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   Table of Contents      
Year : 2017  |  Volume : 22  |  Issue : 4  |  Page : 262-266

Relationship between differentiation of self and attitude towards physician–nurse relationship in hospitals (Isfahan/Iran)

1 Student Research Center, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
2 Nursing and Midwifery Care Research Center, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran

Date of Web Publication14-Aug-2017

Correspondence Address:
Mousa Alavi
Nursing and Midwifery Care Research Center, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1735-9066.212982

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Background: Attitude towards physician–nurse relationship is fundamental to achieve health care quality. Such attitude maybe determined by some personality traits such as differentiation of self. Hence, the present study aimed to investigate the relationship between differentiation of self and attitude to professional physician–nurse relationship. Materials and Methods: This cross-sectional study was done in three hospitals in Isfahan in 2015. The study included all nurses and physicians. In total, 400 participants were recruited through convenience-sampling method. Data gathering instruments included a three-part questionnaire [demographic data sheet, Jefferson Scale of Attitudes toward Physician–Nurse Collaboration (JSAPNC) and differentiation of self-inventory (DSI)]. The data were analyzed through descriptive and inferential statistics [t-test, analysis of variance (ANOVA), and multiple linear regression) by the Statistical Package for the Social Sciences (SPSS) version 16 software. Results: The mean [standard deviation (SD)] of the scores of differentiation of self in physicians and nurses were 86.43 (9.62) and 159.28 (9.53), respectively. The results showed that the predicting model of attitudes towards physician–nurse relationship based on dimensions of differentiation of self both in nurses and physicians were significant. Moreover, the findings from linear regression analyses showed that predictor variables explained 0.18 and 0.14 of the variance of attitudes towards physician–nurse relationships in nurses and physicians, respectively. Conclusions: Considering the significant role of differentiation of self to predict attitudes towards physician–nurse relationship, it is worthwhile to suggest provision of training programs particularly in the nursing and medical students to enhance differentiation of self both in physicians and nurses to improve culture of interprofessional relationships and to achieve optimum professional relationships between doctors and nurses.

Keywords: Attitude, communication, Iran, physicians, nurses

How to cite this article:
Jafary S, Alavi M, Irajpour A, Mehrabi T. Relationship between differentiation of self and attitude towards physician–nurse relationship in hospitals (Isfahan/Iran). Iranian J Nursing Midwifery Res 2017;22:262-6

How to cite this URL:
Jafary S, Alavi M, Irajpour A, Mehrabi T. Relationship between differentiation of self and attitude towards physician–nurse relationship in hospitals (Isfahan/Iran). Iranian J Nursing Midwifery Res [serial online] 2017 [cited 2022 May 27];22:262-6. Available from: https://www.ijnmrjournal.net/text.asp?2017/22/4/262/212982

  Introduction Top

Today, relationship among professional staff is considered as an important and vital strategy due to materializing the objectives of the health system; one of the instances of its transformation through which people from various careers get together to access to common aims which is often the promotion of caring and treating services to the social cases.[1] One of the most egregious of professional relationship within the health system is the relationship and connection among medical and nursing professional staff, which includes counter-interaction between physician and nurse in looking after a given patient due to reach one common treating goal for satisfying patients and solving their problems.[2]

Despite the emphasis on the urgency and importance of relationship between the physician and nurse,[3],[4] to access the goals set by health system, existing evidences indicate that in most cases there is a tension in professional communication between physician and nurse. For instance, the consequences of a study on nurses in perceiving physician–nurse relationships in 2011 suggested that inappropriate interaction between physician and nurse leads to stress, feeling depressed, losing concentration, decreasing cooperation, and reducing data transmitting among the nurses.[5] Iranian researchers have reported the same results too. For example, the results of studies done by Rostami et al.[6] and Irajpour et al.[7] showed that nurses described their professional relationships with physicians awful, and in most cases found them unaware of nurses' tasks and professional functions. Similarly, Lakdizji et al. conducted a study among 250 nurses in 2011 and emphasized the problems with physician–nurse relationships.[8]

According to the existing evidences, physicians' and nurses' attitude towards physician–nurse relationship is a significant factor determining their professional relationships.[9],[10] In addition, based on the results of some studies, this attitude is not appropriate, especially among physicians.[11],[12] Scholars and experts involve many social and professional factors in designating the attitude and professional relationships of nurses and physicians to the physician–nurse relationship, and others have stressed on the preparation of medical and nursing students via interprofessional education in the academic courses.[13]

Despite the fact that, in the mentioned studies and other respective studies, different factors have been involved in determining the attitude of physicians and nurses towards interprofessional relationships; the role of individual and psychological factors has not been taken seriously. It has been emphasized that medical and nursing staff, despite professional affiliation, should be able to enjoy such psychological qualities including intellectual and emotional independence that they can easily share in the course of interactions with other professional groups.[14] Differentiation of self is an important psychological feature affecting the behaviors and relationships among individuals that can explain the attitude and behaviors professional physicians and nurses; however, no study has studied this relationship. The concept of differentiation of self was first introduced by Morry Boen to express some problems of interpersonal relationships among family members, and was utilized by other researchers to analyze the mentioned relationships within the environments other than family. According to Boen, people with high differentiation of self have an egregious perception of partnership and collaboration. These people are able to bring up independently and can preserve their own peace and comfort within profound relationships; whereas, people with lower differentiation of self are intellectually dizzy in stressful situations, stay in ambiguity, and emerge with interpersonal distance in their relationships.[15]

According to some experts, the level of differentiation of self plays an important role in professional behaviors of health system staff.[16] Although it appears that differentiation of self can be one of the significant factors related to interprofessional relationships among physicians and nurses, no study has been found based on extant search and this idea has not been verified. Thus, the researchers of the current study have surveyed the relationship between differentiation of self among medical and nursing staff with their attitude towards physician–nurse relationship in some selected hospitals affiliated to Isfahan University of Medical Sciences (IUMS).

  Materials and Methods Top

The present study is a cross-sectional descriptive study carried out in 2015. Statistical population included all physicians and nurses working in three medical centers affiliated to IUMS. The selected centers were Alzahara Center, Noor and Aliasghar Center, and Ayatollah Kashani Center located in different parts of Isfahan and has the most number of medical and nursing staff. Two hundred physicians and 200 nurses working in the mentioned centers participated in this study. The required sample size of each center was calculated with the view of approximate proportion of employees in each mentioned center at the time of study such that 55% of the employees (including physicians and nurses) from Alzahra Center, 25% from Noor and Aliasghar Center, and 20% from Ayatollah Kashani Center participated in the study. Moreover, the physicians and nurses recruited as two separate groups of participants and therefore the sample size was calculated separately for each group.

Participants of the study were recruited according to convenience sampling method in a way that after determining the necessary sample size of each center and providing the list of the names of physicians and nurses working in each studied units, they were invited to participate. The inclusion criteria comprise having bachelor or master degrees for the nurses without regarding the kind of employment in the selected medical centers, the interest in the study and lack of a great stressful event at least 8 weeks before the study.

Data gathering device consisted of a three-part questionnaire, of which the first part included demographic data of the samples (i.e., age, gender, profession, education level), the second part included differentiation of self-inventory (DSI), and the last part comprised the Jefferson Scale of Attitudes toward Physician-Nurse Collaboration (JSAPNC). The DSI consisted of 45 statements and four subscales including emotional reactivity (ER), I position (IP), emotional cut-off (EC), and fusion with others (FO). Scoring of the items was based upon 6-point Likert scale ranging from not at all true of me (1) to very true of me (6). The score of each scale is achieved by the range of relevant statement scores and the total score is also gained by calculating the range of whole scores, which covers ranges from 1 to 6 and the higher score indicates higher differentiation of self. The reliability of this scale was supported by Yousefi, Etemadi and Bahrami et al. who reported Cronbach's Alpha for ER, ID, EC and FO sub-scales as 0.89, 0.91, 0.81 and 0.86, respectively,[17] and its face and content validity was independently approved by 5 faculty members of IUMS too; and no change was made in the Persian edition of this device. The JSAPNC also consisted of 15 statements and 6-point Likert scale ranging from score 1 for “completely disagree” answer to score 4 for “completely agree” answer. The range of achievable score is various from 15 to 60, of which higher score signifies nurses' more positive attitude to the professional relationship of physicians and nurses. The reliability of this scale was earned by Jasmi et al.[18] (Cronbach's alpha = 0.86, and its face and content validity was approved by independent survey of 5 faculty members of the IUMS.

The method of conducting research was as follows: After the approval of the proposal in IUMS and gaining essential licenses, the researcher went to all mentioned centers and met each of physicians and nurses who agreed with participate in the study while arranging with the officials of all wards and clinical subsets of each center. Then necessary explanations were presented regarding the purposes of the study, volunteer participation, and anonymous questionnaire were assured, informed consent was earned, and volunteers were invited to participate in the study. Afterwards, having arranged and made appointments, each of them was given the questionnaire in each studied units and were filled in the presence of the researcher; any probable question was replied.

The collected data were entered into the Statistical Package for the Social Sciences (SPSS) version 16 software and were analyzed using descriptive [mean, standard deviation (SD), and frequencies], and inferential [independent t-test, analysis of variance (ANOVA), and multiple-linear regression) statistics.

Ethical considerations

The study was approved by the IUMS research committee (code 394299). The participation in the study was voluntarily and informed.

  Results Top

Of 400 distributed questionnaires, all were returned and analyzed (response rate of 100%). The mean (SD) age of the participants was 30.99 (6.68). The relative frequency of gender was 35.8 (143 people) males and 64.2 (257 people) females. Fifty percent (200 people) were physicians and 50% (200 people) were females. Forty six percent (184 nurses) had bachelor degree and 3.8% (15 nurses) had master degree; 30.8% (123 people) were general practitioner and 19.5% (78 people) were medical specialist. Descriptive data relevant to total mean score and subscales of differentiation of self and also the attitude towards physician-nurse relationship among physicians and nurses have been shown in [Table 1].
Table 1: Means and standard deviations of the dimensions of differentiation of self and attitude towards physician-nurse relationship in physicians and nurses

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The findings of the study suggested that nurses enjoy higher score of attitude to physician–nurse relationships than physicians (t = 5.76, df = 377, P < 0.001). In this study, it is hypothesized that this significant difference in attitude to physician–nurse relationship is related to the difference of differentiation of self among physicians and nurses. Supporting this hypothesis, the findings suggested that mean score of differentiation of self in two groups of physicians and nurses have a significant difference with each other such that physicians have higher average score of differentiation of self than the nurses. To gain deeper insight into this significant difference of attitude to physician–nurse relationship and also determine the relative significance of each dimensions of differentiation of self in predicting this attitude among physicians and nurses, multiple-regression analysis have been independently conducted among them.

In [Table 2], the consequences relating to determining the share of each dimension of differentiation of self in expressing the attitude towards physician–nurse relationship among nurses have been offered. They show that the attitude towards physician–nurse relationship among nurses based on quadruple dimensions of their differentiation of self is significant. In other words, it can be predicted based upon quadruple dimensions of their differentiation of self (f4,195 =10.32, P < 0.001). Overall, predicting variables including emotional reactivity, I position, emotional cut-off, and fusion with others explained 17.5% of variance related to nurses' attitude towards physician–nurse relationship (R2 = 0.17). Furthermore, subscales of emotional cut-off (P = 0.013) and fusion with others (P = 0.005) significantly predict nurses' attitude towards physician–nurse relationships, of which the latter is more important.
Table 2: Multiple regression analysis and ANOVA results to evaluate the predicting variables of attitude towards the physician-nurse relationship in the nurses

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Dealing with the share of each predicting variable in expressing the attitude towards physician–nurse relationship, the results suggested that they expressed 0.14 of the variance related to physicians' attitude (R2 = 0.14). The significant results of ANOVA signify that the scores of attitude towards physician–nurse relationship among the physicians can be predicted by the scores of quadruple dimensions of their differentiation of self (P < 0.001, f4,195 =7.69). The results show that emotional reactivity subscale (P = 0.003) significantly has predicted the physicians' attitude [Table 3].
Table 3: Multiple regression analysis and ANOVA results to evaluate the predicting variables of attitude towards the physician-nurse relationship in the physicians

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  Discussion Top

This study was conducted to determine the association of differentiation of self with physician-nurse relationships. The findings of the study suggested that the nurses enjoy higher mean score of attitude towards physician-nurse relationships than the physicians do. This has been confirmed in the same findings in other societies. For example, Amsalu et al.[13] as well as Zakerimoghadam et al.[19] represented in their findings that nurses had more favorable attitude to physician–nurse relationship than the physicians. In these studies, the variation of attitude among physicians and nurses towards interprofessional relationships has been attributed to different factors. In a study performed by Brown et al., for instance, nurses' positive attitude has been attributed to higher levels of professional and educational value.[11] According to some evidences, the attitude variation among physicians and nurses stems from their education period; for example, the result of studies conducted by Wang et al. showed that the mentioned variation to physician–nurse relationships among medical and nursing students was significant, of which the latter enjoyed more favorable attitude.[12]

The innovative aspect of this study is that the construct of differentiation of self has been surveyed as the predicting factor of the attitude toward interprofessional relationships of physicians and nurses for the first time, and the significance of statistical model of predicting attitude based on dimensions of self-differentiation in both physicians and nurses strengthens the correction of this hypothesis. The results of analysis on subgroup of nurses suggested that subscales of emotional cut-off and fusion with others significantly explained nurses' attitude to physician–nurse relationships. These components refer to a range of disorder in individual relationships from extreme separation to extreme fusion, which shows a sort of disorder and weakness in regulating the mentioned relationships and are confirmed by some evidences. In their study, Farmahini et al. stated that although nurses have learned communication skills well during their education, they do not utilize them well during the treatment period.[20] According to Park's study, the crowded ward and shortage of workforce are among the factors causing nurses to face challenges in using communicative skills and not paying enough attention to them.[21]

Similarly, the findings relevant to subgroup of physicians suggested that of differentiation of self-dimensions, emotional reactivity dimension can only predict physicians' attitude to physician–nurse relationships significantly. The emotional reactivity is a psychological strategy through which humans try to acquire more favorable individual relationships by changing their own anxiety level.[22] The existing literature has also emphasized on the importance of reactivity levels in determining humans' behaviors.[23] Stressing on the importance of learning how to manage and control of excitement due to control behavior and attitude, Shapiro[24] claims the medical teaching does not care about the attitudes and the excitements of its learners. Emphasizing the challenge of physicians' emotional load, Lin and Chang[25] also consider it as an effective factor on their professional performance.

Overall, it seems to be able to achieve more favorable attitude towards physician–nurse interprofessional relationships by impressing two dimensions of emotional cut-off and fusion with others of self-differentiation among nurses and then emotional reactivity among physicians. Despite the fact that this study provides a good insight into the role of one of the important psychological factors in predicting and explaining the attitude to interprofessional relationships of physicians and nurses, it deals with a limited dimension of individual and psychological factors. Thus, it is necessary that more dimensions of psychological situation affecting on the attitude to interprofessional relationships of physicians and nurses be considered in the coming studies.

  Conclusion Top

The results of this study introduce the difference of differentiation of self among physicians and nurses as explanation of the variation of attitude to interprofessional relationship of physicians and nurses. According to the findings of the study, it appears to be able to achieve more favorable attitude towards physician–nurse interprofessional relationships by impressing on the levels of differentiation of self to reduce emotional cut-off and fusion with others events among nurses and improve emotional reactivity among physicians. Some studies recommend to survey such facilitating factors as education level and other ground factors in differentiation of self and also attitude towards physician–nurse relationship.


We appreciate all the physicians and nurses who kindly participated in this study. Moreover we thank vice president of research of IUMS and also the managers of the participant hospitals.

Financial support and sponsorship

Isfahan University of Medical Sciences.

Conflicts of interest

There are no conflicts of interest.

  References Top

Irajpour, A. Alavi, M. Health professionals' experiences and perceptions of challenges of interprofessional collaboration: Socio-cultural influences of IPC. Iran J Nurs Midwifery Res 2015;20:99-104.  Back to cited text no. 1
Barrere C, Ellis P. Changing attitudes among nurses and physicians: A step toward collaboration. J Healthcare Qual 2002;24:9-16.  Back to cited text no. 2
Alavi M, Irajpour A, Abdoli S, Saberizafarghandi MB. Clients as mediators of interprofessional collaboration in mental health services in Iran. J Interprof Care 2012;26:36-42.  Back to cited text no. 3
Hellquist K, Bradley R, Grambart S, Kapustin J, Loch J. Collaborative practice benefits patients: An examination of interprofessional approaches to diabetes care. Health Interprofessional Pract 2012;1:3.  Back to cited text no. 4
Azza T, Elithy AT, Harmina MK, Elbialy GG. Nurses and Physicians Perceptions of Their Interprofessional Relationships at Alexandria Main University Hospital. J Am Sci 2011;7:750-7.  Back to cited text no. 5
Rostami H, Rahmani A, Ghahramanian A. The Viewpoint of Nurses about Professional Relationship between Nurses and Physicians. J Res Develop Nurs Midwifery 2010;7:63-72.  Back to cited text no. 6
Irajpour A, Alavi M, Abdoli S, Saberizafarghandi MB. Challenges of interprofessional collaboration in Iranian mental health services: A qualitative investigation. Iran J Nurs Midwifery Res 2012;17:171-7.  Back to cited text no. 7
Lak Dizji S, Mirsaeedi G, Foujazadeh M, Zamanzadeh V. Nurses participation in clinical decision-making process. Tabriz J Nurs Midwifery. 2009;5:19-25.  Back to cited text no. 8
Mary P, Jani F. The doctor-nurse game in the age of inter professional care a view from Canada. Nurs inquiry 2008;15:1-2.  Back to cited text no. 9
Ghafari F. Rafei H, Sanaei B. The effectiveness of Bowen's distinguished family with dependent child. J Subst Abuse Addict Res 2010;3:55-62.  Back to cited text no. 10
Brown SS, Lindell DF, Dolansky MA, Garber JS. Nurses' professional values and attitudes toward collaboration with physicians. Nurs Ethics 2015;22:205-16.  Back to cited text no. 11
Wang Y, Liu Yf, Li H, Li T. Attitudes toward Physician-Nurse Collaboration in Pediatric Workers and Undergraduate Medical/Nursing Students. Behav Neurol 2015;2015:846498.  Back to cited text no. 12
Amsalu E, Boru B, Getahun F, Tulu B. Attitudes of nurses and physicians towards nurse-physician collaboration in northwest Ethiopia: A hospital based cross-sectional study. BMC Nurs 2014;13:1-6.  Back to cited text no. 13
Koushaki SH, Heydarali H, Zahedi S. The relationship between personality and job satisfaction of teachers. J Psychol Res 2010;1:8-26.  Back to cited text no. 14
Sohrabi R, Asadi M, Habibollahzade H, PanaAli A. Relationship between self-differentiation in bowen's family therapy and psychological health. Procedia - Social and Behavioral Sciences 2013;84:1773-5.  Back to cited text no. 15
Beebe R, Frisch N. Development of the Differentiation of Self and Role Inventory for Nurses (DSRI-RN): A tool to measure internal dimensions of workplace stress. Nurs Outlook 2009;57:240-5.  Back to cited text no. 16
Yousefi N, Etemadi O, Bahrami F, Al-Sadat Fatehezade M, Ahmadi SA, Beshlideh K. Structural relationships between self-differentiation and subjective wellbeing, mental health and marital quality: Fitting bowen's theory. Iranian J Psychiatry and Behavioral Sci 2009;3:4-14.  Back to cited text no. 17
Jasemi M. Rahmani A. Aghakhani N. Hosseini FS. Eghtedar S. Nurses and Physicians' Viewpoint toward Interprofessional Collaboration. Iran J Nurs 2013;26:15-26.  Back to cited text no. 18
Zakerimoghadam M, Ghiyasvandian S, Leili AK. Nurse–physician collaboration: The attitudes of baccalaureate nursing students at Tehran University of Medical Sciences. Iran Red Crescent Med J 2015;17:e23247.  Back to cited text no. 19
Farmahini M, Kashaninia Z. Hosiani MA. Biglarian A. Impact of Training Communication Skills to Nurses on Patients Satisfaction with Nurse-Patient Relationship. Iran J Nurs Res 2006;1:47-54.  Back to cited text no. 20
Park EK, Song M. Communication Barriers Perceived By Older Patients and Nurses. Int J Nurs Stud 2005;42:159-66.  Back to cited text no. 21
Trinidad DR, Unger JB, Chou CP, Johnson CA. The protective association of emotional intelligence with psychosocial smoking risk factors for adolescents. Personal Indiv Diff 2004;36:945-54.  Back to cited text no. 22
Parker JD, Taylor RN, Eastabrook JM, Schell SL, Wood LM. Problem gambling in adolescence: Relationships with internet misuse, gaming abuse and emotional intelligence. Personal Indiv Diff 2008;45:174-80.  Back to cited text no. 23
Shapiro J. The feeling physician: Educating the emotions in medical training. Eur J Person Center Healthcare 2013;1:310-6.  Back to cited text no. 24
Lin YW, Chang WP. Physician Emotional Labour and Job Performance The Mediating Effects of Emotional Exhaustion. J Health Manage 2015;17:446-57.  Back to cited text no. 25


  [Table 1], [Table 2], [Table 3]

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