Collaboration between nurses and physicians in an Indonesian Emergency Department

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Australasian Emergency Nursing Journal (2016) xxx, xxx—xxx

Available online at www.sciencedirect.com

ScienceDirect journal homepage: www.elsevier.com/locate/aenj

RESEARCH PAPER

Collaboration between nurses and physicians in an Indonesian Emergency Department Suryanto, M.Nurs a,b,∗ Virginia Plummer, RN, PhD c Beverley Copnell, RN, PhD a a

School of Nursing and Midwifery, Monash University, Australia School of Nursing, Brawijaya University, Indonesia c School of Nursing and Midwifery and Peninsula Health, Monash University, Australia b

Received 7 September 2015; received in revised form 4 April 2016; accepted 6 April 2016

KEYWORDS Nurses; Physicians; Collaboration; Emergency; Attitudes; Indonesia

Summary Background: Positive collaboration between nurses and physicians is essential in emergency practice because it has a significant relationship with the quality, safety, accountability, and responsibility of care. The aim of this study was to examine nurses’ and physicians’ attitudes towards collaboration in the Emergency Department in the Indonesian context. Methods: The study was a comparative study using a modified Jefferson Scale of Attitude towards Physician—Nurse Collaboration. Data were collected from 47 nurses and 24 physicians of one of 25 general hospitals in Malang, Indonesia, by anonymous survey. Results: Emergency nurses had significantly more positive attitudes towards collaboration than emergency physicians (P < 0.001). Emergency nurses had significantly higher scores in three of four domains of the instrument, ‘‘physician dominance’’, ‘‘nurse autonomy’’, and ‘‘caring as opposed to curing’’. The effects of gender, age, and education on nurses’ and physicians’ attitude towards collaboration were not statistically significant. However, experience in the Emergency Department of the general hospital was significantly related to participants’ attitudes towards collaboration (P = 0.023).

∗ Corresponding author at: School of Nursing and Midwifery, Monash University, Australia; School of Nursing, Brawijaya University, Indonesia. Tel.: +61 404194751; +62 81252239373; fax: +61 399044655; +62 341564755. E-mail addresses: [email protected], [email protected] ( Suryanto).

http://dx.doi.org/10.1016/j.aenj.2016.04.001 1574-6267/© 2016 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.

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Suryanto et al. Conclusions: The findings of this study indicate that attitudes towards collaboration among the two professions should be enhanced. Inter-professional education and promotion of teamwork may be solutions to improve the relationship, not only between nurses and physicians, but also other healthcare providers. © 2016 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.

What is known/What this paper adds? There is little published information related to the nurse—physician relationship and collaboration in emergency departments. Most studies have explored nurse—physician collaboration in medical—surgical care settings and intensive care settings. Thus, the results of this study, undertaken in an emergency department in Indonesia, are likely to inform understanding of nurse—physician collaboration in the emergency care setting, especially in Indonesia. Nurses and physicians in emergency departments need to endeavour to build a collaborative relationship, since their professional cultures, including power and status, are different. These differences can lead to conflicts between nurses and physicians when they do not concur on a patient’s care plan due to imbalance in authority. Therefore, close collaboration and positive nurse—physician relationships are essential elements of the patient care and the teamwork environment, resulting in improved patient care and provision of satisfying work roles.

Introduction The health care system has changed rapidly throughout the last decade and this has increased the complexity of the nursing work environment.1,2 This complexity can be characterised by ambiguity, changeability, unsteadiness and incoherence.3 These changes have implications and challenges for the nurse—physician relationship.3 Close collaboration and positive nurse—physician relationships are essential elements of the patient care and the teamwork environment, resulting in improved patient care and provision of satisfying work roles.1,4—6 Nurse—physician collaboration has a positive link with both actual and expected length of stay7 and is associated positively with nurses’ satisfaction.8,9 Nurses and physicians in Emergency Departments (EDs) need to endeavour to build a collaborative relationship, since their professional cultures, including power and status, are different.10,11 These differences can lead to conflicts between nurses and physicians when they do not concur on a patient’s care plan.10 The conflict might be caused by imbalance in authority, which Casanova et al.11 attribute to differences in the focus of the two roles. A study by Kramer and Schmalenberg5 found that power dominant culture was the leading factor influencing nurse—physician

relationships. It is suggested that collegial relationships between two professions create a professional culture that values, respects and rewards.5 Providing emergency care is challenging worldwide; this is because health care providers in EDs often face tense situations due to the critical nature of patient conditions. In Indonesia, the care is further challenged by insufficient stabilisation and care during transportation from the scene to EDs due to an unorganised Emergency Medical Services (EMS) system in the country.12 There is no system of ambulance services or patient retrieval in Indonesia.12,13 Furthermore, as Indonesia is located along the Pacific Ring of Fire and sandwiched between three continental plates, Indonesia is more likely to have natural disasters and mass casualty presentations than most other countries,14 and for which hospital EDs should be prepared. The annual report of Centre for Research on the Epidemiology of Disasters (CRED) reports that Indonesia is the sixth top country worldwide for frequency of natural disasters in 2014.15 In both large scale disasters and the typical emergency scenarios, a good nurse—physician collaborative relationship is essential, as it can enhance the quality and safety of patient care10,16 and job satisfaction.17,18 A study by Rosenstein17 shows that disruptive physician behaviour causes a disturbing and stressful force in the workplace. Most studies have explored nurse—physician collaboration in medical—surgical care settings2,10,19,20 and intensive care settings.8,9,21—23 A collaboration study by Hansson et al.24 involved physicians and nurses from various health centres in the study area. However, there is little published information related to the nurse—physician relationship and collaboration in EDs.25,26 The results of this study are likely to inform understanding of nurse—physician collaboration in the emergency care setting in Indonesia. The aim of this study was to compare nurses’ and physicians’ attitudes towards nurse—physician collaboration in an ED of general hospital, Malang, Indonesia. The term collaboration in this study refers to co-operative teamwork by two professions in all patient care areas in the emergency care settings.

Material and methods Design This study is a quantitative study comparing the attitudes of nurses and physicians regarding collaborative relationships. Nurses and physicians from a hospital ED were recruited to voluntarily participate in the study.

Please cite this article in press as: Suryanto, et al. Collaboration between nurses and physicians in an Indonesian Emergency Department. Australas Emerg Nurs J (2016), http://dx.doi.org/10.1016/j.aenj.2016.04.001

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Setting This study was conducted in one of 25 general hospitals in the area of Malang, East Java, Indonesia. The hospital was chosen because it is the largest public teaching hospital in the area with more than 900 bed capacity owned by the East Java Provincial Government and is a referral hospital for lower level hospitals in Malang and the surrounding area.27 In 2014, there were 29,891 patients admitted to the ED of the hospital.27 Almost half of them (49.7%) were trauma cases.28 Unfortunately, only 11% of the ED patients were transported using ambulances and majority of them were transported by other vehicles.28

Instrument The Jefferson Scale of Attitudes towards Physician—Nurse Collaboration29 was used to measure the attitudes of both nurses and physicians regarding collaboration. Cronbach’s alpha was used to test the reliability of the instrument (0.85), and content validity and construct validity were assessed to measure the validity of the instrument of the instrument.29 The questionnaire was originally developed by researchers at Jefferson Medical College of Philadelphia in Pennsylvania, U.S.A. The instrument is used to measure the attitudes of both nurses and physicians regarding collaboration.29,30 Several studies have utilised the instrument effectively in clinically-based studies including anaesthesia wards, medical—surgical wards, and perioperative settings.2,10,20,24,31 The original questionnaire consisted of 15 questions answered using a four-point Likert-type scale ‘‘strongly agree’’ to ‘‘strongly disagree’’. Four underlying factors that influence attitudes towards physician and nurse collaboration were used to develop the instrument, ‘‘physician’s dominance’’ (question 9 and 11), ‘‘nurse autonomy’’ (question 5, 12, and 14), ‘‘shared education and teamwork’’ (question 1, 3, 6, 10, 13, 15, and 16), ‘‘caring as opposed to curing’’ (question 2, 4, 7, and 8). Based on consultation with experts on healthcare provider collaboration, the researcher found that question 7, which is ‘‘Nurses have special expertise in patient education and psychological counselling’’, has two different main points (patient education and psychological counselling). Therefore, it was divided into two different questions, 7 and 8. Thus, the questionnaire utilised consisted of 16 questions.

Research ethics statement This study was conducted according to the National Statement on Ethical Conduct in Human Research of Australia. The ethical approval was granted from the local University Human Research Ethics Committee (MUHREC) in Australia with Project Number CF09/3384 — 2009001810. However, since the data collection was to be conducted in Indonesia, the Education and Research Department of the hospital asked the researcher to obtain ethical approval from one of the Indonesian Ethical Committee Boards. This was because ethical boards from different countries may have different approaches to decide ethical approval due to different cultural issues. Therefore, the researcher also obtained

3 ethical approval from a local University Ethical Committee. After the researcher presented the study proposal to the local University Human Research Ethics Committee ethical approved was obtained (Project Number 043/EC/KEPK-S2IK/02/2010).

Participants Convenience sampling was used in this study. While convenience sampling technique is believed to increase the risk of sample bias due to time and cost constraints this sampling method was selected. All nurses and physicians in an ED of general hospital, Malang, Indonesia were invited to participate in the study. The study population was 51 nurses and 31 physicians. There is no data shows the number of ED nurses and physicians in Malang, but the total number of nurses and physicians in all health services in area. The general hospital involved in this study is part of health services in Malang City. The data from the Health Department of East Java Province reports that there were 1540 nurses, 123 general practitioners, and 202 specialist doctors working in Malang City hospitals.32 However, these numbers were total numbers of nurses and physicians work in Malang City hospitals, there are 25 hospitals in the area.33 However, data that reports specific numbers of health care providers working in EDs in Malang City is unavailable. The study inclusion criteria for participating are: (1) Indonesian nationality, (2) minimum qualification of Vocational School of Nursing Degree for nurses, (3) minimum general practitioner for physicians, and (4) currently working in ED. Since this study involved an Indonesian emergency care setting, only Indonesian nurses and physicians were included in this study, because culture may influence attitudes and it was important to minimise extraneous variables.

Data collection After the researcher obtained permission to collect data by anonymous survey from the hospital Director, the researcher had a meeting with the Director of the ED of the hospital in order to explain the study. The researcher then met with the Nurse Manager and the Director of the medical team in order to discuss the data collection method. As suggested by the Director of ED, due to the difficulty to provide the information about the study to all ED nurses, nurse coordinators distributed the questionnaires to nurse participants along with the explanatory statement and researcher’s contact number. Nurses who were interested in the study completed the survey and inserted the completed questionnaire into sealed envelopes to maintain confidentiality. The sealed envelopes then were given to the nurse coordinators. The researcher planned to collect the completed questionnaires from nurse coordinators after two weeks. In order to minimise any feeling of pressure or coercion among ED nurses due to data collection by nurse coordinators, the researcher provided the study information regarding the voluntary nature of participation on the explanatory statement. For physician participants, the researcher distributed the questionnaire during the ‘‘Medical Reports’’ meeting. To

Please cite this article in press as: Suryanto, et al. Collaboration between nurses and physicians in an Indonesian Emergency Department. Australas Emerg Nurs J (2016), http://dx.doi.org/10.1016/j.aenj.2016.04.001

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facilitate the return of the questionnaire, the researcher provided a sealed box in a medical common room, and the physician participants placed the completed questionnaires into the box. The questionnaires were collected from the box two weeks after distribution.

Data management and analysis The questionnaire consists of two parts, the demographic data section and the survey. Gender, age, highest education, and experience in EDs were investigated in the first section of the questionnaire. For analysis purposes, participants’ age was divided into two categories, less and more than 40 years old. Participants’ experience in EDs was divided into two types, experience in ED of the hospital involved in the study and experience in EDs of other hospitals. For analysis purposes, the participants’ experience in ED was divided into two groups, less and more than 10 years. Part 2 of the questionnaire consisted of 16 questions and options were a four-point Likert-type scale on which ‘‘strongly agree’’ is marked 4, ‘‘tend to agree’’ 3, ‘‘tend to disagree’’ 2, and ‘‘strongly disagree’’ 1. Interpreting the scores was undertaken by adding the score from each question and the maximum score was 64 and the minimum score was 16. There are different scoring methods for each type of question. The lower the total score on the ‘‘physician’s dominance’’ questions, the higher the factor score. This means that the higher the score on this scale, the more positive is the respondent’s attitude regarding collaboration. A greater degree of agreement with nurses’ participation in decision about patient care is indicated by a high score on the ‘‘nurse autonomy’’ questions. Similarly, the higher the score on the ‘‘shared education and teamwork’’ questions, the higher the orientation regarding interdisciplinary education and inter-professional collaboration. Last, a more positive perception of nurses’ contributions to psychosocial and educational aspects of patient care is manifested in a high score on the ‘‘caring as opposed to curing’’ questions. The higher the scores, the more positive attitudes towards collaboration. Since the study was implemented in Indonesia, the instrument was translated into Bahasa Indonesia by a professional translator. Descriptive statistics and parametric and non-parametric inferential statistics were used in this study. Descriptive statistics were used to present the demographic data of the participants including means and standard deviations (SDs). The inferential statistics were used to measure the differences of two groups based on demographic data and four underlying factors of the questionnaire. Several tests were used in this study including the two-tailed t test, the Fisher’s Exact test, one-way ANOVA, Mann—Whitney, Univariate Analysis of Variance, and the Kolmogorov Smirnov test. Significance was set at 0.05 for all statistical tests. Data were analysed by using the Statistical Package for the Social Sciences (SPSS).

Results Ninety-two percent (n = 47) of the emergency nurses and 77% (n = 24) of the emergency physicians returned the

questionnaire. Several participants, both nurses and physicians, did not complete the demographic data in the questionnaire. Eight participants (11.3%) did not mention their gender, two participants (2.8%) did not mention their age, one respondent (1.4%) did not mention their highest education, and 31 participants (43.7%) did not mention their length of working experience. Also, three nurses (4.2%) did not complete part two of the questionnaire. All incomplete questionnaires were used in the analysis as less than 5% of data were missing.

Demographic characteristics Table 1 reports the difference in frequencies between data provided by emergency nurses and emergency physicians regarding gender, age, education, and experience. Nurses were older than physicians, with 36% of nurses in the age groups over 40 years of age, compared with 16.7% of physicians. Duration of experience in the ED among nurse participants were more varied compared to physician participants. Overall, nurses had worked for longer in the department. However, the physicians group had more experience working in other EDs.

The comparison of nurses’ and physicians’ attitude towards nurse—physician collaboration This study shows that emergency nurses had higher scores compared to emergency physicians, the mean scores were 55.3 (42—64) and 50.5 (44—59) respectively. Also, the maximum score of emergency nurses was 64 while the maximum score for emergency physicians was 59. The demographic differences between nurses’ and physicians’ attitudes towards collaboration is reported in Table 2. As the comparison was based on the mean scores of the two groups, the higher the score, the more positive their attitudes. The relationship between years of experience and collaboration was explored. The difference of collaboration score based on years of experience was significant if doctors and nurses were combined into one group of participants. The mean score for participants with less than 10 years’ experience was 52.3 and the mean score for participants with more than 10 years’ experience was 54.7. The data analysis shows that participants’ experience in the Emergency Department of the hospital in this study had a significant influence on attitudes towards collaboration (P = 0.023, df = 1, F = 5.404). This result shows that the more experienced participants in the Emergency Department of the general hospital are, the more positive their attitudes towards collaboration. The results can be seen in Table 3. This study shows that there was a significant difference between emergency nurses’ and emergency physicians’ attitudes towards nurse—physician collaboration (nurses’ mean score 55.3 ± 4.5, physicians’ mean score 50.5 ± 4.6, t = 4.100, P < 0.001), which means that the emergency nurses had more positive attitudes towards collaboration than the emergency physicians. This result can be seen in Table 4. The difference between the two groups based on four underlying factors of the questionnaire was investigated (Table 5). On analysis of factors the mean scores of the emergency nurses were higher in all four fundamental factors of

Please cite this article in press as: Suryanto, et al. Collaboration between nurses and physicians in an Indonesian Emergency Department. Australas Emerg Nurs J (2016), http://dx.doi.org/10.1016/j.aenj.2016.04.001

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5

Demographic data of participants.

Characteristics

Nurses

Physicians

Differences

12 (50%) 9 (38%) 3 (12%)

P = 0.185a

Gender

Male Female Not mentioned

16 (34%) 26 (55%) 5 (11%)

Age

21—25 years 26—30 years 31—35 years 36—40 years 41—45 years 46—50 years 51—55 years Not mentioned

3 6 10 11 3 8 6 0

Educational background

Vocational School of Nursing Diploma in Nursing Bachelor of Nursing Not mentioned General Practitioner Emergency Medicine Specialist

10 29 7 1

Experience in ED of the general hospital

0—1 year 1—5 years 6—10 years 11—15 years 16—20 years >20 years Not mentioned

4 5 6 14 10 7 1

0 2 18 1 3 0 0

P = 0.000a

Experience in ED of other hospitals

0—1 year 1—5 years 6—10 years 11—15 years 16—20 years >20 years Not mentioned

6 5 1 3 5 0 27

4 1 0 0 0 16 3

P = 0.020a

a

P = 0.022a

1 7 8 4 0 1 1 2

N/A

15 9

Tested using Fisher’s Exact Test.

Table 2

Mean scores based on demographic characteristics.

Demographic data

Nurses

Physicians

Mean score

n

Mean score

n

Gender

Male Female

56.00 53.50

16 26

50.33 50.22

12 9

Age

Less than 40 years old More than 40 years old

55.97 53.12

30 17

50.35 54.00

20 2

Education

Vocational School of Nursing Diploma III in Nursing Bachelor Science of Nursing General Practitioner Emergency Medicine Specialist

55.00 54.45 57.43 N/A

10 29 7

N/A

Experience in ED of the general hospital Malang

Less than 10 years More than 10 years

54.87 55.10

Experience in EDs of other hospitals

Less than 10 years More than 10 years

53.67 53.88

51.27 49.22

15 9

15 31

50.48 50.67

21 3

12 8

50.67 56.00

19 1

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Suryanto et al. Table 3

Demographic data and participants’ attitudes towards collaboration.

Factors

P value Nurses

a c

The difference in attitudes towards collaboration between nurses and physicians.

Total Jefferson Scale

Emergency nurses (mean ± SD, n = 47)

Emergency physicians (mean ± SD, n = 24)

T

df

Pa

55.3 ± 4.5

50.5 ± 4.6

4.100

45.668

0.000

Data were tested using t-test for independent sample (2-tailed) test.

Table 5

The difference based on four underlying factors.

Underlying factors

Value

Pa

Physician dominance Nurse autonomy Shared education and teamwork Caring as opposed to curing

13.415 21.747 5.731 21.470

0.022 0.001 0.197 0.005

a

0.683c 0.796c N/A 0.023c 0.177c

0.958 0.313a 0.252b 0.965b 0.192b

Data were tested using One-Way ANOVA. Data were tested using Mann—Whitney test. Data were tested using Univariate Analysis of Variance.

Table 4

a

All participants

a

0.211 0.213a 0.205a 0.638a 0.980a

Gender Age Education Experience in the general hospital Experience in other hospitals b

Physicians

a

Data were tested using Fisher’s Exact test.

collaboration than the emergency physicians. Both scores were highest in shared education and teamwork and lowest in caring as opposed to curing. It can be seen from Table 5 that there were significant differences in answering the questions on the three other underlying factors, ‘‘physician dominance’’ (nurses’ mean score 6.11, physicians’ mean score 4.71, P = 0.022), ‘‘nurse autonomy’’ (nurses’ mean score 11.11, physicians’ mean score 10.63, P < 0.001), and ‘‘caring as opposed to curing’’ factor (nurses’ mean score 6.11, physicians’ mean score 4.71, P = 0.005).

Discussion The mean score on the Jefferson Scale in Attitude towards Physician—Nurse Collaboration of the emergency nurses was higher than the mean score of the emergency physicians, which indicates that the emergency nurses have a significantly more positive attitude towards collaboration than the emergency physicians. These findings are consistent with previous studies which have also found that nurses have a more positive attitude towards collaboration than physicians.2,10,31 Compared to the emergency physicians, the emergency nurses in the present study had a significantly more positive attitude towards three of the four underlying factors of collaboration: ‘‘physician dominance’’, ‘‘nurse

autonomy’’ and ‘‘caring as opposed to curing’’. However, both groups have shared ideas in relation to the ‘‘shared education and teamwork’’ factor. These findings differ slightly from previous studies2,10 which found that nurses had higher scores than physicians in all four underlying factors. The findings of this study may indicate that emergency physicians still hold traditional views of collaboration, which see the physician as the primary authority in patient care decisions. Sterchi10 argues that physicians have traditional emphasis on expertise, autonomy, and responsibility; while nurses have more emphasis on hierarchy and bureaucracy. This traditional view suggests that physicians were ‘in charge’ and nurses follow physicians’ lead.10 However, since both groups had similar responses on the ‘‘shared education and teamwork’’ factor, this may indicate that the two groups comprehend the importance of working and learning together. This may be a result of the health education system shifting in Indonesia. During the last decades, the interprofessional education (IPE) has been implemented for health-related students including medical, nursing, and pharmacy students in Indonesia.34 It is believed that IPE may enhance teamwork among healthcare workers and improve communication gaps.34 In Malang, the area of this study, for example, one of the leading universities in the area has emphasised the importance of respect for other professions and collegial relationships among health students in the medical, nursing, dentistry, and nutrition fields. Even though there is no shared education programme among them, collegial activities have been encouraged for all students from the first year, including communal orientation programmes, joint student organisations, and informal student activities. Thus, because collegial activities have been established during their studies, nurses and physicians have opportunities to develop common ideas regarding ‘‘shared education and teamwork’’. These collegial activities might also be applied in other universities and may become the beginning of interprofessional education for health students in Indonesia.

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Nurses physicians collaboration Age and experience gaps may influence the different attitudes towards collaboration between emergency nurses and emergency physicians. This study shows that there are significant differences in age and experience between both groups. The nurses are generally older than the physicians. Since 31 (66%) emergency nurses involved in the study have worked there for more than ten years, they may have adapted to every situation and condition in their work place. Therefore, the emergency nurses’ mean score was higher than the emergency physicians. This study indicates that the male nurses have more positive attitudes than the female nurses, 56 and 53.5 respectively. The results are consistent with previous studies.10,31 This study also shows that emergency nurses who graduated with a Bachelor of Science of Nursing have the highest scores. This may indicate that the more educated the nurses are, the more positive their attitudes towards collaboration. This result is consistent with findings of Nelson et al.19 Similarly, the study indicates that younger nurses had more positive attitudes. Higher education may influence these results as the majority of nurse participants were diploma qualified nursing graduates. At the moment, there is no longer a Vocational School of Nursing (equivalent to year 10—12) in Indonesia but professional nursing education programmes which are established in colleges and universities. Therefore, since newly qualified nurses are educated in professional education centres they may be familiar with the importance of collegial relationship among health care providers. This may account for the more positive attitude towards collaboration. These results are consistent with previous studies which indicate that the more educated the nurses are, the more positive their attitudes towards collaboration.19 Previous studies reported that specialist doctors and physicians working in specialty areas had a significantly more positive attitude compared to general practitioners and physicians working in general wards.19,23 Interestingly, based on a raw data of this study, it demonstrates that the emergency medicine specialist physicians involved in this study had less positive attitudes than the general practitioners. The emergency medicine specialist physicians may have lower scores in attitudes towards collaboration because they have more knowledge and skills regarding emergency patient care. Thus, their dependence and networking in practice with other health care providers might not be as high as general practitioners. As previous studies have shown that good nurse—physician collaboration plays an essential part in enhancing patient care quality, particularly in patient safety10,16 and job satisfaction,17,18 this attitude gap should be improved. Nursing and medical education institutions have significant roles in emphasising the importance of nurse—physician collaboration. Health care providers’ attitudes are developed during their study. Thus, if collaboration can be accentuated during their study, more positive attitudes of nurses, physicians, and other health care providers to collaboration may emerge. The concept of inter-professional education may be the answer in these circumstances. Inter-professional education has spread significantly over the past decade,35 and it has been suggested that inter-professional education may improve professional

7 relationships and patient outcomes.36 A study has shown that a ‘‘workshop model’’ of inter-professional education improved students’ attitudes towards inter-professional teamwork where they could learn about the roles of different health professionals.36 This study has several limitations. This study used a nonrandom convenience sample with a small sample size which may lead to sample bias and the risk of Type 1 error. However, the response rate of this study was good, at 92% and 77% for emergency nurses and emergency physicians respectively indicating that clinicians in this study want to participate in research on these topics and have their opinions counted. Another limitation is this is a single site study, thus, the findings of this study may not represent all ED settings. Also, the culture of the community and organisational socialisation may create specific results of this study. The other limitation is the imbalanced proportion of nurse and physician participants which may influence the findings. The imbalance proportion of participants may impact the generalisation of the findings of this study. Due to time constraint, the modified questionnaire used in this study was not tested for reliability and validity which may influence the findings.

Conclusion This study shows that the emergency nurses at this hospital have a statistically significant more positive attitude to collaboration than the emergency physicians. The emergency nurses had significant higher scores in three of the four underlying factors on the Jefferson Scale of Attitude towards Physician—Nurse Collaboration. Both the emergency nurses and the emergency physicians had a common response to the ‘‘shared education and teamwork’’ factor which may indicate that both groups of participants realise the importance of teamwork and learning together. This study also shows that experience has a significant influence on participants’ attitudes towards collaboration. Those with the most ED experience may be more at ease with ED work environment which tended to generate more positive attitudes among them. The creation of opportunities for interprofessional collaboration by employers, education organisations and individuals is recommended. Drawing on the findings of this study, it would be fitting that those with most experience in ED, lead inter-professional programmes of collaboration and mentorship for those with less experience. Future studies should also investigate the correlation between nurse—physician collaboration and patient outcomes and organisational outcomes in Indonesian EDs. The inclusion of a qualitative approach would provide an opportunity for the voices of the health professionals to be heard.

Authorship All authors have participated in the study, been involved in compilation of the manuscript, and have read and approved the submitted version of the manuscript. SS, VP and BC designed the study. SS develop the study protocol. VP and BC refined the study protocol. SS collected the data. VP and BC supervised data collection. SS, VP and

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BC analysed the data. SS, VP and BC prepared and approved the manuscript.

Provenance and conflict of interest The authors declare that there is no competing interest either financial or non-financial for the paper. This paper was not commissioned.

Funding The authors declare that there is no funding support for the paper.

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Please cite this article in press as: Suryanto, et al. Collaboration between nurses and physicians in an Indonesian Emergency Department. Australas Emerg Nurs J (2016), http://dx.doi.org/10.1016/j.aenj.2016.04.001