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From anticipation to confidence: A descriptive qualitative study of new graduate nurse communication with physicians

Abstract Aim The aim of this study was to understand how new graduate nurses experience communication with physicians. Background Communication is necessary for high‐quality health care delivery. With poor patient outcomes as a driving force, knowledge of the dialogue that occurs between new graduate nurses and physicians has been rarely explored. Methods This qualitative descriptive study involved 13 new graduate nurses from an academic teaching hospital in the south‐eastern United States. Data for this study were collected using face‐to‐face and virtual interviews with a focus on having nurses describe their experience communication with physicians in their current practice. Results Analysis led to four themes that describe new graduate nurses experience communicating with physicians. Those themes were gaps in preparation, developing confidence, learning to communicate, and interprofessional care. Conclusions Effective communication with physicians is a stressor for new graduate nurses as they transition to practice. For these nurses, negative emotions in their anticipation of communicating with physicians were developed during their educational experience. Implications for Nursing Management The findings of this study emphasize the importance of enhanced interprofessional training in education and practice that facilitate effective communication between the two professions in the practice environment.

adverse events occur, the results may be death, or permanent harm.
With poor patient outcomes as a driving force, and a persistent interest in nurse physician communication, significant improvements have not been made in improving the dialogue that occurs between nurses and physicians. The research portfolio of nurse-physician communication is not lacking in interventions that are narrow in scope and only applicable to specific contexts (Wang et al., 2018), but there is a lack of research investigating the experience of each discipline communicating with each other. An even larger gap in the literature is an understanding of how new graduate nurses perceive communication with physicians.
The new graduate nurse transition to practice is a highly researched field. Although numerous studies have discussed new graduate nurse and physician communication (Fink et al., 2008;Missen et al., 2016;Song & McCreary, 2020;Theisen & Sandau, 2013), they have focused on the new graduate's broad experience in the transition from student nurse to the health care environment. Much of this research has not specifically investigated how new graduates experience communication with physicians. Chandler's (2012) focus on the knowledge, relationships, skills, and attitudes in the first year of practice found new graduate nurse's experience "blurring" (p. 106) of roles on the interprofessional team. Deppoliti's (2008) qualitative focus on the new graduate's construction of professional identity discovered negotiations for power and authority occurred between nurses and physicians. Nurses that experienced disrespectful behaviour from physicians found ways to cope with this behaviour through increasing knowledge, experience, and observing other nurses (Deppoliti, 2008). Pfaff et al.'s (2014) focus on new graduate nurse confidence provides insight into the factors that challenge and facilitate confidence, such as respect, experience, difficult communication, and lack of experience, to engage in interprofessional collaboration. While these findings are important in understanding the new graduate's intent to participate in the interprofessional relationship, these studies do not differentiate the barriers between roles on the interprofessional team or provide a specific explanation of the new graduate's experience. A renewed focus on their experience will provide a better understanding of communication between new graduate nurses and physicians.
Elicited by a single open-ended question asking for difficulties in transitioning from student nurse, a seminal study by Casey et al. (2004) found that communication with physicians is difficult for new graduate nurses. A secondary analysis of qualitative data collected using the Casey-Fink Graduate Nurse Experience Survey also found concerns among new graduates related to their assertiveness with physicians (Fink et al., 2008). Analysis of this open-ended question provides some insight into the difficulties of new graduate nurses, but the ability to understand the depth of the experience of new graduate nurses communicating with physicians is lacking. Therefore, the purpose of this study is to understand how new graduate nurses experience communication with physicians.

| Design and sample
This study uses a qualitative descriptive design to understand the perspective of new graduate nurses' communication with resident physicians. Fourteen new graduate nurses agreed to take part in this research, nine females and four males. Participants were recruited through email campaign. Participants were included in the study if they had less than 2 years' experience as a nurse and worked in a setting where communication with resident physicians occurred daily.
The experience of participants ranged from 7 to 24 months. Ten nurses were employed on adult medical-surgical units, and four were employed in paediatric units.

| Data collection
This study received IRB approval before participant recruitment. Data for this study were gathered in the form of virtual or face-to-face interviews. The authors interviewed each participant as a facultystudent dyad. The lead author has experience in qualitative interviewing and analysis. The student team member received training on interview technique prior to participating in this study. Virtual interviews were conducted due to a modification in the study protocol due to social distancing guidelines as a result of the COVID-19 global pandemic. The researchers used semi-structured interview technique and began each interview with the over-arching question of "Tell me about your experience communicating with physicians in your current practice?" Probing questions were asked for clarification and further investigation of participant responses. All interviews were audiorecorded and transcribed verbatim. Consecutive interviews were scheduled with ample time between to ensure participants were not cross-exposed. Data collection and analysis occurred concurrently.
Repeated themes were evident after 12 interviews were completed.
The research team continued with two additional interviews to ensure data saturation.

| Trustworthiness
Two hours were allocated for interviews to ensure that participants were given as much time as needed to discuss their experiences communicating with physicians. The researcher ensured confidentiality of the participants to facilitate trust between the researcher and participant. Participants were informed that records of their experiences would remain in the possession of the researchers. Transcribed interviews were de-identified. Transcriptions were read multiple times to prolong engagement with the data.
Triangulation can also be achieved during the analysis of qualitative data. Having multiple researchers analyse qualitative data allows for the similarities and differences in findings to be investigated further. Each member of the research team analysed data independently.
Regular meetings between the research team were scheduled to review findings and validate themes. Discrepancies were resolved by collectively returning to the raw transcripts that composed each theme and ensuring themes remained grounded in the participant data.

| Data analysis
Transcribed interviews were read multiple times prior to analysis. The overarching question was clearly delineated and reviewed during the analysis. With a clear understanding of the research questions, transcribed interviews were analysed line by line. Once line-by-line analysis and thematic extraction were completed, the researcher began to group themes into categories and continued until no further categories could be created.
Patterns and connections, within and between, categories were identified next. The data collected for this research were focused and analysed individually and by groups according to gender and years of experience. The data were also analysed for themes, key ideas, similarities, and differences in responses. Once categories were delineated within the data, the researcher compared responses between participants on similar themes. The researcher also analysed the data for relative importance of categories. The categories developed in this study were tallied and ordered to show importance. Finally, the data were interpreted for meaning and significance. Once data were analysed and triangulated by colleagues, the researcher took time to reflect on the analysis. Notes taken during analysis were reviewed prior to interpretation. Interpretation was completed with constant awareness and reflection on the purpose of this research.

| RESULTS
This study provides a beginning understanding of how novice nurses experience communication with physicians. Initial coding revealed 15 concepts from the transcribed interviews. Further analysis led to the development of four themes. The four themes interact to describe the new graduate nurse's experience communicating with physicians.
Descriptive themes are gaps in preparation, developing confidence, learning to communicate, and interprofessional patient care. They support that effective and efficient communication with physicians is a stressor for new graduate nurses as they transition to practice.
While a mixture of adult and paediatric nurses participated in this study, no differences in themes were observed during the analysis.

| Gaps in preparation
The preparation of new graduate nurses for communicating with physicians emerged as a theme in this study. More specifically, participants expressed a lack of preparation during their educational programs. Interactions with physicians were limited during clinical rotations. Limitation ranged from not allowing students to contact physicians, "I never called a physician. We weren't allowed to call physicians" (RN3) and "… you talk with your nursing instructors, but you never communicate with the physicians" (RN2), to discouragement from communicating with physicians, "In the program I went through they did not encourage physician interaction" (RN5). Participants also discussed a gap in the training they received and actual practice, "We studied about it [communication] from an academic standpoint through textbooks and simulation, but it's different" (RN6) and "… There's things they [instructors] told us, and we would be doing a lot, and it's completely different when you're out in the real world." (RN7). Simulation was mentioned as a methodology participants used to learn how to communicate with physicians. In these instances, the nursing instructor would take the role of the physician and sometimes imitate negative physician behaviour.
Participants also discussed the influence of stories related to bad physician behaviour. Other students and nursing colleagues in the workplace shared their stories of negative communication with physicians. Listening to these stories heightened participant's anxiety related to communicating with physicians, "I've heard different stories of, if you didn't come with the correct facts you might get fussed out" (RN4). Again, nursing instructors contributed to the anxiety by also telling stories of bad physicians' behaviour, "You hear these horror stories from people who are in your nursing class with you and from people you know, like even from our own teachers" (RN5). These stories translate into fear in the practice environment. One participant confident about it … but when you're a student, it's terrifying to talk to a physician." RN4 stated, "I'm more confident now. Before, I feel like I was on the phone stuttering … I didn't know if it was important to say, but now I can critically think more." Another participant highlighted that as nursing judgement improved in practice, confidence in making suggestions to physicians improved, stating "I used to jot give too many suggestions … the more my judgement improves the more I typically know what they [physicians] need." Two participants did not express the initial low confidence of the other nurses. Instead, they had previous life experiences, before their nursing career, that allowed them to be more comfortable when they interacted with physicians as new graduate nurses. RN6 stated that he had no anxiety when communicating with physicians. He attributed his comfort with his prior experience in sales and his many years in the job market. RN5 had been a paramedic before entering the nursing field and a nursing assistant while in nursing school. According to this participant, this experience alleviated any preconceived notions of communication with physicians upon entering the nursing field.

| Learning to communicate
When speaking about their communication with the resident physicians, all the new graduate nurses spoke to how the actual format of the communication was almost universally informal and lacking structure. Most of the nurses claimed that most communication with resident physicians was not face-to-face interaction, but rather via various electronic programs offered through their hospitals. These programs often are compared with "text messaging apps" (RN8), or

| Interprofessional patient care
Participants were also asked about their experience with interprofessional interactions. Specifically, participants were asked about their experience and participation in interprofessional rounds. This relationship did not exist in some instances, "He's doing his thing and I'm doing my thing … it's like two separate jobs instead of working as a team" (RN9). In other instances, nurses had to actively seek out interprofessional opportunities, and the level of activity depended upon the time available, "we barely see them … maybe if we had more time, we would be able to communicate" (RN10).
If participants were able to attend a conference with the physician and patient, they reported having little input or participation in the conversation but remain behind to answer clarifying questions for patients. "I have no input, but I'll listen to what they have to say … when they leave I'll stay behind to make sure they  (Song & McCreary, 2020). This anticipation influences the quality and quantity of patient information that are transferred between the two providers of care.
The participants in this study identified a gap between their education preparation for communication with physicians and how this interaction manifested itself in practice. Similarly, Forbes et al. (2020) found that resident physicians perceived that their relationship with nurses varied based on the experience level of nurses. While an importance is placed on nurses communicating with physicians during educational preparation, sufficient experience communicating with physicians does not occur. In an era of health care that is pressuring interprofessional education and collaboration to improve the quality of health care, nurses must not remain isolated from physician partners. Furthermore, interprofessional education must continue in the practice environment after professionals leave the academic setting (Stucky, Wymer et al., 2022). It is not logical to expect nurses and physicians to practice interprofessional care but educate them separately. Instead The development of confidence among new graduate nurses has been documented (Casey et al., 2004). This study supports Casey et al.'s (2004) findings that confidence is gained during the first year of practice. Casey et al. (2004)   This study provides nurse leaders with insights that can assist with designing programs and strategies that facilitate new graduate nurse confidence in communication and contribution to the interprofessional team.

CONFLICT OF INTEREST
The authors have no conflicts of interest to disclose related to this research study.

ETHICS STATEMENT
This study received IRB approval from the University and Medical Center Institutional Review Board at East Carolina University (ID: 19-002037).

DATA AVAILABILITY STATEMENT
Research data are not shared.