Community Health Centers
Nurs Admin Q Vol. 32, No. 1, pp. 40–48 Copyright c© 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Interdisciplinary Collaboration for Healthcare Professionals
Lori Fewster-Thuente, MSN, RN; Barbara Velsor-Friedrich, PhD, RN
Interdisciplinary collaboration has the capacity to affect both healthcare providers and patients. Research has shown that the lack of communication and collaboration may be responsible for as much as 70% of the adverse events currently reported. The purpose of this article is 2-fold: to exam- ine factors that may influence interdisciplinary collaboration and consequently patient outcomes and to examine the relationship between interdisciplinary collaboration and King’s theory of goal attainment as a theory to support the phenomenon of interdisciplinary collaboration. Key words: communication, goal attainment, healthcare professionals, interdisciplinary collaboration
INTERDISCIPLINARY COLLABORATIONis a vital phenomenon to healthcare providers and patients. The level of collab- oration that takes place among providers can directly impact patient outcomes. Joint Commission currently reports that almost 70% of patient adverse events cite the lack of collaboration and communication between providers as a main cause of error.1 An increase in nurse-physician collaboration and communication can improve both patent outcomes2–6 and provider satisfaction.7,8
The purpose of this article is to exam- ine factors that may enhance or inhibit in- terdisciplinary collaboration, which, in turn, may impact patient and nursing outcomes. Factors such as gender, age, culture, and level of education of the nurse or physician can directly impact the perceived level of collaboration.8–10
From the Marcella Niehoff School of Nursing, Loyola University Chicago, Chicago, Ill.
We thank Dr Imogene King for her expertise and guid- ance in the creation of this article.
Corresponding author: Lori Fewster-Thuente, MSN, RN, Loyola University Chicago, 6525 North Sheridan Rd, Chicago, IL 60626 (e-mail: llfewster@hotmail.com).
An equally important purpose of this article is to examine a theory that has the potential to both support and improve nurse-physician collaboration. Currently, there are no specific structured models or theories found in the literature that provide a base for interdisci- plinary collaboration. This article will exam- ine the relationship between the concept of interdisciplinary collaboration and King’s the- ory of goal attainment. Historically, the theory of goal attainment has focused on the interac- tion between the nurse and the client; how- ever, King stated, “it can be used not only by nurses with their patients but by any individ- ual in any interactions with other profession- als” (I. King, personal communication, April 11, 2006).
The theory of goal attainment has been used to guide nursing practice and research for approximately 30 years. King’s theory has been used by nurses, administrators, and other healthcare providers in more than 13 countries.11 As one can see, this theory has depth and scope beyond bedside nursing. The theory has also been used with nurs- ing administration12,13 and to guide nursing curricula.14 King’s theory has been tested in research and used in every patient popula- tion from infants to the elderly. Specific mod- els such as the Wicks family health model15
40
Interdisciplinary Collaboration for Healthcare Professionals 41
and the Advance directive decision making model16 have been derived from it to guide nursing practice.11 The theory has helped develop research instruments and facilitated other middle-range theories such as the The- ory of Group Power.12 Use of the theory of goal attainment to foster interdisciplinary collaboration with the intended outcome of improved patient and nursing outcomes is presented.
REVIEW OF LITERATURE
A review of the literature reveals similar def- initions among clinicians on the definitions of collaboration. As stated by Lindeke and Siek- ert, “Collaboration is a complex process that requires intentional knowledge sharing and joint responsibility for patient care.”17
The American Nurses Association18 defines collaboration in nursing by looking at 4 main components:
• a partnership with mutual valuing • recognition of separate and combined
spheres of responsibility • mutual safeguarding of legitimate inter-
ests of each party • recognized shared goals In healthcare, collaboration is defined as
“a complex phenomenon that brings together two or more individuals, often from different professional disciplines, who work to achieve shared aims and objectives.”19 This definition was chosen as the working definition as it in- cludes other disciplines and how they work to reach a common goal.
There also seems to be a consensus among authors regarding the defining attributes of the concept of collaboration. Attributes of collaboration include shared power based on knowledge, authority of role, and lack of hierarchy.20 Wells et al21 determined the following attributes related to collaboration: open communication, cooperation, assertive- ness, negotiation, and coordination. As a result of a concept analysis, Henneman et al determined that the following attributes were associated with collaboration: “joint venture, cooperative endeavor, willing participation,
shared planning and decision-making, team approach, contribution of expertise, shared responsibility, nonhierarchical relationships, and shared power based on knowledge and expertise.”22
The term teamwork is often used as a syn- onym to collaboration.23 However, the litera- ture shows that teamwork is 1 attribute of a collaborative relationship.24,25 Topics such as joint practice, communication, and collegial- ity are similar to collaboration but have differ- ent meanings and will, therefore, not be ad- dressed in this article.26
The review of literature did not reveal a specific theory that was used to sup- port or encourage interdisciplinary collabo- ration. Although not specifically developed to address interdisciplinary collaboration, the transaction process of King’s theory of goal attainment, when used by healthcare pro- fessionals, results in collaboration among nurses, physicians, and allied healthcare professionals.
THE THEORY OF GOAL ATTAINMENT
King27 developed a conceptual system, which consists of 3 interacting systems: per- sonal, interpersonal, and social. Each system contains its own defining concepts. The per- sonal system includes individuals interacting with their environment and incorporates the concepts of growth and development, self, space, time, perception, and body image. The interpersonal system involves human beings interacting with one another in a variety of environments. The concepts associated with the interpersonal system are communication, interaction, role, stress, and transaction.
Societal systems consist of groups of 2 or more individuals interacting, each working in its role, toward a collective goal. Healthcare organizations are an example of a social system that consists of groups of those individuals in society who interact with one another for a common purpose, the better patient care. There are groups within groups in each hospital, such as a palliative care team in an oncology ward, which set goals with
42 NURSING ADMINISTRATION QUARTERLY/JANUARY–MARCH 2008
individual patients and families, and work toward achieving those goals. The concepts of a social system are power, status, authority, and decision making.27
Utilizing this conceptual system as the foundation, King developed the theory of goal attainment. Briefly stated, the theory of goal attainment addresses the interactions of nurses with their clients to achieve health outcomes and attain goals. King determined, “The focus of nursing is human beings inter- acting with their environment leading to a state of health for individuals, which is their ability to function in social roles.”27
The theory of goal attainment utilizes the concepts of perception, communication, in- teraction, and transaction. It is an interaction- transaction process in which nurses and clients interact to mutually define and set goals. They proceed through the transac- tion phase, the means by which to achieve goals, toward goal attainment.13 Nurses work to help individuals maintain or regain their health and return to their highest level of functioning.27
The interactions between team members and the client are what contributes to the strength of the process. Interactions are de- fined as “process of perception and communi- cation between person and environment and between person and person, represented by verbal and non-verbal behaviors that are goal- directed.”27 These interactions cause all in- volved to feel respected and positive about the mutual goals set.
The interaction-transaction process can be used in any interaction with 1 or more individuals in healthcare situations. When this process is utilized by the members of the interdisciplinary teams, within the theory of goal attainment, the result is collaboration and hopefully the best patient outcome.
It is through interdisciplinary collabora- tion and patient communication that goals for client’s health outcomes are developed and implemented. In the following quote substituting “physician” or other healthcare provider for “client,” interdisciplinary collab- oration is supported when overlaid with the theory of goal attainment.
Nurse-(physician) interactions are characterized by
verbal and nonverbal communication in which in-
formation is exchanged and interpreted by trans-
actions in which values, needs and wants of each
member of the dyad (team) are shared, by percep-
tions of the nurse, (physician), and the situation, by
self in role of nurse, self in role of (physician), and
other stressors influencing each person and the sit-
uation in time and space.28
Healthcare providers seek to improve the health of their patients. However, health can be a multidimensional goal for both providers and patients, and may have different mean- ings for different people. Although King’s the- ory of goal attainment is focused on nurs- ing, in which it is the work of nursing to help patients optimize their resources to achieve maximum potential for daily living, other healthcare professionals also participate in that work. The path to improved health through collaboration and goal attainment is besieged with barriers that both patients and providers must attempt to overcome every day. It is important to know and understand the barriers in order to overcome them.
BARRIERS
The barriers to goal attainment between nurses and clients are the same as the barri- ers to collaboration among members of the in- terdisciplinary healthcare team. The review of literature discussed the following barriers to collaboration: patriarchal relationships, time, gender, culture, and lack of role clarification. These barriers can also inhibit the ability to set and attain goals. A discussion of these barriers follows.
Patriarchal relationship
The primary relationship in the theory of goal attainment is between the nurse and the client in which the nurse is the author- ity figure. Historically, the nurse-physician re- lationship has been one of hierarchy and power with the balance of power going to the physician. The literature regarding this topic dates back to 1967 when Dr Stein wrote a hallmark article, “The Doctor-Nurse Game.”29
In this article, the relationship between the
Interdisciplinary Collaboration for Healthcare Professionals 43
doctor and the nurse was described as one where the nurse played a very subservient role to the physician. Although advances have been made, this type of portrayal is fea- tured still today in television and films. In this model, it is difficult for collaboration to occur.
Revenue generation amplifies the patriar- chal relationship. As physician services are billed separately, it is easy to see that physi- cians contribute to the bottom line of the or- ganization. The work of nursing is generally compiled into the overall hospital bill. Accord- ing to Fagin,30 the direct impact to the bot- tom line puts the balance of power in favor of the physician. Collaboration can take place only when hierarchy is not present, and ev- eryone’s knowledge is valued and taken into account.
The patriarchal relationship is important to study as physicians are seen as the lead- ers of the interdisciplinary team. Therefore, it is important to understand their perspective and imperative that they participate in the re- search. As noted in the Baggs et al8 study, lack of time or interest is the reason why many physicians have chosen not to participate in interdisciplinary collaborative research. Wells et al21 found that physician participation is a statistically significant element to successful execution of interdisciplinary collaboration.
Goal attainment is a mutual process be- tween any 2 individuals who have formed a relationship such as a nurse and a client. The nurse has the knowledge base and expertise to work in collaboration with the patient to develop health-related goals and, therefore, is in the position of power. Nurses who are un- comfortable in leading and directing patients may feel a conflict over the role they play in the patient’s care. Similarly, a patient who is used to being in the position of power may have difficulty in working with a healthcare provider who may be younger or seem inex- perienced.
Time
Time, or lack of it, was also found to be a barrier to collaboration and goal attainment.
As collaboration is a vital step in the attain- ment of goals, it is imperative that time is al- lotted for team members, including the client, to collaborate.4,31
Because of the nursing shortage, nurses to- day have larger patient loads and a limited amount of time to spend with each patient. These factors may not allow for mutual goal setting or attaining. The use of the services of temporary or agency nursing staff may cause additional confusion as the nurse may not be aware of the organization’s practices and policies. In addition, the organization may not have a structured communication process that allows the team members to discuss pa- tient situations and set appropriate goals. To add to the situation, more nurses are work- ing part-time and, therefore, may not know pa- tients or physicians as well, and may not feel comfortable approaching a physician they do not know. Combine part-time workers with increased patient loads, and there is little time for healthcare providers to interact with each other and their patients.32 Collaboration re- quires trust, and to build trust, people need time for interaction.
Utilizing King’s theory, Rundell33 studied the interaction of patients and nurses in an in- tensive care step-down unit and found com- munication between the two increased as the time spent in the unit increased. Time is re- quired on the part of both, the patient and the provider. Providers who take time to commu- nicate with their patients can help clarify the roles that they each play.
Lack of role clarification
Because of the nursing shortage and eco- nomic changes, unlicensed assistive person- nel are providing a great deal of patient care that was previously rendered by nurses. Physi- cian roles too are changing. Druss et al34
found that by 1997, 36% of outpatient care was provided by nonphysician clinicians such as advanced practice nurses and physician as- sistants. This is up from 30.6% in 1987.
Lack of role clarification is difficult for providers. Without distinct role boundaries as to who has responsibility for the patient, it is
44 NURSING ADMINISTRATION QUARTERLY/JANUARY–MARCH 2008
difficult to determine with whom one would collaborate. The collaboration between the team members and their patients is a result of the transactions that occurred. Transactions occur when human beings are observed in- teracting with their environments.27 It is each person, acting in his or her role with the client, that helps complete a step toward goal attainment. The interaction of these roles and the mutual goals that result together form the interdisciplinary collaboration.
Interdisciplinary collaboration plays an im- portant role in eliminating errors, duplica- tions in care, and clarifying of roles. When collaboration takes place among the nurse, client, and physician, each person under- stands the goals and the process through which to attain those goals.
In addition, lack of role clarification can make it difficult for patients to know who is caring for them. Many of the patient goals can be worked on by other personnel than the nurse; that is, a patient goal is to be ambula- tory; therefore, the certified nursing aide may assist the patient in a walk. However, the goals need to be mutually determined by the patient and the interdisciplinary team; therefore, it is important for patient understanding and com- fort to know the team members and the roles that they fulfill.
It remains a common misunderstanding among patients that roles are clarified by gen- der. The misunderstanding is that a female healthcare provider who comes into a pa- tient’s room must be a nurse and the male provider is a physician.
Gender
Historically, women were nurses and men were physicians. However, as healthcare evolves, more men are becoming nurses, and more women are becoming physicians. Al- though men represent only 7% of the nursing population, medicine is almost equally repre- sented by both men and women.10
However, the impact of male physician’s dominance over female nurses still comes into play. A vignette-based survey was con-
ducted, which studied the female nurses’ (n = 197) responses to physician gender.35 The authors found that when both the physi- cians and nurses were female, the level of collaboration was higher and the balance of power more equal. The study also found that nurses were less likely to confront a male physician. This fact reinforces the dominant role of the male physician. The study did not explore why nurses were less likely to con- front male physicians.
A study by Wear et al10 supported the con- cept that female nurses are more collabora- tive with female physicians. The results from a qualitative survey showed that female nurses reported higher level collaboration with fe- male physicians than with male physicians.
Gender issues between providers and pa- tients still occur today. For example, elderly women, now a large population of patients, may not be comfortable with a male nurse providing their care. Conversely, a man from a male-dominated country may not take direc- tion from a female nurse or physician.
Culture issues are similar to gender issues in that they are based on misunderstanding or the lack of knowledge. These issues tend to occur when people have preconceived no- tions about how things should be, as opposed to how they are.
Culture
The final barrier to collaboration to be dis- cussed is culture. Culture can be discussed from a country, organizational, professional, or an individual perspective.9,22,36 The United States has a culture that values autonomy, in- dependence, and free thinking. This mindset can impact the client’s desire to take direc- tion from the healthcare provider as to the types of goals to be set. In addition, when the provider and client are from different cultures or speak different languages, many issues can occur: lack of translators, difference in ideas for goals, and lack of understanding regarding various cultures and religious practices.
The disciplines of medicine and nurs- ing are rooted in vastly different theoretical
Interdisciplinary Collaboration for Healthcare Professionals 45
frameworks that impart a culture for the care each provides. These ideas strongly contrast with collaboration. Headrick et al36 found healthcare professionals to be autonomous in their work. However, the international study by Hojat et al9 found that US physicians, al- though still dominant, were less hierarchy- based than those in other countries.
In addition to a country’s culture, each individual organization has its own culture. If the organizational culture is one that promotes hierarchy, there is likely to be little collaboration. However, if the organizational culture models and rewards collaborative behavior, there is more of a chance that collaboration will occur. An article by Arford discussed the accountability organizations have to create a climate of collaboration. The values and beliefs of the organization are echoed in team members’ desire to collaboration and communication.37
Barriers such as patriarchal relationships, time, gender, lack of role clarification, and culture can have a negative impact on pa- tient outcomes. There can be many poten- tially harmful outcomes to patients when such barriers inhibit providers and patients from collaborating. On the flip side, there can be positive outcomes for patients and providers when collaboration takes place and goals are attained.
PATIENT OUTCOMES
The goal of interdisciplinary collaboration is to achieve the positive health outcomes for patients. The theory of goal attainment is also focused on positive health outcomes, as these outcomes are a direct measure of the quality of care provided.28 Interdisciplinary collabo- ration and goal attainment are related as col- laboration is necessary to attain the desired goals and reach these outcomes.
Lack of collaboration can have a negative ef- fect on patient outcomes. Organizations such as the Institute of Medicine and Joint Commis- sion have published many studies and reports such as To Err Is Human,38 which discuss in
part that healthcare teams who fail to collab- orate have increased mortality and failure-to- rescue (deaths within 30 days of admission among patients who experienced specific complications) rates. Accreditation agencies such as the Joint Commission have now put collaboration practice guidelines into place for healthcare organizations and are requiring their implementation for accreditation.39 The organizations are graded on such things as in- terdisciplinary practice plans.
Negative patient outcomes related to col- laboration have also been found by Baggs et al.8 In this study, it was determined that the lower the level of nurse-reported collabora- tion, the higher the risk of a negative outcome such as readmission to the intensive care unit or mortality. This point is also supported by the theory of goal attainment in that patient goals cannot be attained if collaboration does not take place.
A study by the Patient Safety Culture and Teamwork40 surveyed high-risk area nurses in the intensive care unit, emergency depart- ment, and operating room (n = 261). The survey measured the levels of communication and collaboration of nurses with physicians and other staff members. The survey of nurses found that almost 70% felt the quality of col- laboration with physicians was low or merely adequate. However, to keep patients safe, al- most all nurses surveyed felt that commu- nication and collaboration were at par with skill. They further discovered that 85% of the respondents felt that more input should be garnered from team members when making patient-care decisions.
The strongest evidence that supports the idea that interdisciplinary collaboration and the theory of goal attainment can impact pa- tient outcomes positively is found in the cur- rent literature. A randomized controlled trial was conducted by Curley et al,6 in which pa- tients and staff were randomized to 6 wards. Three wards received an intervention that included daily interdisciplinary rounds. Dur- ing these rounds, patient-care decisions were made jointly by nurses, therapists, and physi- cians in cooperation with the patient. The
46 NURSING ADMINISTRATION QUARTERLY/JANUARY–MARCH 2008
other three served as the control group. Although no differences in mortality were found, there was a statistically significant de- creased length of stay and reduced hospital charges.
Higgins7 conducted a prospective correla- tional study of collaboration related to pa- tient outcomes. The study tested 4 hypothe- ses, of which 1 was found to be statistically significant. Higgins found that the nurses’ per- ception of collaboration with physicians pos- itively correlated with their level of satisfac- tion regarding their decision-making process of when and where to transfer a patient (cor- relation coefficient of 0.28, P = .000). These patients were found to have fewer readmis- sions to the intensive care unit, decreased length of stay, and decreased mortality.
Use of the transaction process in the the- ory of goal attainment is imperative for posi- tive patient outcomes. Research findings have shown that the collaboration that results from interactions and transactions between pa- tients and their healthcare providers results in goals being set and attained. The theory of goal attainment can be an important step to ensure patient safety.
NURSING BENEFITS
The theory of goal attainment benefits nurses as well as clients. Patient goal attain- ment directly correlates to nursing satisfac- tion, as a major goal of nursing is to see pa- tients return to a functional state of health.
Nurses are also satisfied when collabora- tion is sought regarding patient care, and are dissatisfied when they are not. A cause of nurse dissatisfaction is lack of joint deci- sion making. This is an important component of collaboration to nurses. Baggs et al8 con- ducted a longitudinal descriptive correlation study, using the Collaboration and Satisfaction about Care Decision questionnaire to survey healthcare providers and their patients. The sample included nurses (n = 150), attending physicians (n = 82), residents (n = 74), and patients (n = 1432). A correlation was found
between nurses’ level of dissatisfaction and nurses’ perception of unequal decision mak- ing. However, in this study, lack of collabora- tion did not correlate to retention issues.
A large cross-sectional survey of 820 nurses and 621 patients revealed that on units where nurses report positive working relationships with physicians, there was a significantly lower burnout rate for nurses. In addition, pa- tients from these same units were twice as likely to be “highly satisfied” with their care.5
Studies have revealed the positive out- comes of interdisciplinary collaboration for providers and patients. A significant theory, such as the theory of goal attainment, can guide practice and support the concept of in- terdisciplinary collaboration. There are a few practices that have demonstrated increased interdisciplinary collaboration.
INTERVENTIONS TO ACHIEVE
COLLABORATION
Two methods that aid collaboration and incorporate patient goal setting have been studied and published. Curley et al6 intro- duced, via a randomized controlled trial, an intervention of daily interdisciplinary rounds, which resulted in decreased length of stay and reduced hospital charges. Those who conducted daily rounds included a physi- cian, nurse, social worker, nutritionist, and pharmacist, and consisted of the healthcare providers, discussing each patient and setting short-term and long-term goals. The data in- dicated that this method worked, as patients achieved those goals in a shorter time and were discharged from the hospital.
The other method is collaborative practice order sets for common diagnoses. The use of standardized care plans that are interdis- ciplinary in nature and have been developed by interdisciplinary teams increases the daily collaboration among providers and provides goals for patients with similar diagnoses. The quasi-experimental study conducted by Wells et al21 found that these paths provide a means of collaboration and communication
Interdisciplinary Collaboration for Healthcare Professionals 47
between providers and patients, in both the development and the implementation of the paths.
These 2 interventions, while having pos- itive results, have been limited in their im- plementation. A structured approach that fo- cuses on mutual goals being set and attained may lead to significant positive patient out- comes.
SUMMARY
Healthcare providers have recognized that interdisciplinary collaboration is essential in
the healthcare system to achieve quality care of individuals and groups in communities. The research thus far has found positive pa- tient outcomes associated with positive nurse- physician relationships. To date, however, the interventions to achieve collaboration have been limited in scope and dimension. The ap- plication of the concepts of the goal attain- ment theory can provide a framework for in- terdisciplinary collaboration to move forward in improving outcomes and reducing adverse events. Future recommendations can include testing the use of the transaction process with healthcare professionals.
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