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BMJ Qual Saf. Author manuscript; available in PMC 2021 September 01.
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Published in final edited form as:

BMJ Qual Saf. 2021 September ; 30(9): 747–754. doi:10.1136/bmjqs-2020-011441.

Factors influencing physician responsiveness to nurse-initiated

communication: a qualitative study
Milisa Manojlovich1, Molly Harrod2, Timothy Hofer2,3, Megan Lafferty1, Michaella
McBratnie1, Sarah L Krein2
1School of Nursing, University of Michigan, Ann Arbor, Michigan, USA
2Centerfor Clinical Management Research, Department of Veterans Affair, Ann Arbor Healthcare
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System, Ann Arbor, Michigan, USA

3Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan,
USA

Abstract
Background—How quickly physicians respond to communications from bedside nurses is
important for the delivery of safe inpatient care. Delays in physician responsiveness can impede
care or contribute to patient harm. Understanding contributory factors to physician responsiveness
can provide insights to promote timely physician response, possibly improving communication
to ensure safe patient care. The purpose of this study was to describe the factors contributing
to physician responsiveness to text or numeric pages, telephone calls and face-to-face messages
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delivered by nurses on adult general care units.

Methods—Using a qualitative design, we collected data through observation, shadowing,

interviews and focus groups of bedside registered nurses and physicians who worked in four
hospitals in the Midwest USA. We analysed the data using inductive content analysis.

Results—A total of 155 physicians and nurses participated. Eighty-six nurses and 32 physicians
participated in focus groups or individual interviews; we shadowed 37 physicians and nurses
across all sites. Two major inter-related themes emerged, message and non-message related
factors. Message-related factors included the medium nurses used to convey messages, physician

Correspondence to: Dr Milisa Manojlovich, School of Nursing, University of Michigan, Ann Arbor, MI 48109, USA;
mmanojlo@umich.edu.
Contributors MM conceived the idea. MM, ML, SLK were involved in data collection. All authors were involved in data analysis and
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interpretation. MM drafted the article. All authors were involved in critical revision of the article and gave final approval of the version
to be published.
Twitter Milisa Manojlovich@mmanojlo and Sarah L Krein @Sarahlkrein
Competing interests TH, SLK and MM reports grants from the AHRQ during the conduct of the study. TH and SLK reports grants
from the Department of Veterans Affairs, Health Services Research & Development Service, during the conduct of the study.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited
(BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are
not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content
includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to
local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions
arising from translation and adaptation or otherwise.
 Manojlovich et al. Page 2

preference for notification via one communication medium over another and the clarity of the
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message, all of which could cause confusion and thus a delayed response. Non-message related
factors included trust and interpersonal relationships, and different perspectives between nurses
and physicians on the same clinical issue that affected perceptions of urgency, and contributed to
delays in responsiveness.

Conclusions—Physician responsiveness to communications from bedside nurses depends on a

complex combination of factors related to the message itself and non-message related factors. How
quickly physicians respond is a multifactorial phenomenon, and strategies to promote a timely
response within the context of a given situation must be directed to both groups.

INTRODUCTION
The importance of communication between physicians and nurses in relation to safe patient
care has been well described,1–3 and the literature provides many examples of how patients
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suffer when communication is inadequate.4–6 Communication has been studied in multiple

contexts7–9 and during specific activities such as patient care rounds.1011 Likewise, there
are many theoretical approaches to the study of communication, because the study of
communication evolved independently in many disciplines, so there are numerous theories
that could be applied.12 However, gaps in knowledge on how to improve communication and
prevent potential adverse outcomes for patients hospitalised on general care units remain.
Nurses are the 24-hour surveillance system for hospitalised patients and therefore are often
the first to detect early signs of patient deterioration.1314 How quickly physicians respond
to communications from bedside nurses about deterioration, for example, is important for
the delivery of safe, effective inpatient care. Indeed, delays in physician responsiveness
can impede care or contribute to patient harm,1516 but we still lack actionable information
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on factors contributing to delays. Thus, we took a practical approach to try to identify

actionable aspects of communication between nurses and physicians that might be more
amenable to intervention.

Factors currently cited in the literature as affecting physician responsiveness include

personal and interpersonal characteristics17 and differences in workflow patterns and
workloads.16 However, other factors could also play a role, and these have not been
explored adequately. Although face-to-face communication provides the greatest opportunity
for shared understanding of a situation, nurses and physicians are rarely together in the same
space and time, leaving them to rely on a variety of communication mediums (eg, electronic
health records, pagers and cell phones) that may affect how a message is understood and
acted on. For example, how an outgoing message is framed or ‘packaged’ by a nurse,18 how
the message is received by a physician who may be engaged in other activities at the time
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and the communication medium used to deliver a message could all influence how and when
a physician responds.

In a prior study, we described communication practices, work relationships and

communication technologies broadly and noted that physician responsiveness was a
particularly important concept.10 Thus, the specific purpose of the present study was to
describe the factors contributing to physician responsiveness to text or numeric pages,

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telephone calls and face-to-face messages delivered by nurses on adult general care units in
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four hospitals.

METHODS
Study design, site selection and data collection
This study used a descriptive qualitative design. Survey findings and telephone interviews
from the prior, broader investigation were used to identify and recruit sites, all in the
Midwest USA. More information about the methods for the prior study has been published
elsewhere.1019 Hospitals represented a mix of academic medical centres and community
hospitals of different sizes and included one site from the US Department of Veterans
Affairs health system. We collected data from physicians and nurses (ie, clinicians) who
worked on general care units at those sites. Clinicians were told that the purpose of
the study was to observe communication practices and work relationships. Two or three
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research assistants spent 2 weeks at each site. We deliberately chose the sequence of
our methods, beginning with general observation, to allow clinicians to acclimate to our
presence, progressing to shadowing individual clinicians and concluding with interviews
and focus groups. We adapted focus group and interview questions based on what research
assistants observed to develop a deeper understanding of our subject.20 As the focus of this
research was on clinicians, there was no patient or public involvement.

Through observation, we saw the ‘what’: communication activities among clinicians.

Observation sessions ranged from 2 to 4 hours in length. Each research assistant observed
for a total of 13–26 hours at each site. They observed on various days of the week
(including weekend days). Research assistants captured observations in unstructured field
notes. Immediately after each observation session, they compared field notes, augmented
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the data from each independent perspective and created a detailed summary focusing on
the main study objectives (ie, use of technology, work relationships and communication
practices). Through shadowing (ie, following a single individual for a set period of time),21
we understood ‘how’ clinicians communicated. In general, four to seven nurses and three
to six physicians were recruited for shadowing on each unit. Shadowing sessions each
lasted about 2 hours. Hand-written observation and shadowing notes were electronically
transcribed.

Focus groups and interviews helped answer ‘why’ certain patterns emerged. Focus groups
or individual interviews were conducted with physicians and nurses depending on their
availability. Our preference was to conduct focus groups, but if only one clinician (physician
or nurse) was available, research assistants conducted an interview. Physicians participated
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during their workday so focus groups lasted about 25 min on average. Nurse focus groups
occurred before or after scheduled shifts and were between 45 and 60 min in length.
Interviews and focus groups were conducted using a similar guide (see online supplemental
files 1 and 2), then were audio-recorded and transcribed verbatim by a proprietary service.
We achieved data saturation by using multiple data collection methods and spending
extended time in the field.

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Data analysis
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The entire data set (including field notes) was coded as part of the broader investigation
and analysed using inductive content analysis.22 Three authors (ML, MH and MM)
independently coded 20% of the same transcripts then met to compare codes. We created a
codebook using the process of consensus. During regular coding meetings, coded transcripts
were compared line by line, and through discussion, codes that most accurately reflected the
data were chosen. We documented codes and definitions in a codebook and the remaining
transcripts were divided and coded by individual team members. If we identified new codes,
they were added to the codebook, and previously coded transcripts were reanalysed. We
used NVivo to manage the data and create code reports.

Codes containing data relevant to the topic of physician responsiveness to nurses’ messages
included: interpersonal relationships, role responsibilities, experience level and shared
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understanding. All authors, who came from different disciplines: anthropology (ML, MH
and MMcB), medicine (TH) and nursing (SK and MM), participated in data analysis.
To promote reflexivity among team members during analysis meetings, we discussed our
insights, perceptions and potential biases to make sure they were accounted for in the
interpretation of data.23 This approach also brought a high level of trustworthiness or
credibility to our analysis.24 Two of the four sites invited us to present findings; those who
attended our presentations validated our results through member checking.25

RESULTS
Across all sites 155 physicians and nurses participated in shadowing, interviews and focus
groups (table 1).
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Two broad inter-related themes emerged that we characterised as message and non-message
related factors, and within each theme, we identified several factors as contributing to
physician responsiveness. Message-related factors that affected physician responsiveness
included the medium nurses used to convey messages, physician preference for notification
via one communication medium over another and the clarity of the message. Non-message
related factors included trust and interpersonal relationships and different perspectives
between nurses and physicians on the same clinical situation. We describe both message
and non-message related factors in detail below.

Message-related factors
The medium used to convey messages—The medium that nurses used to convey
messages affected the ability of physicians to respond in a timely way. The use of
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asynchronous mediums such as pagers and texts could result in longer response times, so
many nurses considered the nature of the issue when determining the type of medium to use.
One nurse told us,

I really don’t prefer the text paging because if there’s something that I’m really
concerned about and I page them…how much time do I give them?
(Registered nurse (RN) 3, site A, focus group (FG) 1)

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Physicians also recognised that the use of synchronous mediums enhanced responsiveness.
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During observation at site D we noted,

[The hospitalists] try to stay available in the dictation room so they can have f2f
[face-to-face] communication with nurses, which is easier and faster than through
phone calls.

Physician preference—Physicians expressed a variety of preferences for how they

wanted to be notified, and their preference affected responsiveness. In general, physicians
preferred not to get a page consisting only of a telephone number because the display of
numbers on a pager gave no indication of message content or urgency, so responses to
numeric pages were variable. One physician told us why he preferred not to get numeric
pages,

[I]f you’re in the middle of [something] and you just get a numeric page you’re like
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‘is this an emergency?… Should I return this page immediately?’ Most of the time
I do, just to make sure. And then, you leave the sick patient that you should be like
giving your full attention to return a page.
(Medical doctor (MD) 1, site C, interview)

However, nurses had to identify the preferred notification route for each physician, which
could take time and delay responsiveness. During one shadowing session at Site A, a nurse
presented the process to a research assistant:

RN1 shows me the process for paging MDs from the hospital intranet. During
business hours, RNs can search the hospital directory to find MDs within the
system. The phone numbers listed for MDs may be an office phone or hospital
phone (or even their personal cell phone); it varies by individual.
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Message clarity—The clarity of the message delivered by nurses to physicians was

frequently obscured by two factors: the tendency of many nurses to provide information
but not request that a specific action be taken and nurses’ use of indirect language
in communicating with physicians. Physicians looked for direct, succinct messages that
included a request for a specific action because it lessened the cognitive burden required to
figure out what was needed. One physician explained,

We need to know what people want from us, because we don’t have time to sit and
talk and figure out what that person needs.
(MD2, site B, interview)

Physicians often could not interpret what nurses were asking for because of nurses’ use
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of indirect language. Nurses confirmed their use of indirect language, which physicians
interpreted as not needing immediate action. One factor contributing to the use of indirect
language was nurse inexperience. One nurse said,

When I was a new nurse, I was like, ‘oh, if you could please, maybe, perhaps,’ and
they would say like ‘I’ll get to it when I get to it’….
(RN2, site B, FG5)

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Another contributing factor may have been differences in training, because nurses are
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trained to provide the context surrounding an issue that physicians may not have the time for
or appreciate.

During one shadowing session at site B, we were told,

In nursing school, I was trained that, when communicating with physicians,

first describe the patient’s identifiable information, then problem, finally give
suggestions. I did that in my practice. But I think physicians think that is stupid.
They wouldn’t listen.

Non-message related factors

Trust and interpersonal relationships—Trust between nurses and physicians affected
physician responsiveness and was the result of interpersonal relationships that developed
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over time. Interpersonal relationships were affected by the experience and skill levels of both
physicians and nurses, could be positive or negative, and affected responsiveness.

Two factors affected relationship quality, and relationship quality then affected the
medium used for communication, so that there was overlap between message and non­
message related factors. First, both nurses and physicians acknowledged that establishing
relationships and building trust took time. As one nurse said,

It gets better the longer [the physicians] are here. (RN1, Site D, focus group).
Because then they learn to trust us and realize that we know what we’re doing, said
another nurse during the same focus group (RN2).

One nurse quantified the time element and provided a rationale,

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… [I]t takes months to develop a relationship with someone. They have to see you
as competent.
(RN4, Site B, FG1)

Second, relationship quality was affected by the outcome of previous interactions, which
could be positive or negative. One physician noted that previous interactions with nurses
influenced his relationships with them and thus responsiveness, in effect intimating that
because of a poor relationship he might not respond as quickly even though a delay could be
harmful:

Like there’s some nurses that just page all the time about something and you are
like ‘this is not important.’ And maybe it is…
(MD1, site B, focus group)
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Once a relationship was established, nurses could better interpret physician’s lack of
responsiveness, because nurses recognised the lack of responsiveness as being outside of
physicians’ usual pattern of behaviour.

Once you know a doctor’s style you know this is pretty unusual that they didn’t get
ahold of me pretty quick.
(RN3, site A, FG1)

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For some physicians, the relationship with the nurse influenced the physician’s preferred
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route and timeliness of their response:

If it’s one of the nurses that has my direct number… I can just text them back an
answer. That’s only with nurses that I’m more familiar with.
(MD3, site A, interview)

Physicians described how nurse experience contributed to the development of trust. One
physician said, ‘You donť trust that many people…and [the ones you do trust are] almost
invariably people who have greater than 10 years of experience’ (MD1, site B, focus group).
According to another physician, ‘The nurses that have been around longer tend to…have
a lot more input and a lot more insight, which is really helpful’ (hospitalist1, site A,
interview). Having trust in nurses meant that the physician could act on the information
provided by the nurse without having to go to the bedside and see the patient, thereby
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improving responsiveness. As one physician noted, ‘There are sometimes when a nurse tells
you that the patient is sick, you don’t ask a question’ (site D, interview). In contrast, a lack
of trust in nurses could compel a physician to go to the bedside to see firsthand what was
happening.

And so… I know the ones that I don’t trust and if there is some kind of
questionable information… I’m going to the bedside… I need to see that for
myself… I can’t trust that everything’s okay or that everything’s going terribly…
(MD2, site B, focus group)

Both nurses and physicians believed that experience was important to responsiveness,
whether ‘experience’ referred to the number of years in training or in the organisation.
One nurse explained how contacting an inexperienced physician could cause a delay in
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responsiveness.

Some [physicians in training] say ‘I’ll talk to my attending.’ And then 30 minutes
later you’re like ‘hey, did you talk to your attending about this?’ And they’re like
‘no, I haven’t found him yet’.
(RN2, site B, FG)

Physicians were aware of their own lack of experience and its effect on responsiveness. As
one physician said,

[The intern] has less of an idea of what an emergency is than I do. I have less of an
idea of what an emergency is than an attending does.
(MD1, site B, focus group)
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A nurse recognised how responsiveness could be affected by experienced physicians who

were new to the organisation.

Providers that are new don’t manage their time as well, so they’re overwhelmed by
pages. They might not get back to you as quickly.
(RN1, site A, FG4)

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Different perspectives on the same clinical situation—Physicians and nurses had

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different perspectives on the same clinical situation that affected perceptions of what was
important or urgent and in turn could affect responsiveness. Nurses’ sense of urgency
derived in part from being with patients for longer periods of time than physicians. One
physician confirmed this saying, ‘they obviously spend a lot more time with the patients than
the physicians’ (MD2, site A, interview), while another physician from the same site said,
‘I’m seeing them for maybe 15, 20 minutes a day, you know?’. Nurses acknowledged that
their sense of urgency was not always based on objective clinical data but often on their
subjective knowledge of the patient. During a shadowing session at site B, a nurse clarified
differences in perspectives:

I asked her if she thinks RNs and physicians define ‘emergency’ differently, that is,
something a RN thinks is urgent may not be urgent to a physician. She said, ‘Oh,
yeah, definitely. I mean for something, like at 5 or 6 am, if a patient’s Potassium
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level is 3.6. It is not urgent. It can wait until day shift. But if a patient keeps asking
about a stool softener 4–5 times, it is urgent to me, because he wants it now’.

As a result of this difference in perspectives, when physicians did not respond to nurse
perceptions of urgency, some nurses activated the rapid response system that brought the
rapid response team (RRT) to the bedside. We heard from several nurses how they called the
RRT when physicians did not respond to their messages. As one nurse told us,
I ended up calling Rapid and everybody else because he [the physician] wasnť
giving me any help. And I donť know if it was because he was busy doing other
things and he didnť feel that it was as big of an issue as I felt it was.
(RN2, site B, FG3)

Some physicians described strategies for dealing with these differing perceptions and
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how they responded to a situation. One physician, in acknowledging the differences in

perceptions of urgency for the same situation, described a strategy he used to mitigate the
difference, saying

[W]hen they’re concerned about something that I may not be as concerned about or
there may be a conflict, I try to listen to them and get their viewpoint’.
(MD2, site A, interview)

Going to a patient’s bedside was another strategy that some physicians used and which
improved their ability to understand the nurse’s perspective, as in the story recounted by
one physician who did not believe what the nurse was telling him about a patient, ‘then I
witnessed what she was talking about. Something I never dealt with before’ (MD4, site D,
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interview).

DISCUSSION
Our results showed that physician responsiveness depended on a complex, inter-related
mix of message and non-message related factors. In terms of message-related factors, we
found that nurses and physicians were thoughtful when choosing communication mediums,
considering factors such as the situation and time allotted for response. However, messages

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themselves could still lack clarity and cause confusion, even when delivered via text or
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alphanumeric page. Our study demonstrates how physician responsiveness was associated
with trust and positive interpersonal relationships, which then influenced physicians’
preferred medium for response. Different perspectives on the same clinical situation led
to different perceptions of urgency and thus responsiveness in our study.

While our results demonstrate how different message and non-message related factors can
affect physician responsiveness, they also confirm findings from other studies demonstrating
that both the medium and the messages currently in use for communication purposes are
far from ideal. One study examined the content of alphanumeric pages sent to surgical
residents during a 3-month period, finding that a significant number lacked sufficient
information and did not indicate the urgency of the page.26 In another study where an
email system for communication was instituted, 50% of nurses’ requests for email response
went unanswered.27 By including non-message related factors and including a broader range
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of mediums, our study provides insights into why nurse requests for response may go
unanswered and why pager messages lack depth. Because of differences in training and
socialisation, nurses do not ‘speak’ the same language as physicians and communication
mediums may not translate nurses’ words into language physicians understand.2829

Previous investigations have also found a gap in perceived urgency between nurses and
physicians. In one, time-sensitive and contextual issues (such as angry family members)
were labelled ‘urgent’ by nurses but not by physicians,16 while in another almost half of
nurses’ pages that brought physicians to the bedside were for routine–not urgent—matters.30
In our study, the physician’s responsiveness to the situation depended on factors not
explored in previous research such as the relationship that the physician had with the nurse
and prior experience in responding to other situations that the nurse brought forward.
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For example, one potential consequence of the inability to bridge unique perspectives in our
study was that nurses called the RRT to the bedside. RRTs were developed as a mechanism
to address preventable adverse events,31–34 yet some nurses told us they called the RRT
to circumvent lack of physician responsiveness to nurse concerns. This unintended use of
the RRT is a new finding and represents a workaround to bypass poor interdisciplinary
communication with implications for patient safety.

Our findings provide further justification for the use of direct language by noting an
association between the use of indirect language and delays in physician responsiveness,
possibly posing a risk to patient safety. Nurses’ use of indirect language is not a new finding,
having previously been characterised as ‘hint and hope’,35 meaning that by hinting at what
they want from physicians (rather than making an explicit request), nurses hope to get
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what they are really asking for. There is a large emphasis in the literature on standardising
communication, achieved through the use of tools such as checklists36 and hand-offs.37 The
‘Situation, Background, Assessment, Recommendation’ (SBAR) tool is one example of such
a tool developed specifically to help improve communication.38 However, the effectiveness
of SBAR and other standardised communication tools has been variable.3940 When viewed
in light of our findings, a possible explanation emerges. While such tools do provide nurses

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with a structure for communicating with physicians, they do not address how to bridge the
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unique perspectives of separate groups of healthcare professionals.

We found that while physicians preferred information such as patients’ physiological

lparameters to determine how quickly they should respond, nurses’ sense of urgency did
not always derive from the same type of information. Others have found that nurses use
a limited amount of objective physiological data when deciding on a situation’s urgency41
despite the value of this type of information to physicians.18 Interestingly, our study showed
how once a physician had established a good relationship with and had trust in that
nurse, the nurse’s perspective, although different from the physician’s, was valued. This
finding suggests that different perspectives and the development of trust can be inter related
and provides added significance to the importance of establishing trust through positive
interpersonal relationships.
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Implications for practice include adopting strategies such as encouraging nurses to use
synchronous mediums such as face-to-face or telephonic communication for urgent matters
whenever possible, as we and others4243 have found that asynchronous mediums delay
responsiveness. Teaching nurses to use direct language29 and present quantifiable evidence
of deterioration to physicians18 is another strategy. ‘Numbers’ such as vital signs succinctly
describe deterioration and are unambiguous because they are not open to interpretation and
thus are valued by physicians.18 Finally, building relationships possibly through colocating
hospitalist physicians on dedicated units with nurses44 is another strategy with the potential
to improve responsiveness if for no other reason than the physicians are close at hand and
can respond quickly.

There are numerous strengths of this study. We conducted the study at multiple sites,
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used sequential qualitative methods and embedded ourselves for 2 weeks at a time at each
site. Multiple study team members representing various disciplines were involved in data
analysis, which helped to reduce bias; results were member-checked by two of our four sites.
In addition, including sites with various organisational, technological and communication
characteristics may make our findings transferable to similar contexts.

There are also several weaknesses. There may be selection bias because participating units
were chosen by hospital leadership. Our presence on study units may have contributed to a
Hawthorne effect, but our prolonged engagement at each site along with data analysis from
multiple sources likely minimised it.

CONCLUSIONS
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Physician responsiveness to communications from bedside nurses depends on a complex

combination of inter-related factors related to the message itself and non-message
related factors. How quickly physicians respond is a multifactorial phenomenon, and our
study suggests several avenues for intervention development that might help improve
responsiveness. Importantly, our study demonstrates that it is not enough to target only
one group of clinicians. To promote a response that is timely within the context of a given
situation interventions must be directed to both groups.

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Supplementary Material
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Refer to Web version on PubMed Central for supplementary material.

Funding
This project was supported by grant number R01HS022305 from the Agency for Healthcare Research and Quality
(AHRQ).

Data availability statement

Data are available on reasonable request. Deidentified participant data are available from the
first author on request.

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Table 1

Study participants by site

Site A Site B Site C Site D Total number of participants

Type of site 200-bed community hospital 600-bed university medical centre 100-bed VA hospital 600-bed community hospital
Manojlovich et al.

RN interview/ FG participants 24 33 18 11 86
RN shadowing 7 6 4 7 24
MD interview participants 3 10 14 5 32
MD shadowing 3 6 4 0 13
155

FG, focus group; MD, medical doctor; RN, registered nurse; VA, US Department of Veterans Affairs.

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