In total, 430 nurses responded to the survey. Of the respondents, 349 (81.2%) were female. The median age was 45 (IQR: 35–51) years, and the median years of experience were 19 (IQR: 12–25). The highest number of respondents (272 participants, 63.3%) were graduates of vocational schools. Among the participating nurses, 122 (28%) had experience in managerial positions. A total of 103 participants (24.0%) had specialized skills. Community-based hospitals were the most common type of institution, with 212 participants (49.3%). The most common workplace size among participants was institutions with 100 beds, accounting for 164 nurses (38.1%). In total, 263 (61.2%) nurses were concerned about their physician’s diagnoses. A univariate analysis was used to compare those concerned about the physician’s diagnosis (“Concerned Group”) and those without any concerns about the physician’s diagnosis (“Non-Concerned Group”). Those with longer careers were more likely to feel concerned (odds ratio [OR], 1.15; 95% CI, 1.03–1.28; P = 0.013).
Those in managerial positions were more likely to feel concerned (OR, 1.73; 95% confidence intervals [CI], 1.10–2.71; P = 0.018). Compared to those working in community-based hospitals, nurses working in a clinic (OR, 0.62; 95% CI, 0.49–0.99; P = 0.047) and a university hospital (OR, 0.41; 95% CI, 0.23–0.74; P = 0.003) were less likely to experience concerns. Further, nurses working in 101–500-bed institutions were more likely to feel concern compared to ≤ 100 beds (OR, 1.72; 95% CI, 1.10–2.70; P = 0.018). In the multivariate analysis, nurses with longer careers were more likely to feel concerned (adjusted OR [aOR], 1.21; 95% CI, 1.01–1.44; P = 0.039; Table 1).
Table 1: Comparison of the Concerned and Non-Concerned groups | Uni variate | Odds ratio | CI | P Value | Multi variate | Co efficient | Odds ratio | CI | P Value |
| Total N = 430 | Concerned group N = 263 | Non-Concerned group N = 167 | LL | UL | LL | UL |
Sex Female | 349(81.2) | 215(81.8) | 134(80.2) | | 1.04 | 0.63 | 1.73 | .875 | | 0.01 | 1.01 | 0.58 | 1.77 | .961 |
Age median (IQR) | 45(39–51) | 46(40–51) | 45(36–51) | | 1.05 | 0.95 | 1.17 | .354 | | -0.10 | 0.91 | 0.76 | 1.09 | .313 |
Career median (IQR) | 19 (12–25) | 20(13–25) | 16(9–25) | | 1.15 | 1.03 | 1.28 | .013 | | 0.19 | 1.21 | 1.01 | 1.45 | .039 |
Educational background | | | | | | | | | | | | | | |
Vocational or Junior college | 272(63.3) | 167(63.5) | 105(62.9) | | Reference | | | | | | Reference | | | |
University school | 116(27.0) | 71(27.0) | 45(27.0) | | 1.03 | 0.65 | 1.61 | .911 | | 0.20 | 1.22 | 0.73 | 2.05 | .449 |
Graduate school | 42(9.8) | 25(9.5) | 17(10.2) | | 0.93 | 0.48 | 1.80 | .823 | | -0.19 | 0.83 | 0.39 | 1.76 | .623 |
Managerial position | 122(28.3) | 86(32.7) | 36(21.6) | | 1.73 | 1.10 | 2.71 | .018 | | 0.24 | 1.27 | 0.77 | 2.09 | .352 |
Specialty skill | 103(24.0) | 70(26.6) | 33(19.8) | | 1.49 | 0.93 | 2.39 | .099 | | 0.18 | 1.20 | 0.69 | 2.10 | .523 |
Institution | | | | | | | | | | | | | | |
Community-based hospital | 212(49.3) | 150(57.0) | 62(37.1) | | Reference | | | | | | Reference | | | |
Clinic | 135(31.4) | 79(30.0) | 48(33.5) | | 0.62 | 0.39 | 0.99 | .047 | | -0.65 | 0.52 | 0.20 | 1.35 | .179 |
University hospital | 60(14.0) | 30(11.4) | 30(17.9) | | 0.41 | 0.23 | 0.74 | .003 | | -0.73 | 0.48 | 0.23 | 1.00 | .051 |
Others | 23(5.4) | 4(1.5) | 19(11.4) | | 0.17 | 0.08 | 0.36 | .000 | | -1.85 | 0.16 | 0.06 | 0.44 | < .001 |
Urban | 219(50.9) | 131(49.8) | 89(52.6) | | 0.89 | 0.60 | 1.31 | .541 | | -0.04 | 0.96 | 0.63 | 1.47 | .846 |
Bed number | | | | | | | | | | | | | | |
≦ 100 | 164(38.1) | 92(35.0) | 72(43.1) | | Reference | | | | | | Reference | | | |
101–500 | 171(39.8) | 118(44.9) | 53(31.7) | | 1.72 | 1.10 | 2.70 | .018 | | -0.27 | 0.76 | 0.31 | 1.91 | .564 |
501 over | 95(22.1) | 53(20.2) | 42(25.2) | | 0.98 | 0.59 | 1.64 | .935 | | -0.54 | 0.58 | 0.21 | 1.63 | .301 |
During the multivariate analysis, 429 participants were analyzed, except for 1 participant in the group in which the sex was unknown. The group that did not feel concern (Non-concerned group) about the physician’s diagnosis was used as the reference. CI: confidence interval, OR: odds ratio, aOR: adjusted odds ratio, LL, lower limit, UL, upper limit. |
Of the 263 individuals concerned about their physicians, 138 (52.5%) could not communicate their concerns to the physicians. A univariate analysis was conducted between the group that could not express their concerns (non-communicating group) and those that could express their concerns (communicating group). Compared to those working in community-based hospitals, nurses working in clinics conveyed fewer concerns (OR, 2.88; 95% CI, 1.58–5.24; P < 0.001). In respect of bed numbers, those working in institutions with ≤ 100 beds conveyed fewer concerns than those working in 101–500-bed institutions (OR, 0.34; 95% CI, 0.19–0.61; P < 0.001) and in institutions with > 500 beds (OR, 0.30; 95% CI, 0.15–0.60; P < 0.001). Regarding the physicians’ age, nurses were significantly less likely to communicate their concerns with physicians aged 30–70 years than with those in their 20s. Moreover, a multivariate analysis showed that the younger the nurse, the less likely they were to communicate their concerns (aOR, 0.72; 95% CI, 0.53–0.97; P = 0.030). The longer their careers, the less likely they were to express their concerns (aOR, 1.35; 95% CI, 1.01–1.79; P = 0.040). Nurses were less likely to express their concerns to physicians aged 40–50 years (aOR, 18.10; 95% CI, 4.09–80.06; P < 0.001), 50–60 years (aOR, 7.87; 95% CI, 1.83–33.77; P < 0.001), and 60–70 years (aOR, 8.82; 95% CI, 1.79–43.54; P = 0.008) compared to expressing their concerns to those who were in their 20s (Table 2).
Table 2: Comparing the Communicating and Non-Communicating Groups | Uni Variate | Odds ratio | CI | p value | Multi variate | Co efficient | Odds ratio | CI | p value |
| Total N = 263 | communicating group N = 125 | Non-communicating group N = 138 | LL | UL | LL | UL |
Nurse characteristics | | | | | | | | | | | | | | |
Sex Female | 215(81.8) | 105(84.0) | 110(79.7) | | 0.81 | 0.43 | 1.55 | .529 | | -0.18 | 0.84 | 0.39 | 1.81 | .657 |
Age median (IQR) | 46(40–51) | 46(40–50) | 46(39–51) | | 0.95 | 0.82 | 1.10 | .504 | | -0.33 | 0.72 | 0.53 | 0.97 | .030 |
Career median (IQR) | 20(13–25) | 20(13–26) | 20(13–25) | | 1.01 | 0.88 | 1.15 | .940 | | 0.30 | 1.35 | 1.01 | 1.79 | .040 |
Educational background | | | | | | | | | | | | | | |
Vocational or Junior college | 167(63.5) | 83(66.4) | 84(60.9) | | Reference | | | | | | Reference | | | |
University school | 71(27.0) | 26(20.8) | 45(32.6) | | 1.67 | 0.94 | 2.97 | .079 | | 0.63 | 1.88 | 0.91 | 3.86 | .086 |
Graduate school | 25(9.5) | 16(12.8) | 9(6.5) | | 0.56 | 0.23 | 1.33 | .187 | | -0.58 | 0.56 | 0.19 | 1.65 | .294 |
Managerial position | 86(32.7) | 40(32.0) | 46(33.3) | | 1.11 | 0.66 | 1.87 | .684 | | 0.20 | 1.22 | 0.65 | 2.29 | .528 |
Specialty skill | 70(26.6) | 37(29.6) | 33(23.9) | | 0.78 | 0.45 | 1.36 | .385 | | 0.17 | 1.19 | 0.57 | 2.48 | .653 |
Institution | | | | | | | | | | | | | | |
Community-based hospital | 150(57.0) | 84(67.2) | 66(47.8) | | Reference | | | | | | Reference | | | |
Clinic | 79(30.0) | 25(20.0) | 54(39.1) | | 2.88 | 1.58 | 5.24 | < .001 | | 0.07 | 1.07 | 0.30 | 3.81 | .913 |
University hospital | 30(11.4) | 16(12.8) | 14(10.1) | | 1.21 | 0.54 | 2.68 | .645 | | 0.75 | 2.11 | 0.69 | 6.48 | .193 |
Others | 4(1.5) | 0 | 4(2.9) | | 3.45 | 0.88 | 13.51 | .076 | | 0.69 | 2.00 | 0.36 | 11.06 | .429 |
Urban | 131(49.8) | 61(48.8) | 70(50.7) | | 1.06 | 0.65 | 1.73 | .804 | | 0.25 | 1.28 | 0.71 | 2.30 | .409 |
Bed number | | | | | | | | | | | | | | |
≦ 100 | 92(35.0) | 28(22.4) | 64(46.4) | | Reference | | | | | | Reference | | | |
101–500 | 118(44.9) | 65(52.0) | 53(38.4) | | 0.34 | 0.19 | 0.61 | < .001 | | -1.02 | 0.36 | 0.11 | 1.17 | .089 |
501 over | 53(20.2) | 32(25.6) | 21(15.2) | | 0.30 | 0.15 | 0.60 | < .001 | | -1.65 | 0.19 | 0.05 | 0.80 | .023 |
Physician’s characteristics | | | | | | | | | | | | | | |
Sex Female | 34(12.9) | 16(12.8) | 18(13.0) | | 1.03 | 0.50 | 2.12 | .937 | | 0.14 | 1.15 | 0.47 | 2.81 | .757 |
Age | | | | | | | | | | | | | | |
20s | 21(8.0) | 18(14.4) | 3(2.2) | | Reference | | | | | | Reference | | | |
30s | 68(25.9) | 39(31.2) | 29(21.0) | | 4.46 | 1.20 | 16.59 | .026 | | 1.42 | 4.13 | 1.00 | 17.18 | .051 |
40s | 59(22.4) | 17(13.6) | 42(30.4) | | 15.75 | 4.08 | 60.82 | < .001 | | 2.90 | 18.10 | 4.09 | 80.06 | < .001 |
50s | 68(25.9) | 31(24.8) | 37(26.8) | | 7.16 | 1.93 | 26.60 | .003 | | 2.06 | 7.87 | 1.83 | 33.77 | .006 |
60s | 35(13.3) | 15(12.0) | 20(14.5) | | 8.00 | 1.99 | 32.23 | .003 | | 2.18 | 8.82 | 1.79 | 43.54 | .008 |
70s and over | 12(4.6) | 5(4.0) | 7(5.1) | | 6.00 | 1.05 | 34.21 | .044 | | 1.43 | 4.17 | 0.58 | 30.20 | .157 |
Managerial position | 124(47.2) | 53(42.4) | 71(51.5) | | 1.42 | 0.87 | 2.32 | .160 | | -0.38 | 0.69 | 0.35 | 1.34 | .271 |
Department | | | | | | | | | | | | | | |
General medicine | 25(9.5) | 12(9.6) | 13(9.4) | | Reference | | | | | | Reference | | | |
Internal medicine | 113(43.0) | 48(38.4) | 65(47.1) | | 1.23 | 0.52 | 2.94 | .640 | | 0.15 | 1.16 | 0.42 | 3.20 | .770 |
Surgery | 31(11.8) | 18(14.4) | 13(9.4) | | 0.67 | 0.23 | 1.93 | .454 | | -0.41 | 0.67 | 0.19 | 2.34 | .527 |
Psychiatry | 21(8.0) | 11(8.8) | 10(7.3) | | 0.84 | 0.26 | 2.68 | .767 | | -0.59 | 0.55 | 0.14 | 2.16 | .394 |
Orthopedics | 20(7.6) | 7(5.6) | 13(9.4) | | 1.58 | 0.47 | 5.35 | .460 | | 0.61 | 1.83 | 0.46 | 7.40 | .394 |
Others | 53(20.2) | 29(23.2) | 24(17.4) | | 0.79 | 0.30 | 2.06 | .631 | | -0.33 | 0.72 | 0.23 | 2.21 | .561 |
During the multivariate analysis, 260 participants were analyzed, except for 3 participants in the group in which the sex of the doctor was unknown. The group that was able to communicate their concerns (communicating group) to the doctor was designated as the reference. CI: confidence interval, OR: odds ratio, aOR: adjusted odds ratio, LL, lower limit, UL, upper limit. |
The most common reasons included concern about hurting the physician’s pride (59, 21.1%), fear that their concerns would be dismissed (52, 18.6%), and the belief that the physician should be responsible for making the diagnosis (44, 15.7%). These top three reasons were cited by 155 nurses (55.4%; Table 3).
Table 3: Reasons why nurses failed to communicate concerns to physicians and the frequency of occurrence | Total N = 280 | (%) |
Felt that it would hurt the physician’s pride | 59 | 21.1 |
Felt that the concern would be ignored or not taken seriously | 52 | 18.6 |
Believed that diagnosis is a task for physicians | 44 | 15.7 |
Felt that expressing concern would result in anger from the physician | 40 | 14.3 |
Lack of confidence in the diagnostic assessment | 34 | 12.1 |
Only realized after the end of the clinical session (after outpatient clinic, discharge, etc.) | 17 | 6.1 |
Because the patient or their family was present | 11 | 3.9 |
The physician seemed too busy | 7 | 2.5 |
Out of respect for the physician | 4 | 1.4 |
Other reasons | 12 | 4.3 |
The 136 nurses who were unable to express their concerns to the physicians were asked to select more than one of the 10 items above. |