A survey on the medical interns’ attitudes toward the interactions between interns and nurses in teaching hospitals

Abstract

BACKGROUND:

Effective communication among healthcare professionals, particularly physicians and nurses, is paramount in delivering top-notch patient care. Therefore, it is imperative for medical interns aspiring to become doctors to gain experience in this crucial aspect of healthcare. Interns should be able to provide feedback on the quality of communication within their team in a constructive and nonjudgmental manner. Therefore, this study was conducted to investigate the attitude of medical interns toward the interactions between interns and nurses in Teaching Hospitals.

MATERIALS AND METHODS:

In this cross-sectional study, medical interns were surveyed using a questionnaire developed by the researchers. The validity of the questionnaire was confirmed by experts using the content validity confirmation method, and its reliability was assessed using Cronbach’s alpha. The data collected were analyzed using SPSS v26 software.

RESULTS:

The study found no significant relationship between interns’ attitudes toward the interactions with nurses based on gender (P = 0.249), grade point average (P = 0.758), previous university education (P = 0.942), or the duration past of internship period (P = 0.373). However, a statistically significant difference was observed in interns’ attitudes toward the quality of interactions based on the teaching department (P = 0.001) and the teaching hospital (P = 0.013).

CONCLUSION:

It appears that conducting training courses on professional communication skills and revising the policies of teaching department to enhance the involvement of interns in the treatment process with the assistance of nurses could be an effective solution to address the issues in the interactions between interns and nurses.

Introduction

Interaction is a dynamic and continuous process that involves mutual convergence and trust, through which messages or information were exchanged using speech, writing, symbols, and behavior. This process is irreversible, reciprocal, and content based.[1] Professional interaction refers to the communication between professional individuals and the division of responsibilities.[2] In healthcare setting, professional communication between team members, particularly doctors, and nurses, is crucial for achieving the common the therapeutic goal of treating patients. Studies have shown that 80% of doctors’ time is spent in various forms of communication.[3,4]

It appears that the ideal time to establish a solid foundation for effective future communication between physicians and other healthcare team members is during the clinical training of medical interns.[5] Medical students, who are valuable members of the healthcare team, play a crucial role in teaching hospitals. Therefore, Training programs should encourage interns to provide feedback on the quality of communication with their team members, particularly nurses, in an open-minded and nonjudgmental manner. This feedback allows interns to share their perspectives on the professional and communicative skills of nurses, ultimately leading to more efficient collaboration.[6]

In recent years extensive studies conducted in Iran which have focused on the impact of the educational atmosphere and environment on students’ learning experiences in hospital settings. These studies have explored various aspects of communication and interaction within healthcare teams, shedding light on the importance of effective communication in providing quality patient care.[7,8,9,10,11,12,13,14,15] However, very few have explored the interactions between nurses and interns who will become future physicians. Therefore, this study aims to investigate the attitude of medical interns toward their interactions with nurses in teaching hospitals affiliated with Islamic Azad University, Mashhad Medical Sciences in 2022.

Materials and Methods

Study design and setting

This cross-sectional and descriptive-analytic study were conducted in three hospitals affiliated with Islamic Azad University, Mashhad Medical Sciences (22 Bahman, 17 Shahrivar, and Aria). The study has been conducted between June 2022 and May 2023.

Study participants and sampling

This study was conducted on all medical interns at the Islamic Azad University, Mashhad Medical Sciences. Participants were provided with a detailed explanation of the study and gave informed consent before entering the study. Participants in this study were required to have completed a minimum of 3 months of their internship. Interns who reported known psychiatric disorders or submitted incomplete questionnaires were excluded from the study.

Data collection tool and technique

A researcher-made questionnaire was used in this study which was refined through input from experts and professors in the medical and educational fields, as well as hospital managers. The validity of the questionnaire was confirmed through the content validity index (CVI) and content validity ratio (CVR) using the content validity confirmation method based on the ratios introduced by Lawshe for CVR[16] and a CVI index greater than 0.79 through the opinions of 16 members of relevant experts and specialists. The reliability of the questionnaire was assessed using Cronbach’s alpha, which yielded a value of 0.9, indicating high reliability. After validation and reliability testing the questionnaire, an interval measurement scale was used to assess the population. The questionnaire consisted of two parts: demographic questions and items related to the evaluation of interactions between interns and nurses. The latter included 23 items divided into four subscale areas: belongingness (3 items), quality of patient information circulation (8 items), the nursing support role (8 items), and nurses’ professional competencies (4 items). The study used a five-point Likert scale to assess items, with responses ranging from 1 for “completely disagree” to 5 for “completely agree.” Questionnaire scores varied from 23 to 115, while belongingness scores ranged from 3 to 15. Scores for patient information circulation and nurses’ competencies fell between 8 and 40, and nurses’ professional competencies scores ranged from 4 to 20.

Questionnaires were distributed to students online through Google Forms and in person through authorized student groups. Once a sufficient number of completed questionnaires were collected, the data were analyzed using SPSS version 26.

Quantitative variables were presented using mean and standard deviation, whereas qualitative variables were displayed as percentages. The normality of the data were assessed using the Kolmogorov-Smirnov one-sample test with Lilliefors correction. The independent-sample t-test (Student’s t-test) was used to compare two groups of quantitative variables with a normal distribution, and the ANOVA test was used for comparisons involving three or more groups with a normal distribution. Pairwise comparisons were conducted using the Dunn-Bonferroni post-hoc test. The Pearson correlation test was used to explore linear relationships between quantitative variables. The analysis was conducted with a significance level set at less than 5%.

Ethical consideration

This research was approved by the Ethics Committee of Islamic Azad University, Mashhad Medical Sciences, a member of Iran’s National Ethics Committee (Registration number: IR.IAU.MSHD.REC.1401.103). The students entered the study with informed consent. The questionnaires were anonymous, and the students’ information remained confidential.

Results

Out of 130 interns going through internship in 2022, a total of 103 medical interns participated in this study, Of these, 20 (19.4%) were male and 83 (80.6%) were female. The average duration of their internship was 8.07 ± 4.514 months. The majority of participants (85.4%) did not have prior university education. Among the 15 participants (14.6%) with previous university education, 7 (8.6%) had studied fields related to medicine. The average grade point average (GPA) of the participants was 16.12 ± 0.95 out of 20.

Questionnaire scores ranged from 40 to 114, with the lowest and highest scores recorded. The study did not find any statistically significant relationship between the attitudes of medical interns toward interactions between interns and nurses based on gender (P = 0.249), GPA (P = 0.758), previous university education (P = 0.942), and time since internship (P = 0.373). However, the attitudes of medical interns toward these interactions were statistically linked to the teaching hospital and department (P < 0.05). Please refer to Tables 1 and 2 for more detailed information.

Table 1.

Attitudes of interns towards the interactions between interns and nurses based on teaching hospitals

Hospital		Score
		Number		Minimum		Maximum		Mean		Std. deviation		Test statistic		P
Aria		44		40		101		31.75		67.12		F=4.531		P=0.013
22 Bahman		40		51		114		85.79		20.16
17 Sharivar		19		41		102		84.67		12.15

Table 2.

Attitudes of interns toward the interactions between interns and nurses based on teaching departments

Department		Score
		Number		Minimum		Maximum		Mean		Std. deviation		Test statistic		P
Pediatric		17		51		86		29.68		10.11		F=4.302		P=0.001
Internal medicine		25		41		104		32.73		8.17
Obstetrics and gynecology		18		40		98		11.74		91.14
General surgery		17		60		95		76.75		87.9
Psychiatrics		7		62		114		85.95		43.16
Emergency		11		69		110		81.82		50.12
Cardiology		8		58		86		87.74		11.8

According to the results in Table 3, the quality of patient information circulation and the nursing support role for interns received higher mean scores compared with the professional competencies of nurses as perceived by interns, as well as the sense of belongingness. Conversely, Table 4 shows statistically significant differences in the domains of belongingness, nursing support role for interns, and patient information circulation quality. The Dunn-Bonferroni posthoc test revealed that the highest and lowest mean scores for attitudes toward the quality of interactions among teaching hospitals were observed in 22 Bahman and 17 Shahrivar hospitals, respectively.

Table 3.

Descriptive indices for the interns’ attitudes toward subscales of interactions between interns and nurses, categorized by different teaching hospitals

Hospitals		Belongingness				Quality of patient’s information circulation				Nursing support role for interns				Nurses’ professional competencies from the perspective of interns
		Mean		Std. deviation		Mean		Std. deviation		Mean		Std. deviation		Mean		Std. deviation
Aria		57.9		14.2		34.26		7.5		66.25		88.4		75.13		18.3
22 Bahman		9.1		69.2		13.27		79.6		38.27		86.5		45.14		10.3
17 Sharivar		68.8		58.2		74.23		46.5		23		31.6		42.12		10.3

Table 4.

Factorial analysis of attitudes of interns toward interactions between interns and nurses based on teaching hospitals

Variable		Subscale variable		Sum of Squares		df		Mean Square		F		P
Teaching hospitals		Belongingness		88.72		2		44.36		8.6		3
		Quality of patient’s information circulation		25.15		2		12.75		18.2		118
		Nursing support role for interns		93.248		2		47.124		4.4		21
		Nurses’ professional competencies from the perspective of interns		8.53		2		54.26		70.2		72

Significant statistical differences were observed in the levels of belongingness among Aria and 22 Bahman hospitals (P = 0.043), 22 Bahman and 17 Shahrivar hospitals (P = 0.005), as well as in the nursing support role between 22 Bahman and 17 Shahrivar hospitals (P = 0.017). Moreover, upon comparing the attitudes of students toward interactions between interns and nurses across various teaching departments [as depicted in Table 5], it was noted that interns rated the quality of patient information circulation and nursing support role higher than nurses’ professional competencies from their perspective, along with their sense of belongingness.

Table 5.

Descriptive indices for the interns’ attitudes toward subscales of interactions between interns and nurses, categorized by different teaching departments

Teaching departments		Belongingness				Quality of patient’s information circulation				Nursing support role for interns				nurses’ professional competencies from the perspective of interns
		Mean		Std. deviation		Mean		Std. deviation		Mean		Std. deviation		Mean		Std. deviation
Pediatric		9.06		2.33		9.92		4.73		24.35		4.54		13.24		2.39
Internal medicine		9.68		2.73		21.65		6.15		24.68		6.79		12.92		3.33
Obstetrics/gynecology		9.61		2.25		26.04		5.69		25.33		5.64		14.11		4.24
General surgery		9.47		2		25.06		4.12		24.82		4.45		13.94		2.49
Psychiatrics		13		2.08		27.53		6.11		31.86		6.23		16		3.32
Emergency		11.36		2.46		35		4.97		29.09		4.25		14.91		2.91
Cardiology		9.5		2.88		27.45		3.06		26.13		4.76		13		2.51

The results presented in Table 6 reveal statistically significant differences in the subscale domains of belongingness, nursing support role for interns, and patient information circulation quality. The Dunn-Bonferroni post-hoc test highlighted that the emergency department had the highest mean score for attitude toward interaction quality, whereras the pediatric department had the lowest.

Table 6.

Factorial analysis of attitudes of interns toward interactions between interns and nurses based on teaching departments

Variable		Subscale variable		Sum of Squares		df		Mean Square		F		P
Teaching department		Belongingness		109.94		6		18.32		3.13		0.008
		Quality of patient’s information circulation		965.95		6		160.99		5.89		<0.0001
		Nursing support role for interns		463.76		6		77.29		2.59		0.023
		Nurses’ professional competencies from the perspective of interns		79.34		6		13.22		1.33		0.253

Significant statistical differences in belongingness were observed between the pediatric and psychiatric departments (P = 0.01), internal medicine and psychiatric departments (P = 0.038), obstetrics and gynecology and psychiatric departments (P = 0.046), general surgery and psychiatric departments (P = 0.033). Similarly, significant differences in patient information circulation quality were noted between the pediatric and general surgery departments (P = 0.03), internal medicine and psychiatric departments (P = 0.003), obstetrics and gynecology and psychiatric departments (P = 0.001), general surgery and psychiatric departments (P = 0.041), pediatric and psychiatric departments (P ≥ 0.01), and cardiology and psychiatric departments (P = 0.035).

Table 7 presents the findings of a linear regression analysis conducted to explore the individual impact of each variable on medical students’ attitudes toward interactions between interns and nurses. The analysis revealed that, among the variables examined, only the affiliation with a teaching department showed a statistically significant relationship with interns’ attitudes toward these interactions (P < 0.05).

Table 7.

Linear regression analysis to examine the independent effects of each variable on attitudes towards interactions between interns and nurses among studying students

Model		Variable		Unstandardized coefficients				Standardized coefficients		t		P
				B		Std. error		Beta
*1		(Constant)		68.408		31.237				2.19		0.031
		Gender		3.319		3.83		0.089		0.866		0.388
		GPA		-0.38		1.858		-0.022		-0.205		0.838
		Time elapsed since the internship		0.235		0.329		0.072		0.716		0.476
		Teaching department		2.083		0.876		0.26		2.378		*0.019
		Teaching hospital		-0.377		2.146		-0.019		-0.176		0.861
		Previous university education		-0.674		2.825		-0.025		-0.238		0.812

Discussion

This study focused on assessing interns’ attitudes toward the quality of their interactions with nurses. The results indicated that the teaching department and teaching hospital had a significant impact on interns’ attitudes toward these interactions.

This study found that the average attitude score toward interactions was 72.25 for male interns and 76.53 for female interns. Although female interns had a higher mean score, there was no statistically significant difference in attitudes toward interactions between male and female interns. This finding aligns with a study by Hojat et al.[17] but contrasts with the results of a study by Hansson et al.,[18] which demonstrated a slight positive effect of gender, particularly female gender, on the quality of interactions between physicians and nurses as perceived by medical students.

In this study, interns’ attitudes toward interactions with nurses were also examined based on their GPA. Despite a normal distribution of GPAs, the mean attitude score showed no significant differences, indicating that academic performance may not accurately reflect communication skills or professional relationships in healthcare.

However, a statistically significant difference was found in the mean attitude scores toward interactions with nurses based on the teaching departments. Specifically, the psychiatric department showed a significant difference compared with the pediatric, internal medicine, obstetrics and gynecology, and general surgery departments. These findings contradict a previous study by Hojat et al.,[17] which did not find a significant impact of teaching department on interactions between physicians and nurses. This discrepancy may be attributed to cultural differences between the two countries.

The variation in attitude scores among teaching departments suggests that the policies in the psychiatric department, which involve interns’ evaluation of patients in their treatment process, may lead to more effective interactions with nurses for decision-making compared with other departments. On the other hand, the nature of the psychiatric department, which requires a compassionate and communicative approach, likely may explain this difference too. Among the teaching departments, the emergency department had the highest mean attitude scores toward interactions, whereas the pediatric department had the lowest.

An overall comparison of the mean scores of the subscales of the questionnaire revealed that the quality of patient information circulation and the role of nursing support for interns have higher means compared with the professional competencies of nurses perceived by interns and in terms of their belongingness. The results also indicated statistically significant differences in the domains of belongingness, nursing support for interns, and patient information circulation quality. This discrepancy suggests that while both nurses and interns understand the importance of receiving and circulating patient information, the significance of support and the sense of reliability regarding various skill and practical knowledge-related areas have not been well-established in both groups. Consequently, efforts to address this gap in patient information circulation have not yielded significant results thus far.

Furthermore, the mean score of the attitude toward the quality of interactions, based on the teaching hospital, shows a statistically significant difference, particularly between 22 Bahman and 17 Shahrivar hospitals. The highest and lowest mean scores for the attitude towards the quality of interactions were recorded in 22 Bahman and 17 Shahrivar hospitals, respectively. Among the subscale domains, the quality of patient information circulation and the role of nursing support for interns have higher means than the professional competencies of nurses perceived by interns and belongingness.

The researcher posits that the disparity in attitude scores between teaching hospitals may be attributed to 22 Bahman Hospital being a fully teaching hospital, while 17 Shahrivar Hospital is a semi-teaching hospital. At 22 Bahman Hospital where interns play a significant role in patient treatment decisions and have increased interaction with nursing staff. This collaboration fosters a desire to improve patient information circulation and strengthens support for interns among nurses.

In contrast, at 17 Shahrivar Hospital, which is a semi-teaching hospital, as Nadolski et al.’s[19] study states, nurses seldom engage in evaluating students or seeking their consultation, leading to limited interaction between the two groups. Consequently, this lack of engagement may lead medical students to perceive nurses as playing a minimal role in their education. In addition, because of a shortage of medical faculty’s teaching staff, nonteaching staff often take on roles traditionally held by medical professors, creating ambiguity in interns’ involvement in patient treatment decisions. As a result, the importance of interactions between interns and nurses is diminished.

Notably, this study revealed no significant difference in interns’ attitudes toward interactions with nurses based on their prior university education. This finding aligns with previous research by Hansson et al.[18] However, Pollard et al.’s[20] study presented contrasting results, indicating that students with backgrounds in nursing, physiotherapy, radiotherapy, occupational therapy, or social work, who have prior experience in treatment teams, exhibited a more negative attitude toward interdisciplinary collaboration.

According to the findings of this study, there was no significant difference in the mean score of interns’ attitudes toward interactions with nurses based on the duration past of their internship period. However, Delunas et al.[21] discovered a negative attitude among medical students toward interdisciplinary interactions with nurses at the end of the clinical period compared with the beginning. Conversely, Epstein et al.[22] proposed that experience and knowledge acquired over time can enhance the quality of interactions among healthcare team members, as they become less stressed and better equipped to handle challenging situations.

A noteworthy observation from this study is that, among the variables examined, teaching department, which also was determined through a linear regression analysis to explore the independent impact of each variable, was the only variable significantly related to medical students’ attitudes toward interactions with nurses. This outcome suggests that there may be variability in the quality of interactions between interns and nurses across different departments within a hospital and further research is needed to understand the reasons for this variability. Overall, this result highlights the importance of human relationship dimension in shaping medical students’ attitudes toward working with nurses.

In light of the study’s findings, Implementing Interprofessional Education (IPE) courses, which have garnered attention from numerous universities worldwide in recent years, may benefit hospital nursing staff and interns by improving professional communication skills and understanding roles within the healthcare team. This can lead to enhanced communication and collaboration between nurses and interns, ultimately improving patient care.

Furthermore, enhancing the teaching department’s policies to elevate the involvement of interns in assessing treatment progress alongside nurses can further strengthen the relationship between these two groups.

Limitation and recommendation

This study is based on self-reported data from respondents and did not consider feedback from nurses regarding their attitudes toward interactions with interns, which could introduce biases into the collected data. In addition, selecting participants solely from a few teaching hospitals may restrict the generalizability of the findings.

To enhance the validity and applicability of the study’s results to the future studies, it is recommended to conduct nationwide studies across various hospitals and to perform qualitative research in this area to identify detailed factors influencing interactions. Furthermore, comparing the attitudes of medical interns toward interaction quality with nurses to those of residents could provide valuable insights.

Conclusion

The findings of this study indicate that medical interns express a moderate level of satisfaction with their interactions with nurses. Variables such as gender, academic standing, previous university education, and the time past of internship do not appear to significantly impact the quality of these interactions. However, the specific clinical department and teaching hospital do influence students’ perceptions. Therefore, it may be advantageous to promote interprofessional education (IPE) to cultivate positive interactions between nursing staff and medical interns within this setting.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.