addition, the participants asserted that
confirmation and reconfirmation was important in each stage of
providing orders, and it was important to listen to nurses' reports
with an open mind.
“There should be some clues that nurses can find and deliver to me.
Why is there pain in the right lower abdomen of the patient? Is
something pooled there? Is the patient bleeding? There could be
completely different reports on the same case. Was the wound
infected? If nurses check the patient once more and send a notifi-
cation with unusual clues, physicians hardly ever miss the notifi-
cation.” (Physician 7)
“If we receive a notification of lower BP, the attending physician
wonders about central venous pressure and other stuff. If the nurse
does not know about this, he/she asks the doctors to wait and
checks on each patient. Physicians get annoyed by this. It would be
good if nurses understand what's relevant and give us an overall
notification or trend.” (Physician 9)
Category 5: Apathetic agreements rather than improvements
Inevitable agreements. When faced with communication issues
with work, the participants reported that they were initially angry
and they expressed their anger; however, they soon noticed that it
was useless and responded with ignorance, patience, silence, or
resignation. The participants did not want to worsen their re-
lationships with nurses and wanted to stay on good terms with
nurses or with the other party.
“When I was fighting with a nurse, the entire ward was looking at
us. They were watching us fight. Then I realized that I didn't want to
quarrel with the nurse. Let's stop talking. Let's just do the work. Not
everyone works the way I think. So, I just have to work alone, not
fully communicating with them. What else can I do?” (Physician 2)
“Resident doctors need to stay, and the experience is almost
hammered in you … any conflicts make me more stressed out. I
need to survive and look successful to the professor so I avoiding
any trouble.” (Physician 8)
Apathetic responses. The participants felt the need to improve the
communication system with nurses and the problem-solving ac-
tivities to ensure patient safety. In the face of communication is-
sues, they looked to the head nurse, chief resident, or professors to
intervene, with little results. The participants asserted that there
are almost no problem-solving interventions. Moreover, the par-
ticipants asserted the need for experienced nurses to support the
work of new nurses to ensure patient safety.
“When I put in efforts to figure things out, I told the nurse-in-charge
or the head nurse to change it because it's wrong. There are some
types of responses from them. Usually they just say ‘It's because
nurses are busy. Please understand us'. Some nurses do come up
and tell us that they'll change it, but nothing changes … after this
happens once or twice, I don't tell them anymore. It's not like
someone can change immediately.” (Physician 6)
Category 6: Gradually developing mutually complementary
communication
Achieving effective communication through long-term efforts.
The participants increasingly became comfortable as they
171
progressed through being interns, and 1st or 2nd year residents, and
they responded effectively while communicating with nurses. The
participants asserted that nurses and physicians must have flexi-
bility and expertise in patient-centered communication to ensure
patient safety. Moreover, the patients asserted that the ability to
communicate effectively by merging the individual, professional,
and situational characteristics in a diverse range of clinical situa-
tions is not achieved over a short period. They asserted that this was
possible only through experiencing actual cases and obtaining
wisdom.
“I think that, during my first year, I was just so busy and so easily
annoyed. I'm reflecting on myselfdI have more flexibility as I spend
more time here … and when nurses provide me with bad news, I
used to react in a bad way, but now I'm sorry about how I used to
behave earlier … I try to be friendly and nice, thank them for their
help, and tell professors that the nurses were of great help in
achieving great results, in front of the nurses.” (Physician 5)
Engaging in mutually complementary communication with nurses.
The participants felt that mutually complementary communication
with nurses was possible when understanding and respecting the
work of other parties and showing trust, leading to optimal patient
safety. As time passed, the participants observed the general
working attitude of nurses or the results of their efforts and began
trusting them. They respected nursing work and the nurses’ per-
spectives. Moreover, the participants would learn from experienced
nurses, receive professional help, and seek advice from them. As
such, the participants developed camaraderie with nurses through
flexible communication and feedback, striving to communicate
effectively to ensure patient safety.
“I'm thankful because they're teaching me something I don't know.
They're very experienced, and if they think that a particular
medication is not right for the client, then they tell me so. They say,
‘Doctor, there's way too much fluid compared to yesterday, and the
swelling is bad. Could you reduce the dosage of …’ I'm thankful for
such help.” (Physician 6)
“I have no issues when talking with experienced nurses. When I
was working in the ICU, and a colleague of mine said that I should
listen to the nurse-in-charge. If that nurse says a patient is going
into arrest within a few hours, then the patient actually does end
up going into arrest … experience cannot be ignored. I rely on them,
ask them for help when they have more experiential knowledge
and more insights on such situations … nurses-in-charge are often
of great help.” (Physician 9)
Discussion
This study used a phenomenological method to explore the
experience of physicians’ communication with nurses regarding
patient safety and delineated six categories. At the core of the
experience of communication with nurses was the valid execution
of roles in the context of high workload, while engaging in mutually
complementary communication to ensure patient safety. The focal
concepts of communicating with nurses regarding patient safety
were assuming a superior position, expecting consideration,
apathetic agreement, and gradual development of complementary
communication.
This study indicated that medical residents with less capacity
and experience were required to manage work overload and
complex roles. Work overload was a common phenomenon in both
domestic and foreign studies [19e22] on communication between
nurses and physicians. Under the human resource training systems
of hospitals, all physicians and nurses start as beginners, who often
lack the knowledge and experience required to solve a diverse
172 K.-O. Park et al. / Asian Nursing Research 12 (2018) 166e174
range of patient issues in the complex clinical environment,
sometimes failing to accurately identify patient conditions. Such
requests for increased work capacity and increased competence
have been reported in both domestic and foreign studies, and 53%
nurses and medical staff stated that the increased competence of
their colleagues would solve the issue of communication [15].
Furthermore, highly stressful environments were classified as a
cause of ineffective communication [28]. Both these previous
findings support the findings of the present study.
In the complex situation in which safety cannot be afforded, the
participants experienced a status comparatively superior to those of
nurses within the authoritative atmosphere of hospitals. This hierar-
chy is because physicians consider nurses as actors in the treatment
process, rather than cooperators with whom they need to commu-
nicate regarding patients' status and treatment plans [28]. These re-
sults were similar to the present findings, asserting that the superior
position and attitude of physicians complicate physicianenurse
communication [25]. The present results also indicate that the
authoritative culture has adverse effects on the relationship between
physicians and nurses, which in turn influences others’ and their own
work. Furthermore, as the hierarchical culture between new and
experienced nurses influences work handovers or reporting to phy-
sicians, the same needs to be carefully examined by nursing
managers.
In an authoritative environment, the participants wished to be
cared for without knowing the perspective of nurses during work.
The participants had little understanding of nursing as a profession,
remained ignorant about the human aspects of nurses, and shared
different work priorities and interests. These results are in line with
studies asserting that the physicians and nurses are educated in
different ways, and therefore, communication problems can only be
resolved by developing an understanding of the other
party's perspective [15]. Previous studies have also stated that
nurses consider communication methods depending on their
counterparts and carefully consider physicians [20]. Professional
role identity is a key aspect of communication between physicians
and nurses. If the physician fails to nurture an accurate image of
nurses or does not have the right perception of the duties, roles, and
work tasks of nurses, it leads to communication issues with nurses
[26]. Therefore, participants' neglect of nurses found in this study
needs to be addressed. The present results indicated that the par-
ticipants wished to be cared for by nurses during work-related
communication. One interesting aspect is that in a study on physi-
cians' communication with nurses [20], the latter were engaged in
considerate communication, such as understanding what the other
party is thinking, emotional sharing, pausing and reflecting, and
reaching out. On the other hand, there were difficulties in forming
relationships between participants and nurses because of frequent
movements in work locations. Other studies have also reported the
lack of continuity in the connection between nurses and physicians.
This indicates that their connection is fluid given the frequency of
their movements and that their relationship is superficial [20]. In
addition, their conversations were work related and often lacked
nonwork discussions [15]. Thus, it appears that methods to improve
relationships between the participants and nurses are required.
The results of this study indicated that the participants were able
to contribute to patient safety by communicating using valid role
divisions and key clues. The participants argued strongly that clear
orders, filtering orders, and communicating using key evidence in a
general context were essential for ensuring patient safety. These
basic principles begin with the roles of physicians and nurses.
Although these roles appear to be clearly divided from the outside,
they are practically mutually dependent and influence patient
outcomes [5,25]. The present results verified the importance of this
perspective. On the other hand, in a focus group study with
physicians and nurses [25], participants reported that effective
communication was related to the clarity and accuracy of infor-
mation based on validity, cooperative problem-solving, calm and
supportive response to stressful conditions, and the maintenance of
mutual respect and true understanding of unique roles, which
supported the present results. However, filtering orders, which was
identified as an important element in the present study, is not
covered in school education or textbooks. Thus, the present findings
confirmed that order filtering has an important role in ensuring
patient safety. These results indicate that nurses should ask ques-
tions about the accuracy of prescriptions, point out wrong pre-
scriptions, and suggest alternatives [15]. Nurses are often the eyes
and ears of the physician as they observe and record patients' states
in the absence of physicians [26]. This supports the present finding
that the participants identified meaningful evidence from the
clinical information of patients, incorporated them into discussions,
and wished to discuss the patients' situations with nurses. Similar
findings were emphasized in other studies in the context of dis-
cussing patients’ situation [28]; obtaining patient data [29]; sensible
information exchange suitable to the situation [30]; inability to
communicate about topics, disagreements, and situations with
nurses; and summarizing valid clinical information [19]. On the
other hand, to identify key evidence from patient data, integrate
them into reports, and engage in discussions, nurses need to be
confident about their work. However, nurses engage in communi-
cation without such confidence [15] and expect safe provision of
services without emphasizing on professional communication [25].
Hence, there is a need to focus on the situation, task, intent, concern,
and calibration method, which enables nurses to express unseen
evidence to the physicians, and use such tools in providing educa-
tion about physicianenurse communication.
In this study, the participants inevitably accepted and unen-
thusiastically responded to such situations rather than improving
communication issues. The inevitable acceptance observed in this
study included holding back their expression, letting issues go,
ignoring issues, and giving up problem-solving. These findings
were in line with those of a study that found that participants either
hold back, wait, or remain silent based on the belief that voicing
their opinions would result in punishment or other negative results
in cases in which they are unable to reach an agreement [30]. The
findings were also in line with those of other studies in which, as
on-site personnel, the participants were directly experiencing
communication issues but lacked the ability to spearhead
improvement and report problems to senior physicians, professors,
head nurses, or experienced nurses. Furthermore, there were no
improvements after reporting communication issues to superiors,
and this trend of mild change at the management level was
observed in other studies [2]. In a study on perceptions regarding
the culture of patient safety, physicians generally shared a negative
outlook on the hospital leadership [2]. Other studies have reported
the need for an open forum and logical resolution process to
address communication difficulties [20] and systematic devices
such as conversations between nurses and residents [26], which
supported the findings of the present study. It is important to note
that the present participants faced difficulties when working with
new nurses and emphasized the need for support from experienced
nurses, from a human resources perspective.
In this study, the participants engaged in mutually comple-
mentary and beneficial communication with nurses owing to a
long-term learning process, striving to ensure patient safety. These
results were supported by other studies that revealed that physi-
cians trust nurses as partners in treatment [27] and that nurses
contribute practically to patient safety by providing patient infor-
mation and being a part of the treatment team [29]. Despite
working together in the same space, physicians and nurses have
 K.-O. Park et al. / Asian Nursing Research 12 (2018) 166e174
rarely been found to share common training processes [21]; for the
development of mutual understanding and trust, it is necessary to
provide education using mock situations, role play, and discussions
[25,28].
The present study found that the heavy workload and tradi-
tional culture of physicians’ authority complicate physicianenurse
communication, a finding that was similar to those of previous
studies. However, physicians in the present study revealed that
they learned that they needed to complement nurses for the sake of
patient safety and developed an appreciation for the empirical
importance of complementary cooperation.
There are some limitations to this study. The first is due to the
subjective nature of qualitative research as the researcher is the
investigative tool and analyses are a function of interpretations of
participants’ subjective experience. Second, participants may have
given socially desirable responses during the interviews. Finally,
the study was conducted at academic tertiary hospitals in the
metropolitan city areas of Korea, and the number of participants
was low and nonrepresentative. Thus, findings may differ at general
hospitals or at facilities in rural areas.
Implications for nursing practice
The outcomes of this study provided a positive outlook for
desirable relationships within health-care teams. The under-
standing of physician's viewpoint on the communication experi-
ence with nurses about patient's safety is expected to present a new
direction to ensure the safety of patients in the clinical nursing
field. Based on the study results, nurses' feedback to physicians
such as order filtering should be promoted to ensure patient safety,
facilitating atmosphere for open communication between health-
care staff implemented at the institutional level through strong
leadership. Furthermore, the findings of this study offer training
nurses and physicians together which helps to prevent the under-
valuing or misunderstanding of each discipline's contribution. This
study can be used in developing guidelines for effective commu-
nication between nurses and physicians.
Conclusion
This phenomenological study explored the experience of phy-
sicians’ communication with nurses related to patient safety. The
present results indicate that the points of significance in the
experience of communicating with nurses are as follows. In gen-
eral, physicians lacked an understanding about the roles and tasks
of nurses. However, they engaged in mutually complementary
communication with experienced and intelligent nurses, obtaining
desirable patient outcomes. The participants perceived clear
ordering and order filtering by nurses as a mechanism to ensure
patient safety; specifically, they emphasized that it was important
to engage in communication from an overall patient treatment
perspective using key clues for patient safety.
Thus, the importance and different forms of complementary
communication between physicians and nurses need to be
described and taught in depth using practical cases. In addition, the
level of communication ability differs among physicians and nurses
based on their work experience; therefore, they should attend ac-
tivities such as workshops or role plays in clinical practice.
Furthermore, communication between physicians and nurses ap-
pears to be critical for patient safety; however, it is not weighed as
such in the education due to its practical nature. Finally, the present
findings suggested that it is important for managers to act as pro-
active change agents to bring improvements in the communication
173
between physicians and nurses. Schools and hospitals should
implement educational strategies that combine work and
communication.
Funding
This article was supported by Bumsuk Academic Research Fund
in 2014.
Conflicts of interest
The authors declared no conflict of interest.
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