Urgent, urg

DOI: 10.1111/nuf.12287

C O N C E P T A N A L Y S I S

Conceptualizing collaboration in nursing

Cheryl Emich MSN

The University of Alabama in Huntsville,

College of Nursing, Huntsville, Alabama

Correspondence

Cheryl Emich, MSN, The University of

Alabama in Huntsville, College of Nursing,

301 Sparkman Drive, Huntsville, AL 35899.

Email: [email protected]

Abstract

Nurses practicing at every level need a clear definition of collaboration before

applying the concept in daily practice. Additionally, a conceptual definition of

collaboration in nursing assists nurse researchers in finding or developing instru-

ments for measuring collaboration and attributes of collaboration, which will enhance

research findings. Collaboration extends beyond communication and includes sharing,

teamwork, and respect. Multiple databases including CINAHL, PubMed, and ERIC

were searched using the keywords collaboration, nursing, concept analysis, sharing,

respect, and teamwork. For this analysis, using Walker and Avant’s method, the

conceptual definition of collaboration in nursing is an intraprofessional or

interprofessional process by which nurses come together and form a team to solve

a patient care or healthcare system problem with members of the team respectfully

sharing knowledge and resources. Two instruments consistent with the conceptual

definition of collaboration are The Mayo High Performance Teamwork Scale

(MHPTS) and Team Strategies and Tools to Enhance Performance and Patient Safety

(Team STEPPS) and these instruments are summarized in this study. Finally, case

scenarios are given to illustrate exemplars of collaboration in clinical practice.

K E Y W O R D S

collaboration, concept analysis, nursing, respect, sharing, teamwork

1 | INTRODUCTION

Collaboration is an important concept in healthcare and particularly

in nursing. In 2010, the Institute of Medicine (IOM) included

collaboration as one of the recommendations in “The Future of

Nursing: Leading Change, Advancing Health” report. Additionally, the

American Association of Colleges of Nursing1 stipulated that

interprofessional communication and collaboration are two of the

core essentials for baccalaureate and advanced practice nursing

education programs. The Interprofessional Education Collaborative

(IPEC) (2011) is an organization committed to promoting inter-

professional learning to enhance the collaborative approach to

patient care and to improving healthcare outcomes. In 2016, IPEC2

determined that collaboration was the central concept from which

interprofessional education (IPE) emerged. Furthermore, the Quality

and Safety in Nursing Education Institute3 emphasized the impor-

tance of collaboration within nursing and interprofessional teams.

Changes in federal regulations are also prompting a focus on

collaboration. Senot et al4 noted that collaboration between

physicians and nurses during healthcare delivery could help facilities

avoid financial penalties imposed by the Centers for Medicare and

Medicaid Services (CMS) for not meeting minimum quality require-

ments. The CMS is the federal government’s regulatory entity that

decides reimbursement to healthcare facilities and providers. In

2011, CMS adjusted the reimbursement rules to address confor-

mance of healthcare facilities with quality measures and enhance-

ment of the patient experience to reduce hospital readmission rates

and improve the quality of patient care and patient satisfaction

(Medicare Program; Hospital Inpatient Prospective Payment

Systems, 2011).5 This change in reimbursement is an impetus for

emphasizing collaboration in nursing. By working collaboratively with

other healthcare providers, nurses help to develop and implement

strategies to improve patient experience and decrease readmission

rates, thus increasing CMS reimbursement to the healthcare facility.

Nurs Forum. 2018;1-7. wileyonlinelibrary.com/journal/nuf © 2018 Wiley Periodicals, Inc. | 1

Furthermore, The Joint Commission on hospital accreditation6

correlated the increased collaboration among healthcare providers

to increased patient safety, decreased morbidity, and decreased

mortality. Also, in 2010, the World Health Organization contended

that the detection, prevention, and treatment of serious global

diseases such as HIV/AIDS and tuberculosis needed collaboration of

every type of healthcare worker.

With multiple organizations supporting collaboration as an

essential part of a nurse’s work, collaboration is an essential part

of nursing practice, education, and research. When teaching about

effective collaboration in the nursing curriculum, educators need a

thorough understanding of the concept. Nurses practicing at every

level need a clear definition of collaboration before applying the

concept in daily practice. Developing a conceptual definition of

collaboration in nursing assists nurse researchers in identifying or

developing instruments for measuring collaboration and attributes

of collaboration, which will enhance research findings. Also, a review

of current healthcare literature showed a need for current analysis of

the concept of collaboration in nursing to bridge the communication

gap between healthcare facilities and primary care nurses.7 The aim

of this paper, therefore, is to develop an operational definition of the

theoretical concept of collaboration, identify attributes of collabora-

tion, and illustrate collaboration in nursing using Walker and Avant’s8

approach to concept analysis.

2 | EXPLORING COLLABORATION IN THE LITERATURE

The term collaboration originated from the Latin word collaboratus

meaning to work together.9 As defined in Merriam Webster's Online

Dictionary, collaboration means working with another person or

group to achieve a goal.9 Surprisingly, one definition found in

Merriam‐Webster's Online Dictionary for collaboration has a negative

connotation of rendering aid to an invading enemy during times of

war. Another definition of the concept used by the US military is

shared power and authority.10

Alternatively, in business, collaboration may refer to individuals

working together toward a common purpose to achieve a mutual

benefit (Association for Information and Image Management,

2018).11 Viki12 defined collaboration as people from various

disciplines working together to share an array of views. Viki12 also

associated collaboration with help‐seeking and help giving. Colla- boration can occur within and between organizations, between

individuals, and between countries.13 Green and Johnson13 also

described collaboration as a well‐defined, mutually beneficial relationship between two or more organizations with the purpose

of achieving common goals.

In the liberal arts, the concept of collaboration can refer to

coauthorship, such as the collaboration of Shakespeare and

Fletcher.14 Also, Gardner15 (para. 9) provided a germane definition of

collaboration as “…a process and outcome in which shared interests

or conflict that cannot be addressed by any single individual is

addressed by key stakeholders.” This definition of collaboration is

markedly similar to the definition used in education. Montiel‐ Overall16 used terms such as respect, sharing, collegiality, and trust

to describe collaboration in education. A comprehensive definition of

collaboration used in education expresses the formal commitment of

agencies to work together to achieve a common mission while

sharing resources, power, and authority.17

Sims et al18 described collaboration in healthcare as team

members communicating and working together in a supportive and

respectful atmosphere. Mulvale et al19 inferred that teams and team

structure are critical components of collaboration in the healthcare

setting. Hojat and Gonnella20 identified teamwork as an important

construct of collaboration. Alternatively, Pajarillo21(p.1) described

collaboration as “a process that is evolving, changing, and emerging in

response to a critical situation or problem that is patient or health‐ care related.” Researchers stressed the importance of mutual respect

for team members during collaboration.13,18,22

More specifically, in nursing, collaboration may refer to intrapro-

fessional interaction, between nurses, or interprofessional interac-

tion, between nurses and others outside the nursing profession.

Interestingly, O’Leary et al23 studied the phenomenon of nurse‐ physician collaboration and reported that physicians described

collaboration with nurses as positive, whereas nurses insisted

collaboration with physicians was lacking. This discrepancy resulted

from the varying definitions of collaboration noted between the two

parties. Physicians defined collaboration as the nurse assisting the

physicians24 and nurses defined collaboration as physicians listening

to the nurses’ ideas while formulating plans.25 Fewster‐Thuente26

derived a grounded theory of the process of nurse‐physician collaboration and found that collaboration is a basic social process

occurring in two stages: forming a group and achieving harmony and

as a process that should not be confused with communication.

Though sometimes used interchangeably with collaboration in

the literature, communication is not the same concept. Communica-

tion is “the act or process of using words, sounds, signs, or behaviors

to express or exchange information or to express your ideas,

thoughts, feelings.”27 According to IPEC (2011), collaboration

encompasses more than just the exchange of information. Collabora-

tion, as noted in IPEC’s 2011 report, includes active listening,

questioning, and discussing. Other concepts closely related to

collaboration, as derived from Merriam Webster's Online Dictionary

cooperate, conspire, conjoin, affiliate, combine, connive, and ally. As

indicated in the discussion thus far, common themes noted in the

definitions for the concept of collaboration extracted from the

literature indicate collaboration includes teamwork, sharing, and

respect.

3 | ATTRIBUTES OF COLLABORATION

The characteristic most often attributed to collaboration in the

literature is “sharing.” D’Amour and Oandasan28 discussed shared

objectives and goals as a necessity for multidisciplinary collaboration.

2 | EMICH

Sharing encompasses more than goals and objectives. Sharing,

concerning collaboration, also involves sharing of resources13 and

in decision‐making.15,22,23,29 Gardner15 stated, sharing in the deci- sion‐making process is one of the key traits of collaborative relationships. Green and Johnson13 expanded the meaning of sharing

to include sharing of costs and risks when collaborating as well as

sharing in the rewards for positive collaborative outcomes.

In addition to sharing, “teamwork” is another defining attribute of

collaboration noted in the literature. Collaboration requires working

together with open minds and valuing the contributions of each team

member.13 In education, administrators facilitated teamwork by

restructuring lecture planning times to enhance teacher‐to‐teacher collaboration.30 Teamwork encompasses the sharing of expertise,

cooperating, and coordination with other professionals, as in the

healthcare field.31 Additionally, the National League for Nursing’s32

recommendation for nursing faculty called for the development of

learning opportunities that promote nurses as members of inter-

professional teams. Teamwork allows for collaboration and coordina-

tion of care by members of the healthcare team.18

Researchers identified teamwork as an attribute of collabora-

tion20 and collaborative behavior.33 Research also supports the

implementation of healthcare teams and teamwork. For example,

teams and teamwork appeared to be integral in caring for older

people as noted in a study by Fulmer.34 Also, researchers noted

positive outcomes when pharmacists, physicians, and nurse practi-

tioners (NPs) worked as a team, such as improved decision‐making related to drug therapy, continuity of care, and patient safety.35

Health professions students reported teamwork was a key factor in

the improvement of patient outcomes.36

The final attribute of collaboration discussed in the literature is

“respect.” Mutual respect for each healthcare team member’s role

and profession is necessary for effective collaboration.13,18,22 Team

members must value what other members of the healthcare team

bring to the discussion13 including the roles and knowledge of the

team members.22 Respect requires healthcare teams to forego any

hierarchical structure and allows all members to be equals.22

Furthermore, physicians and nurses need a positive and respectful

relationship to ensure the quality of patient care.4

These attributes, “sharing,” “teamwork,” and “respect,” also serve as

empirical referments for the concept. Empirical referments are how one

can determine that the concept has occurred.8 In the literature,

collaboration can refer to intraprofessional or interprofessional team

committees or team rounds.35,37 However, attendance during team

rounds does not guarantee that collaboration occurred. Team members

must take part in the teamwork by sharing of information and resources

and show respect for other team members while discussing and

developing patient care plans or solutions to health system problems.

4 | ANTECEDENTS AND CONSEQUENCES

Before collaboration begins, certain antecedents, or conditions, must

be present. Initially, nurses need a willingness to participate in

collaboration.12,26,38 Next, nurses need to possess effective commu-

nication skills, interpersonal skills, and the ability to work as a

team.15,26,39-41 Rossler and Kimble41 also stressed the importance of

a common vocabulary to improve understanding among various

disciplines, specifically within the healthcare setting.

Another important antecedent of collaboration is an opportunity

to collaborate. Nurses depend on leaders to encourage collaboration,

optimize work schedules, and structure work environments that

facilitate collaboration.12,22,30,40 Along with the opportunity to

collaborate, nurses need a precipitating event that causes collabora-

tion. In nursing, this event is often a patient‐related problem or a health system problem that one cannot solve alone.12,26 Gardner15

cautioned, however, that not all problems need collaboration. For

example, a NP can diagnose and treat hypertension without involving

a team of healthcare providers. However, a NP should collaborate

with a physician and pharmacist when managing a critically ill patient

on multiple medications.

An equally important antecedent of collaboration is knowledge of

one’s roles and skills as well as the roles and skills of others. Knowing

the roles and skills of each member of the healthcare team allows for

contacting the person best equipped to aid in solving the identified

problem.26,38,40 Finally, nurses willing to take part in collaboration

must be willing to accept the group consensus.12,26,38

Consequences of a concept equate to outcomes and may yield

future research variables.8 Positive consequences of collaboration in

nursing include improvements in patient safety, patient satisfaction,

patient care, and decreases in error rates, patient mortality, patient

length of stay, and healthcare staff turnover rates.42 Makowsky

et al35 noted that when pharmacists collaborated with NPs and

physicians about patients’ medications, the collaboration improved

the knowledge of the providers and, thus, improved patient outcomes

such as adherence to medication instructions. Another positive

consequence of collaboration is job satisfaction for nurses.28,43

A negative consequence of collaboration is the inability to work

independently due to excessive collaboration.44 Seeking a group

consensus on every decision can stymie the workflow.44 Knowing

when to start and stop collaboration is important in decreasing

excessive or unnecessary collaboration.13,26

5 | CONCEPTUAL AND OPERATIONAL DEFINITION OF COLLABORATION IN NURSING

For this analysis and based on the discussion from the previous

sections, the conceptual definition of the concept of collaboration in

nursing is an intraprofessional or interprofessional process by which

nurses come together and form a team to solve a patient care or

healthcare system problem with members of the team respectfully

sharing knowledge and resources.

Researchers have used various instruments to measure colla-

boration or a person’s readiness to engage in collaboration.39,41,45

However, few instruments exist that measure the attributes of

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collaboration in a nursing or healthcare setting. For the purpose of

this study, two instruments which are consistent with the conceptual

definition of collaboration, were reviewed, The Mayo High Perfor-

mance Teamwork Scale (MHPTSP)46 and Team Strategies and Tools

to Enhance Performance and Patient Safety (Team STEPPS).47 These

instruments contain some items specific to the attributes of

collaboration: sharing, teamwork, and respect.

MHPTS is a 16‐question survey completed by team members rating the effectiveness of teamwork on a scale of 0 to 2 with 0

meaning never or rarely and 2 meaning consistently.46 Self‐rated items on the MHPTS consistent with the attributes of collaboration are:

each team member demonstrates a clear understanding of his or her

role, team members repeat back instructions for clarity, all team

members are involved and participate in the activity, and team

members call attention to actions that may cause errors or

complication. Malec et al46 concluded that the MHPTS has

satisfactory internal consistency and construct validity.

TeamSTEPPS is a 23‐item observation tool consisting of a 1 to 5 rating scale with 1 meaning very poor and 5 meaning excellent.48

Observational items included on the TeamSTEPPS tool consistent

with the attributes of collaboration are: includes patients and families

as part of the team, identifies team members’ roles and responsi-

bilities, seeks information from all available sources, verifies that

information is communicated, role models team behaviors, fosters

communication, and effectively advocates for the patient.48 The

Department of Defense and the Agency for Healthcare Quality and

Research (AHQR) jointly developed TeamSTEPPS49 and the validity

and reliability were supported by Castner.50 The most effective

means of measuring collaboration requires the researcher’s keen and

consistent observations of team behaviors in addition to peer

evaluations of the team members.

6 | EXEMPLARS OF COLLABORATION

Four exemplar models, including model case, borderline case, related

case, and contrary case are discussed below. The model case is an

ideal representation of the attributes of collaboration and presents a

clear picture of collaboration. The borderline case has most of the

attributes of the concept, but not all. The related case is an

illustration of a related or similar concept, but the attributes of the

concept of focus. Finally, the contrary case is an example of what the

concept is not.8

6.1 | Model case

A NP incidentally noted a mass on a patient’s neck during an office visit.

After examining and questioning the patient, the NP realized the mass

was highly suspicious for malignancy. The NP discussed this with the

patient, including the need for a timely workup. The patient was grateful

and agreed to the expedited workup. The NP called the radiologist and

related the examination findings and her concerns. Together, they

discussed which imaging study would provide the best diagnostic data.

The NP called an ears, nose, and throat (ENT) specialist, and discussed

the patient’s case and related the plan she had initiated with the

radiologist. Also, the NP and the ENT specialist agreed that after the

patient finished the imaging study ordered by the NP, he should go

directly to the ENT specialist’s office to discuss the results. The

radiologist called the NP and ENT specialist with a report and confirmed

the findings of a mass suspicious for malignancy. The radiologist sent a

copy of the films with the patient for the ENT physician to review. The

ENT specialist called the NP at the end of the day to thank her for the

referral and related that the patient was pleased with the prompt and

caring service they had received from all providers.

This case illustrates the attributes of collaboration as well as the

benefits of collaboration. The NP showed respect for the patient by

having a frank discussion with him regarding the seriousness of the

findings as well as taking the time to expedite the work up and

referral. The radiologist and the NP exhibited teamwork and sharing.

Together, they discussed the findings and planned what tests to

order. The ENT specialist and NP also demonstrated mutual respect

for each other’s opinion. They engaged in teamwork by coordinating

the care of the patient. Each provider and the patient shared in the

decision‐making process. The result was an expedited process to managing the patient’s problem and high patient satisfaction.

6.2 | Borderline case

Angela is the Clinical Nurse Specialist (CNS) for the medical floor at a

local hospital. Angela wanted to develop a mentoring program for

newly hired nurses assigned to the medical floor. Angela randomly

surveyed individual nurses to assess positive and negative percep-

tions they had about the work environment on the medical floor.

Angela thanked the nursing staff for their participation, demonstrat-

ing that she respected their input and perspectives. Angela used the

feedback to design a mentoring program and distributed the new

mentoring policy to the nursing staff.

This case illustrates two of the attributes of collaboration. First,

this scenario demonstrates respect for the nurses who participated in

the survey. Angela sought their input and thanked them for

participating. Second, the nurses who participated in the survey

shared their opinions and concerns with Angela. This case falls short

of collaboration in that teamwork did not occur. Angela surveyed the

nurses individually as opposed to bringing the nurses together to

discuss the topic as a group. Angela did not include the nurses in the

decision‐making process, thus reinforcing that teamwork was a missing attribute in this process.

6.3 | Related case

The physician comes to the intensive care unit (ICU) to see a patient

recently admitted from the emergency department (ED). After

interviewing and examining the patient, the physician writes his notes

and orders in the chart. The physician tells the bedside nurse the list of

medical orders for the patient and asks the nurse to notify him if the

patient’s condition deteriorates. The nurse acknowledges the physician’s

4 | EMICH

orders and notifies the physician of another consult in the ICU. The

physician goes to see the new consult.

While this case is typical of many nurse‐physician interactions in the hospital setting, the exchange falls short of collaboration and is

a better example of communication. The nurse and physician

exchanged information; however, important attributes of collabora-

tion are missing. The nurse and physician did not share information

and knowledge, or share in the decision‐making, nor did they function as a team or demonstrate respect. The nurse and physician

functioned in the typical hierarchical relationship of the physician

giving orders to the nurse to carry out without discussing patient

care and goals. Likewise, the nurse merely passed along information

to the physician without elaborating on the patient’s condition.

6.4 | Contrary case

Paramedics brought a 60‐year‐old female to the ED by ambulance after she fell into the lake trying to exit a boat. Initially, paramedics

recorded a blood pressure of 138/80 mm Hg; however, on arrival to

the ED, the patient’s blood pressure was recorded as 90/60 mm Hg.

The nurses and physicians in the ED failed to review the records from

the paramedics. X‐rays of the patient’s hips confirmed a left hip fracture for which she underwent surgical repair.

The following day, the patient was complaining of shortness of

breath, which she attributed to her asthma. The nursing staff did not

note any wheezing on the examination and did not discuss this with the

orthopedic surgeon. The orthopedic surgeon, who was now in charge of

the patient’s care, ordered the continuation of the patient’s home

medications and started an anticoagulant postoperatively to reduce the

patient’s risk of blood clot formation. The nurse reviewed the patient’s

medication list and discovered that the patient usually took two

medications to lower her blood pressure. When the nurse called to

confirm the order to continue the blood pressure medications, the

orthopedic surgeon’s angry reply was to follow the orders and not to call

back unless there was a change in the patient’s status. The patient’s

morning blood pressure was 85/58 mm Hg; however, the nursing staff

assumed the surgeon saw this when he reviewed the chart before

ordering the home medications. The nurse decided not to administer the

blood pressure medication due to the low blood pressure. The hospital

transferred the patient to a rehabilitation facility without addressing the

low blood pressure and without further evaluation of her shortness of

breath. After arriving at the rehabilitation facility, the patient’s shortness

of breath worsened, and her blood pressure remained low. The staff

at the rehabilitation facility transferred the patient back to the ED for

re‐evaluation. The ED physician ordered a chest x‐ray and diagnosed blood around the lungs (a hemothorax) and two fractured ribs. A

vascular surgeon placed chest tubes to drain the blood from around the

lungs and ordered a transfusion of four units of blood. By the following

day, the patient’s breathing and blood pressure had improved.

This case illustrates a complete lack of collaboration that resulted

in readmission for the patient and additional procedures and costs.

The nurse and the surgeon never fully evaluated the cause of the

patient’s shortness of breath or low blood pressure. Each assumed

the other was monitoring the situation. More importantly, the patient

assumed each member of the healthcare team was communicating

and coming together to provide her with the best possible medical

and nursing care. This case demonstrates a lack of shared decision‐ making, lack of mutual respect, and lack of teamwork. This case

represents what collaboration is not.

7 | SUMMARY

In summary, collaboration is a complex process requiring sharing,

respect, and teamwork. Whether intraprofessional or interprofes-

sional, collaboration leads to improved patient safety, improved quality

of care,19,35,36,42 and job satisfaction for healthcare providers.28

Multiple national and international organizations such as AACN,1

CMS (2011),3,31,32,51 and WHO42 acknowledge that collaboration is an

essential concept in nursing and healthcare. Nurse researchers need to

evaluate the effectiveness and outcomes of collaboration. However,

nurse researchers need a clear conceptual definition of collaboration

in nursing because an inclusive definition of collaboration aids in

the development of instruments to measure collaboration and is useful

in teaching the process of collaboration. Finally, nurses must model the

attributes of collaboration: engaging in teamwork, sharing in the

decision‐making process, and showing respect for other members of the healthcare team to improve the quality of patient care.

ORCID

Cheryl Emich http://orcid.org/0000-0001-6705-6568

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How to cite this article: Emich C. Conceptualizing

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