SPECIAL ARTICLE
Exploration of the concept of collaboration within the context of nurse practitioner-physician collaborative practice Sharon Bridges, DNP, ARNP, FNP-BC (Nurse Practitioner) Orlando Health Physician Group, Orlando, Florida
Keywords Collaboration; healthcare collaboration; concept analysis; nurse practitioners; nurse practitioner communication. Correspondence Sharon Bridges, DNP, ARNP, FNP-BC, 1111 Arbor Hill CIR, Minneola, FL 34715. E-mail: [email protected] Received: August 2011; accepted: June 2012 doi: 10.1111/1745-7599.12043
Abstract Purpose: Collaboration in the healthcare setting is a multifaceted process that calls for deliberate knowledge sharing and mutual accountability for patient care. The purpose of this analysis is to offer an increased understanding of the concept of collaboration within the context of nurse practitioner (NP)physician (MD) collaborative practice. Data sources: The evolutionary method of concept analysis was utilized to explore the concept of collaboration. The process of literature retrieval and data collection was discussed. The search of several nursing and medicine databases resulted in 31 articles, including 17 qualitative and quantitative studies, which met criteria for inclusion in the concept analysis. Conclusions: Collaboration is a complex, sophisticated process that requires commitment of all parties involved. The data analysis identified the surrogate and related terms, antecedents, attributes, and consequences of collaboration within the selected context, which were recognized by major themes presented in the literature and these were discussed. An operational definition was proposed. Implications for practice: Increasing collaborative efforts among NPs and MDs may reduce hospital length of stays and healthcare costs, while enhancing professional relationships. Further research is needed to evaluate collaboration and collaborative efforts within the context of NP-MD collaborative practice.
Introduction Supporting and strengthening relationships between nurses and physicians (MDs) have been recognized for some time as beneficial in fostering an environment that supports high-quality patient care (Martin & Coniglio, 1996; Vazirani, Hays, Shapiro, & Cowan, 2005). Effective collaboration in the healthcare environment requires intentional knowledge sharing and shared accountability for patient care (Lindeke & Sieckert, 2005). The purpose of this analysis is to offer an increased understanding of the concept of collaboration within the context of nurse practitioner (NP)-MD collaborative practice. This concept was chosen because there is a gap in the literature regarding the concept of collaboration in the context of NP-MD collaborative practice. Over the last three decades, a growing body of literature has emerged that explores the concept of nurse-MD collaboration from a nursing perspective (Avery, 1995; Boyle 402
& Kochinda, 2004; Henneman, Lee, & Cohen, 1995; Lindeke & Sieckert, 2005; Nelson, King, & Brodine, 2008; Rodts, 2008). However, there is a lack of clarity on this concept within the realm of NP-MD collaborative practice. It is important to conceptually clarify collaboration from this perspective as the roles of staff nurses and NPs differ significantly. Understanding collaboration within the context of NPMD collaborative practice is significant for NPs because it is often applied within different clinical, management, and reimbursement situations, and it is easily misinterpreted if inadequately defined. Additionally, NPs and MDs often experience disagreement regarding issues of autonomous nursing practice. MDs often do not understand the NP role and where the NP fits into the nursing or medical field (Martin et al., 2005). Thus, a clearer conceptualization of the concept of collaboration within this context is warranted to provide knowledge for NPs to guide their practice. Journal of the American Association of Nurse Practitioners 26 (2014) 402–410 C 2013 American Association of Nurse Practitioners
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Concept analytic methodology Rodger’s revolutionary view of concept analysis is utilized for the examination of the concept of collaboration within the context of NP-MD collaborative practice (Rodgers & Knafl, 2000, pp. 77–102). This method is an inductive process that maintains concepts are not stagnant but change over time and are influenced by the context in which they are used (Tofthagen & Fagerstrom, 2010). Thus, the evolutionary model of concept analysis embraces the dynamic nature of concepts, such as of collaboration, and provides a method of continual concept refinement where new meanings can be introduced over time. This model seeks to reveal the attributes of the concept by recognizing its everyday use in existing literature, offering a basis for future inquiry and concept maturity (Russell, 2012). This method of concept analysis does not provide a conclusive definition of the concept of collaboration, but it will provide a direction for further research (Tofthagen & Fagerstrom, 2010).
Literature retrieval and data collection Considering the context of NP and MD collaborative practice, the concept of collaboration was found to have great interest in the fields of nursing and medicine. Therefore, the sample was selected from the population of literature in these domains. The review was limited to publications in the English language. To be included in the analysis, the studies had to be original research or articles from peer-reviewed journals. Thus, dissertations, theses, or news reports were excluded from the analysis. A comprehensive computerized review of the literature was performed to identify prose in the selected domains related to the concept of collaboration within the context of NP-MD collaborative practice. The discussions of the concept of collaboration in regards to NPs and MDs started in the literature in the early 1980s and increased in the 1990s and even more so up to the present time. Therefore, a broad time frame was selected, 1980–2011, to allow for the emergence and significant changes of the meaning of the concept to develop over time. An electronic search of databases, such as Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, Medscape, and Cochrane, was done. The search was performed using all literature indexed under the subject heading of nurse-physician collaboration. The search produced 666 articles in CINAHL, 1089 in PubMed, and 3 in Cochrane. A secondary search on NPphysician collaboration produced four articles in CINAHL, four articles in PubMed, and zero articles in Cochrane. A third search was conducted in CINAHAL, PubMed, and
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Cochrane using the term collaborative practice. This search demonstrated 3167 articles in CINAHAL, 7921 articles in PubMed, and 9 articles in Cochrane. After narrowing this search to articles pertaining to NP, 129 articles in CINAHAL and 406 articles in PubMed were found. Medscape articles are searchable online from 1990 to present. Using the subject heading of nurse-physician collaboration, 696 references were found. A search in Medscape using the term NP-physician collaboration revealed 300 references and another 258 references on NP-physician collaborative practice. There are other surrogate terms (Table 1) for the concept of collaboration and the search using these terms alone in CINHAL demonstrated >12,000 articles, when this search was narrowed to include NP and physician, results demonstrated 134 articles, mostly overlapping previous searches. With such a large yield of articles to choose from with discussions on the concept of collaboration, the sample was derived from articles that were found (a) by using the search terms: nurse-physician collaboration, NP-physician collaboration, or NP-physician collaborative practice, (b) to have collaboration defined and to be relevant to NP-MD collaborative practice, (c) to have discussions of NP-MD collaborative communications, or (d) to have models or discussions regarding the impact on NPMD collaborative practice on healthcare outcomes. The overall search provided a total of 17 studies (Table S1). Of these, there were seven qualitative, eight quantitative, and one mixed method designs from the fields of medicine and nursing, and one qualitative method design from the field of pharmacology. Furthermore, there were two included conceptual analysis and 12 published review articles on the topic of NP-MD collaboration. After the sample was chosen, the published reports were read at least twice to categorize the related concepts and surrogate terms, definitions, attributes, antecedents, and consequences. Similarities and differences of the concept of collaboration with the chosen context were identified and contrasted to make known an operational definition of the concept and to describe the major aspects of the concept.
Critical analysis of the literature Surrogate terms and related concepts Surrogate terms are words that are used interchangeably to express a concept’s characteristics (Tofthagen & Fagerstrom, 2010). Recognizing surrogate terms prior to starting the formal analysis is necessary because every concept is a part of an association of similar concepts and doing so gives perspective to help convey meaning to the concept of concern (Cypress, 2011). 403
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Table 1 Surrogate terms, antecedents, attributes, and consequences of collaboration within the context of NP-MD collaborative practice Surrogate terms Collaborative communication, open communication, sharing of communication, nurse- or NP-physician interaction, consultation, teamwork, and partnerships
Antecedents
Attributes
Consequences
Individual readiness (prior experience), understanding and acceptance of one another’s role and expertise, confidence in each other’s ability, effective group dynamics, communication skills, respect, and trust, environment support of team orientation
Work together cooperatively in a joint adventure, open communication, individuals view themselves as members of a team and contribute to a common goal, shared responsibility and accountability for outcomes, participants offer their expertise and are acknowledged and respected by other team members for their contribution to the process, power is shared in a nonhierarchical relationship, shared planning, problem solving, and decision making, working together cooperatively and coordinating care jointly, assertiveness, autonomy, approachability with consistent consultation, and trust
Advance role integration, foster role clarity, autonomy, and develop trust and respect from both patients and colleagues of NP, reduce healthcare costs and improve patient outcome, improved strategic alliances, improved productivity for both physicians and organizations, noncollaborative work environments contribute to dissatisfaction, job strain, lack of respect, negative behaviors, and role confusion
The selected studies and review articles used common surrogate terms in conveying the concept of collaboration. Communication itself is a method by which the exchange of ideas is transferred between individuals and the term by itself does not contain the exact attributes of collaboration. However, sharing of communication, open communication, and collaborative communication are terms with the same attributes and are used interchangeably with collaboration (Cypress, 2011). Collaborative practice is used interchangeably with collaboration. Moreover, collaboration is often used interchangeably with the terms consultation (a meeting for deliberation, discussion, or decision), teamwork (cooperative or coordinated efforts of a group acting as a team for a common goal), and partnerships (an association of two or more people conducting a business; retrieved online from http://dictionary.reference.com/). It is imperative to discern the concept of collaboration from related terms because although related terms may have something in common with the concept, they do not possess the same characteristics (Tofthagen & Fagerstrom, 2010). The term relationship implies a state of being connected, associated, or involved (retrieved online from http://dictionary.reference.com/). While the term relationship alone has no association to and does not have similar attributes with collaboration, the term collabora404
tive relationship between the NP and MD, which consists of mutual problem solving and accountability, has the same attributes to NP-MD collaborative practice (Kuebler & Bruera, 2000). Additionally, collaboration is often defined in relation to conflict resolution. The terms accommodating, assertive, corporative, and avoidance refer to varying degrees of conflict resolution. Although collaboration denotes some of the attributes of conflict resolution, such as individuals being both assertive and corporative, it does not have the characteristics of individuals being accommodating (unassertive) or displaying avoidance. Thus, although related in some ways, the characteristics of conflict resolution are dissimilar to those of collaboration (Henneman et al., 1995). Also, collaboration does not imply supervision (to direct or oversee performance). Although this term may be related to some NP and MD work relationships, it does not share the same attributes with collaboration (Lindeke & Sieckert, 2005; retrieved online from http://dictionary.reference.com/).
Definitions Collaboration has been defined as a true partnership in which both sides value each other’s power with acknowledgment and acceptance of combined and
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separate fields of responsibility and activity. Moreover, where those involved collectively safeguard the rightful interests and the unity of goals that is acknowledged by each party (Dougherty & Larson, 2005). Thus, collaboration is a manner of working together, with mutual action and planning, which includes shared decision making and communication. It is an interaction with eager cooperation on the basis of mutual authority and power with joint responsibility for the outcome (Dougherty & Larson, 2005; Lamb & Napodano, 1984; Taylor, 2009). Collaboration incorporates the individual point of views and proficiency of team participants on behalf of imparting excellence in patient care (O’Brien, Martin, Heyworth, & Meyer, 2009). Collaborative practice between NPs and MDs is defined as a process through which these providers work concurrently toward a mission of exceptional patient care, implying team members work collegially and cohesively and strive for a common goal (Hallas, Butz, & Gitterman, 2004; Martin, O’Brien, Heyworth, & Meyer, 2005; Norsen, Opladen, & Quinn, 1995). Likewise, it is an interdisciplinary course of action for decision making and communication so as to facilitate the individual skills and knowledge of the healthcare providers. It is an interaction in an atmosphere in which there is a sharing of knowledge and expertise with complementary practice styles, open communication, and mutual trust and respect. Moreover, these providers consult as needed to positively influence the patient care provided to reach the collective goal of achieving quality (Bailey Jones, & Way, 2006; Hallas et al., 2004; Makowsky et al., 2009; Martin et al., 2005; Nelson, King, & Brodine, 2008; Vazirani et al., 2005). The collaborative interaction focuses not only on quality of patient care and outcomes, but also on a relationship that enhances professionalism and mutual understanding (Neale, 1999). Similarly, collaborative communication has been defined as MDs and nurses working in cooperation, mutually accountable for conflict management, problem solving, communication, coordination, and decision making in effort to enhance patient outcomes (Boyle & Kochinda, 2004).
Antecedents Antecedents are contextual features of a concept and are phenomena or events that precede instances of the occurrence of the concept (Cypress, 2011; Tofthagen & Fagerstrom, 2010). The findings of the investigation indicate that instances of the concept of collaboration within the context of NP-MD collaborative practice are preceded by both personal and environmental factors and these were more obvious in the qualitative research studies
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selected for this examination. The extent and breadth of antecedents that have to transpire prior to the incidence of collaboration may well justify healthcare leader’s and clinician’s lack of achievement in promoting collaborative practice (Clarin, 2007; Henneman et al., 1995; Lindeke & Sieckert, 2005). Personal factors. A variety of personal factors have been expressed as previous circumstances to collaboration. These antecedents relate to uniqueness of the group, team, or individuals and convey the readiness of a team member to engage in this manner of interpersonal behavior. This inclination may be the product of a number of factors, such as maturity, prior experience working in similar situations, and educational preparation (Henneman et al., 1995; Lindeke & Sieckert, 2005). Successful group dynamics plays a crucial position in the process of collaboration. Included in the ability to maintain effective group dynamics is the combination of excellent communication and interpersonal skills. These interpersonal skills include approachability, mutual trust and respect, sharing and listening skills, and verbal message skills. In addition, problem solving and conflict management skills are required (Bailey et al., 2006; Boyle & Kochinda, 2004; Goldman, Meuser, Rogers, Lawrie, & Reeves, 2010; Hallas et al., 2004; Henneman et al., 1995; O’Brien et al., 2009). The ability to communicate openly and effectively is a key antecedent to effective collaboration (Clarin, 2007; Lindeke & Sieckert, 2005; Martin et al., 2005; Todd, Resnick, Stuhlemmer, Morris, & Mullen, 2004). Open communication requires that NPs and MDs listen to each other’s points of view, while being self-confident in conveying their own perspective. It is by way of communication that NPs and MDs express their contributions to managing and evaluating patient care (Boyle & Kochinda, 2004; Henneman et al., 1995). A component of open communication is effective social skills that incorporate a comprehension and adjustment of each other’s work styles and limitations. Open communication permits these team members to constructively negotiate together and operates as a means for conveying other important antecedents to collaboration, such as reciprocated respect, trust, and sharing (Boyle & Kochinda, 2004; Henneman et al., 1995; O’Brien et al., 2009). Conflict management skills and problem solving are other important antecedent to collaboration and are the abilities of NPs and MDs to actively convey information to ensure that available expertise are used in conflict negotiation so the best feasible resolution is realized (Boyle & Kochinda, 2004; Kuebler & Bruera, 2000; Martin et al., 2005; Nelson et al., 2008). Collaboration incorporates mutually compatible solutions with recognition 405
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and concern of both disciplines (Maylone, Ranieri, Griffin, McNulty, & Fitzpatrick, 2010). Approachability is an important antecedent to collaboration in so much as NPs and MDs both value approachable partners and the ease in accepting and conveying information is essential for collaboration to happen (Martin et al., 2005; O’Brien et al., 2009). Both endorse the merit of listening, which involves concentration, hearing, comprehension, remembering, and considered retorts to guarantee information is integrated into the workflow. Furthermore, both value verbal message skills as important precursors to collaboration. Verbal message proficiency involves corollary capabilities, including multitasking, time managing, follow-up, and the ability to report, synthesize, and organize findings (O’Brien et al., 2009). Collaboration between NPs and MDs requires many types of sharing, including shared knowledge, values, responsibility, and vision (Hallas et al., 2004; Henneman et al., 1995; Linkeke & Sieckert; 2005). Most importantly is a shared dedication of those clinicians concerned to put effort into the relationship (Henneman et al., 1995; Martin et al., 2005). In any team activity, respect for, and acknowledgment of, each other’s experience and judgment is a prerequisite to collaborative practice (Almost & Laschinger, 2002, Bailey et al., 2006; Hallas et al., 2004; Makowsky et al., 2009; Martin & Coniglio, 1996; Martin et al., 2005). This respect necessitates that each discipline have a basic level of understanding of each others’ expertise and roles and a acknowledgment for the body of knowledge, abilities, proficiency, and uniqueness of each discipline (Henneman et al., 1995). Additionally, self-confidence and recognizing the limitations of one’s own role is essential to collaboration. This self-assurance is often the result of prior recognition of worth from other team members and feelings of proficiency in one’s field of expertise and knowing when to seek consultation (Copnell et al., 2004; Hallas et al., 2004; Henneman et al., 1995; Herrmann & Zabramski, 2005). The opportunity to seek expert consultation between providers must be legitimate and the consultant must have confidence in the person seeking the consultation (Kuebler & Bruera, 2000). Similarly, role clarity and knowledge of each disciplines scope of practice are necessary components of collaboration (Bailey et al., 2006; Burgess & Purkis, 2010; Goldman et al., 2010; Makowsky et al., 2009; Martin et al., 2005; Taylor, 2009; Vazirani et al., 2005). One of the hurdles to successful collaboration among NPs and MDs includes lack of MD understanding of the NP scope of practice and role. MDs should be familiar with the NP’s scope of practice to suitably allocate duties of patient 406
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management (Clarin, 2007). A transparent understanding regarding the NP scope of practice is essential because of the issue of practicing within scope as it defines the legal parameters for a written collaborative agreement (Norsen et al., 1995). Clinical competence is necessary for effective collaboration (Bailey et al., 2006; Hallas et al., 2004). Competency refers to collaborators remaining up to date with medical guidelines and knowledgeable about the other disciplines profession, as well as certifications and educational requirements (Hallas et al., 2004). Moreover, trust between the NP and MD is an essential precursor to collaboration (Almost & Laschinger, 2002; Hallas et al., 2004). Trust requires that individuals search out knowing one another in the course of sharing and communicating ideas. However, trust, similar to respect, is gained over the course of time (Bailey et al, 2006; Henneman et al., 1995; Martin et al., 2005), making it also a consequence of collaboration. Furthermore, MDs’ perceived hierarchal medical framework creates an obstacle to effective collaboration with NPs and can be understood by NPs as a lack of respect. This perception, along with not completely understanding the concept of collaboration with NPs, is unfavorable to any shared endeavor. MDs’ understanding of collaboration may not mirror that of NPs. MDs tend to view collaboration as NPs practicing dependently under them. On the other hand, NPs tend to view collaboration as an autonomous role, consulting when needed (Clarin, 2007; Taylor, 2009). Further personal factors essential to collaboration are willingness to cooperate and coordinate care collegially, autonomy, responsibility for outcomes (Bailey et al., 2006, Neale, 1999), and accountability for one’s own actions (Kuebler & Bruera, 2000). Reluctance to accept each other’s uniqueness and contributions toward patient care could be explained by lack of knowledge, previous unsuccessful experiences, and poor role modeling (Martin & Coniglio, 1996). Ineffective communication, inflated egos, unassertive nurses, and aggressive MDs can contribute to failure in collaborative practice (Neale, 1999). Environmental factors. Collaboration calls for an atmosphere supportive of a team direction (Bailey et al., 2006; Henneman et al., 1995). Clinicians are strongly persuaded by the opinions of their educators, professional culture and norms, and the distinctive lingo of their own profession. These differences in socialization can make collaboration difficult to occur. In clinical practice, leadership and role modeling of collaborative practice skills are critical. A new culture of collaboration is considered necessary at the organizational level to merge the unique strengths of each profession to decrease energy
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exhausted on territoriality and control issues (Henneman et al., 1995; Lindeke & Sieckert, 2005). An organization that promotes team development, including team structure, reverent consideration, conflict negotiation, and control of unconstructive behaviors, is essential for collaboration to occur. Likewise, organizational leaders that support collaborative practice promote a shared vision and a devotion to common objectives. These leaders offer a unified direction to a team, yet foster resourcefulness and independence in decision making (Henneman et al., 1995; Lindeke & Sieckert, 2005). Facility design can directly impact collaboration by improving collaboration when space is allotted in the practice sites to enhance formal and informal interactions among team members. Factors related to design include privacy, noise control, seating space, and convenience (Goldman et al., 2010; Lindeke & Sieckert, 2005). These antecedents are detailed in Table 1.
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which is the bond that unites the other attributes insomuch as without trust the other attributes are hampered (Avery, 1995; Boyle & Kochinda, 2004; Dougherty & Larson, 2005; Goldman et al., 2010; Lamb & Napodano, 1984; Lindeke & Sieckert, 2005; Makowsky et al., 2009; Martin & Coniglio, 1996; Martin et al., 2005; Meyer & Miers, 2005; Neale, 1999; Nelson et al., 2008; Norsen et al., 1995; O’Brien et al., 2009; Rodts, 2008; Taylor, 2009). The data analysis revealed that effective NP-MD collaboration is characterized by both individuals working together as a team in a collegial relationship in an environment where there is open communication, mutual respect and trust, sharing of clinical expertise and knowledge, and consultation as needed to meet the shared goal of achieving excellent patient care. These attributes are detailed in Table 1.
Consequences Attributes of the concept Attributes are clusters of characteristics that allow for identification of situations that can be categorized under the concept (Tofthagen & Fagerstrom, 2010). The attributes constitute the real definition of the concept as opposed to the dictionary definition and allow the concept to be set apart from other concepts. The detection of the attributes of the concept denotes the primary accomplishment of the concept analysis and the process identifies characteristics without which collaboration cannot occur (Cypress, 2010; Henneman et al., 1995). The identification and analysis of the attributes of collaboration in the context of NP-MD collaborative practice yielded a number of dimensions of the concept. They include but are not limited to the following: (a) interactions where professionals work together cooperatively in a joint adventure, (b) sharing of and open communication, (c) individuals view themselves as members of a team and contribute to a common goal with willingness and openness to learn from others, (d) shared responsibility and accountability for outcomes, (e) participants offer their expertise and are acknowledged and respected by other team members for their contribution to the process, (f) power is shared in a nonhierarchical relationship based on the knowledge and expertise, versus role or title, (g) shared planning, problem solving, and decision making, (h) working together cooperatively and coordinating care jointly, (i) assertiveness where individuals on the team support their views with confidence, (j) autonomy in which individual team members carry out the plan of care as a compliment to team work, (k) team member approachability with consistent consultation and interaction regarding patient needs, and (l) trust
The complexity of collaboration makes it difficult to distinguish consequences of collaboration from antecedents to collaboration, that is, one could make a case that only in a situation where collaboration is present could these processes take place, which would classify them as consequences. Yet, the case could be made that these processes must exist prior to collaboration beginning, which categorizes them as antecedents. For example, collaboration has been shown to advance role integration, foster role clarity, autonomy, and develop trust and respect from both patients and colleagues of NPs (Burgess & Purkis, 2010). Yet, as discussed earlier, trust, respect, autonomy, and role clarity were also antecedents to collaboration. Furthermore, collaboration has been said to generate team capacity, which again has been illustrated to be an antecedent to collaboration (Bailey et al., 2006; Burgess & Purkis, 2010). Individuals who participate in collaboration gain from the encouraging and supportive environment it produces by substantiating the distinctive and vital role of team member, by emphasizing opinions of competency, confidence, and worth. Possibly the most important part of collaborative practice is the ability the process has to promote collegial relationships and enhance mutual respect among professionals. When the nature of collaboration is cyclical in this way (respect→collaboration→greater respect), it ensures the sustained use and success of interpersonal interaction (Henneman et al., 1995). Benefits. Collaboration has been shown to have a number of benefits. Collaborative alliances between the NP and healthcare leaders has served to advance the NP role and promote strategic alliances to collectively remedy start-up problems of practices, develop needed 407
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infrastructure and policies, and negotiate resources for improving patient care (Burgess & Purkis, 2010). Inside the milieu of collaborative practice, NPs encounter greater occasions to make use of their knowledge and skills, thus being able to more directly influence the quality of patient care (Martin et al., 2005). Collaborative practice has been reported by NPs to enhance holistic client-centered care (Burgess & Purkis, 2010) and to reduce healthcare cost and improve patient outcomes (Cowan et al., 2006; Meyer & Miers, 2005; Sennour, Counsell, Jones, & Weiner, 2009). Collaborative communication has been shown to increase opinions of nursing leaders and improve problem-solving tasks. Nurses’ reports lower personal stress despite perceiving significantly more situation stress and ability to meet family demands, technical aspects of care, and job satisfaction (Boyle & Kochinda, 2004). For MDs, collaborative practice may allow more time for meeting increased demands for consultations and to devote to complex cases (Martin et al., 2005). Economically, collaborative practice between NPs and MDs derives financial benefits because of the ability to see an increased number of patients with an increased accessibility to the practice for patients, referring MDs, and other members of the healthcare team (Martin & Coniglio, 1996). Collaboration among NPs and physician assistants (PAs) with attending MDs and residents has also been found to increase patient approval in care delivery as well as satisfaction of attending staff and residents. More significantly, patient care outcomes were comparable to the resident service and the NP and PA service had reduced length of stays (Todd et al., 2004). Likewise, the addition of an NP to the team, along with initiation of multidisciplinary rounding and the appointment of a hospitalist director in one facility, was shown to increase collaboration and communication between MDs and nurses. This effort produced a decrease in overall costs and length of stay without a reduction in quality of life or satisfaction among patients between the two groups studied (Vazirani et al., 2005). Institutions that encourage collaboration also profit in several ways. Collaboration promotes greatest efficiency as team members use their abilities and expertise in a supportive and noncompetitive manner. Retention and commitment of team members is improved when team members perceive that their contributions are respected and they are able to share in decision making and planning (Henneman et al., 1995; Martin & Miers, 1996). Moreover, achievement of this goal frequently translates into a decreased length of hospital stays because of coordinated care provided by the NP and MD (Martin & Miers, 1996). The NP receives numerous additional benefits to collaborative practice. The NP can perform in a truly au408
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tonomous style, utilizing the expertise distinctive to the NP role, which can contribute to increased job satisfaction, personal and professional growth and development, and the satisfaction of being able to provide patients excellent care (Almost & Laschinger, 2002; Martin & Coniglio, 1996). Successful NPs and MDs who establish collaborative practice arrangements both can benefit from learning that occurs by both individuals exchanging their knowledge and experiences of ways to improve patient care (Norse et al., 1995). Both NPs and MDs acknowledge learning as a consequence of collaboration; however, MDs tend to relate while NPs could learn from them, they tend not to concede learning as a reciprocal feature of their working relationship (Martin et al., 2005). Sharing knowledge and ideas has not yet reached the point where MDs consistently view NPs as valuable in regard to exchanging expert knowledge (Hallas et al., 2004). Negative consequences. Negative consequences of ineffective collaboration include fragmented care, poor patient outcomes, and patient discontentment. Sharing of information is a key aspect of any conflict-resolution method and lack of such collaboration within the NP and MD partnership could ultimately affect patient care (Martin et al., 2005). Noncollaborative work environments may be a factor in role discontentment and tension for clinicians in charge of assuring quality patient care (Almost & Laschinger, 2002; O’Brien et al., 2009) and role confusion of healthcare team members and, more broadly, the public (Neale, 1999). Furthermore, noncollaborative work environments can contribute to lack of respect of partners, territorial and control issues, undesirable attitudes and behaviors, and competency issues. Thus, thwarting the development of successful collaborative practice relationships (Burgess & Purkis, 2010; Clarin, 2007; Hallas et al., 2004; Maylone et al., 2010). Consequences of collaboration are detailed in Table 1.
Proposed operational definition Based on the definitions and attributes identified in this review, the following operational definition is proposed: Collaboration is defined within the context of NP-MD collaborative practice as an interaction in which both individuals work as a team in a collegial relationship in an environment where there is mutual trust and respect and open communication. It is an interaction in which both individuals share knowledge and clinical expertise, decision making, and problem solving. In addition, it is an interaction in which both parties consult when needed to meet the shared goals of achieving excellent patient care and improved patient outcomes.
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Exemplar case The purpose of the exemplar case is to offer a practical demonstration of the concept in a relevant context to illustrate the characteristics of the concept to enhance clarity and effective application of the concept of interest (Tofthagen & Fagerstrom, 2010). The exemplar case of collaboration within the context of NP-MD collaborative practice was found in the literature and was described by Lamb and Napodano (1984) as follows. The NP interviews an elderly woman with a recent development of fatigue. This woman has a past medical history of obesity and noninsulin dependent diabetes mellitus. The NP gathers the history and does a physical exam, orders laboratory data, and recognizes there has been no change in the patient’s report of her diet, activity level, or any objective changes in her diabetic control, blood counts, or thyroid status. This woman does not seem more depressed than prior meetings with the NP and the NP is not able to discover a reason to explain the symptom of fatigue. Therefore, the NP involves the MD for assistance in finding additional potential causes for the fatigue. This interaction is scored as collaborative. As requested by the NP, the MD questions the patient along with the NP. The MD’s process of gathering additional information in this instance merely adds to the data already gathered by the NP and therefore is not considered to be collaborative. However, in later discussions, the two clinicians recognize that the women answered remarkably different to each of them, and placed a different importance on specific symptoms and used dissimilar nonverbal gestures during the interaction with each of them. This assessment of the history data by the clinicians with the detection of a distinctive pattern of communication with the patient leads to a new differential diagnosis based on the assimilation of the data from both interviews and viewpoints. As a result, this interaction is counted as collaborative.
Implications for research and practice This analysis has brought to light that collaboration is foundational to NP practice, yet, collaboration is cultivated by a broad context of healthcare culture. Organizational efforts to effectively promote collaboration between NPs and MDs are needed. Organizations should host routine educational sessions for team members teaching effective communication skills, problem-solving skills, and verbal message skills to improve collaborative practices in their facilities. Research is needed to determine what interventions are useful in promoting interdisciplinary collaboration between NPs and MDs and to describe their perceptions’ of the meaning of collaboration.
Research has shown that both NPs and MDs concur on the language related to collaboration, but hold a different view with regard to the invariants, which characterize its achievement (O’Brien et al., 2009). Research is needed to determine what NPs and MDs expect from one another to collaborate effectively. Qualitative methods may be an effective means in increasing an understanding of collaboration between NPs and MDs. Education of both the public and MDs regarding the roles of NPs is warranted to help change misconceptions of subordination and promote a collaborative practice (Neale, 1999).
Summary and conclusions This concept analysis has demonstrated that collaboration is a multifaceted, complicated process that obliges commitment to all of those involved. Within the context of NP and MD collaborative practice, patience, nurturing, and time are needed to develop a rapport where collaboration can take place (Henneman et al., 1995, Lamb & Napodano, 1984). A rare chance occurs for NPs who work with other individuals who are encouraging and experienced about collaborative practice. It allows NPs to work autonomously, utilizing the expertise and experiences distinctive to their role, allowing for them to be creative, effective, and productive while providing quality care to their patients (Almost & Laschinger, 2002).
Acknowledgments Dr. Clelia Lima, FNP-BC, MSN, DNP, is personally acknowledged for her contribution to this manuscript in the form of unpaid editorial assistance.
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advanced practice nurse collaboration on hospital costs. Journal of Nursing Administration, 36(2), 79–85. Cypress, B. (2011). Exploring the concept of nurse-physician communication within the context of health care outcomes using the evolutionary method of concept analysis. Dimensions of Critical Care Nursing, 30(1), 28–38. doi:10.1097/DCC.0b013e3181fd02e1 Dougherty, M., & Larson, E. (2005). A review of instruments measuring nurse-physician collaboration. Journal of Nursing Administration, 35(5), 244–253. Goldman, J., Meuser, J., Rogers, J., Lawrie, L., & Reeves, S. (2010). Interprofessional collaboration in family health teams. Canadian Family Physician, 56, e368-e374. Hallas, D., Butz, A., & Gitterman, B. (2004). Attitudes and beliefs for effective pediatric nurse practitioner and physician collaboration. Journal of Pediatric Health Care, 18(2), 77–86. doi:10.1016/j.pedhc.2003.09.009 Henneman, E., Lee, J., & Cohen, J. (1995). Collaboration: A concept analysis. Journal of Advanced Nursing, 21, 103–109. Herrmann, L., & Zabramski, J. (2005). Tandem practice model: A model for physician-nurse practitioner collaboration in a specialty practice, neurosurgery. Journal of the American Academy of Nurse Practitioners, 17(6), 213–218. Kuebler, K., & Bruera, E. (2000). Interactive collaborative consultation model in end-of-life care. Journal of Pain and Symptom Management, 20(3), 202–209. Lamb, G., & Napodano, R. (1984). Physician-nurse practitioner interaction patterns in primary care practices. American Journal of Public Health, 74(1), 26–29. Lindeke, L., & Sieckert, A. (2005). Nurse-physician workplace collaboration. Online Journal of Issues in Nursing, 10(1), retrieved online from EbscoHost. doi:10.3912/OJIN.Vol10No01Man04 Makowsky, M., Schindel, T., Rosenthal, M., Campbell, K., Tsuyuki, R., & Madill, H. (2009). Collaboration between pharmacists, physicians and nurse practitioners: A qualitative investigation of working relationships in the inpatient medical setting. Journal of Interprofessional Care, 23(2), 169–184. doi:10.1080/13561820802602552 Martin, D. R.,O’Brien, J. L., Heyworth, J. A., & Meyer, N. R. (2005). The collaborative healthcare team: Tensive issues warranting ongoing consideration. Journal of the American Academy of Nurse Practitioners, 17(8), 325–330. Martin, B., & Coniglio, J. (1996). The acute care nurse practitioner in collaborative practice. AACN Clinical Issues, 7(2), 309–314. Maylone, M., Ranieri, L., Griffen, M., McNulty, R., & Fitzpatrick. (2010). Collaboration and autonomy: Perceptions among nurse practitioners. Journal of American Academy of Nurse Practitioners, 23, 51–57. doi:10.1111 /j.1745–7599.2010.00576.x Meyer, S., & Miers, L. (2005). Cardiovascular surgeon and acute care nurse practitioner. Collaboration on postoperative outcomes. AACN Clinical Issues, 16(2), 149–158.
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Neale, J. (1999). Nurse practitioners and physicians: A collaborative practice. Clinical Nurse Specialist, 252(258), 252–258. Nelson, G., King, M., & Brodine, S. (2008). Nurse-physician collaboration on medical-surgical units. MEDSURG Nursing, 17(1), 35–40. Norsen, L., Opladen, J., & Quinn, J. (1995). Practice model: Collaborative practice. Critical Care Nursing Clinics of North America, 7(1), 43–52. O’Brien, J., Martin, D., Heyworth, J., & Meyer, N. (2009). A phenomenological perspective on advance practice nurse-physician collaboration within an interdisciplinary healthcare team. Journal of the American Academy of Nurse Practitioners, 21, 444–453. doi:10.1111/j.1745–7599.2009.00428.x Rodgers, B. & Knafl, K (eds.). (2000). Concept analysis. An evolutionary view, chapter 6. In Concept development in nursing: Foundation techniques, and applications (2nd ed., pp. 77–102). Philadelphia, PA: W-B Saunders Company. Rodts, M. (2008). Nurse-physician collaboration. Orthopaedic Nursing, 27(2), 93. Russell, A. (2012). Moral distress in neuroscience nursing: An evolutionary concept analysis. Journal of Neuroscience Nursing 44(1), 15–23. Sennour, Y., Counsell, S., Jones, J., & Weiner, M. (2009). Development and implementation of a proactive geriatrics consultation model in collaboration with hospitalists. Journal of the American Geriatrics Society, 57(11), 2139–2145. doi:10.1111/j.1532–5415.2009.02496.x Taylor, C. (2009). Attitudes toward physician-nurse collaboration in anesthesia. American Association of Nurse Anesthetists Journal, 77(5), 343–348. Todd, B., Resnick, A., Stuhlemmer, R., Morris, J., & Mullen, J. (2004). Challenges of the 80-hour resident work rules: Collaboration between surgeons and nonphysician practitioners. Surgical Clinics of North America, 84, 1573–1586. doi:10.1016/j.suc.2004.06.014 Tofthagen, R., & Fagerstrom, L. (2010). Rodgers’ evolutionary concept analysis-a valid method for developing knowledge in nursing science. Scandinavian Journal of Caring Sciences, 24, 21–31. doi:10.1111/j.1471–6712.2010.00845.x Vazirani, S., Hays, R., Shapiro, M., & Cowan, M. (2005). Effect of a multidisciplinary intervention on communication and collaboration among physicians and nurses. American Journal of Critical Care, 14(1), 71–77.
Supporting Information Additional Supporting Information may be found in the online version of this article at the publisher’s web site: Table S1. Features of studies included for concept analysis.
Exploration of the concept of collaboration within the context of nurse practitioner-physician collaborative practice Sharon Bridges, DNP, ARNP, FNP-BC (Nurse Practitioner) Orlando Health Physician Group, Orlando, Florida
Keywords Collaboration; healthcare collaboration; concept analysis; nurse practitioners; nurse practitioner communication. Correspondence Sharon Bridges, DNP, ARNP, FNP-BC, 1111 Arbor Hill CIR, Minneola, FL 34715. E-mail: [email protected] Received: August 2011; accepted: June 2012 doi: 10.1111/1745-7599.12043
Abstract Purpose: Collaboration in the healthcare setting is a multifaceted process that calls for deliberate knowledge sharing and mutual accountability for patient care. The purpose of this analysis is to offer an increased understanding of the concept of collaboration within the context of nurse practitioner (NP)physician (MD) collaborative practice. Data sources: The evolutionary method of concept analysis was utilized to explore the concept of collaboration. The process of literature retrieval and data collection was discussed. The search of several nursing and medicine databases resulted in 31 articles, including 17 qualitative and quantitative studies, which met criteria for inclusion in the concept analysis. Conclusions: Collaboration is a complex, sophisticated process that requires commitment of all parties involved. The data analysis identified the surrogate and related terms, antecedents, attributes, and consequences of collaboration within the selected context, which were recognized by major themes presented in the literature and these were discussed. An operational definition was proposed. Implications for practice: Increasing collaborative efforts among NPs and MDs may reduce hospital length of stays and healthcare costs, while enhancing professional relationships. Further research is needed to evaluate collaboration and collaborative efforts within the context of NP-MD collaborative practice.
Introduction Supporting and strengthening relationships between nurses and physicians (MDs) have been recognized for some time as beneficial in fostering an environment that supports high-quality patient care (Martin & Coniglio, 1996; Vazirani, Hays, Shapiro, & Cowan, 2005). Effective collaboration in the healthcare environment requires intentional knowledge sharing and shared accountability for patient care (Lindeke & Sieckert, 2005). The purpose of this analysis is to offer an increased understanding of the concept of collaboration within the context of nurse practitioner (NP)-MD collaborative practice. This concept was chosen because there is a gap in the literature regarding the concept of collaboration in the context of NP-MD collaborative practice. Over the last three decades, a growing body of literature has emerged that explores the concept of nurse-MD collaboration from a nursing perspective (Avery, 1995; Boyle 402
& Kochinda, 2004; Henneman, Lee, & Cohen, 1995; Lindeke & Sieckert, 2005; Nelson, King, & Brodine, 2008; Rodts, 2008). However, there is a lack of clarity on this concept within the realm of NP-MD collaborative practice. It is important to conceptually clarify collaboration from this perspective as the roles of staff nurses and NPs differ significantly. Understanding collaboration within the context of NPMD collaborative practice is significant for NPs because it is often applied within different clinical, management, and reimbursement situations, and it is easily misinterpreted if inadequately defined. Additionally, NPs and MDs often experience disagreement regarding issues of autonomous nursing practice. MDs often do not understand the NP role and where the NP fits into the nursing or medical field (Martin et al., 2005). Thus, a clearer conceptualization of the concept of collaboration within this context is warranted to provide knowledge for NPs to guide their practice. Journal of the American Association of Nurse Practitioners 26 (2014) 402–410 C 2013 American Association of Nurse Practitioners
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Concept analytic methodology Rodger’s revolutionary view of concept analysis is utilized for the examination of the concept of collaboration within the context of NP-MD collaborative practice (Rodgers & Knafl, 2000, pp. 77–102). This method is an inductive process that maintains concepts are not stagnant but change over time and are influenced by the context in which they are used (Tofthagen & Fagerstrom, 2010). Thus, the evolutionary model of concept analysis embraces the dynamic nature of concepts, such as of collaboration, and provides a method of continual concept refinement where new meanings can be introduced over time. This model seeks to reveal the attributes of the concept by recognizing its everyday use in existing literature, offering a basis for future inquiry and concept maturity (Russell, 2012). This method of concept analysis does not provide a conclusive definition of the concept of collaboration, but it will provide a direction for further research (Tofthagen & Fagerstrom, 2010).
Literature retrieval and data collection Considering the context of NP and MD collaborative practice, the concept of collaboration was found to have great interest in the fields of nursing and medicine. Therefore, the sample was selected from the population of literature in these domains. The review was limited to publications in the English language. To be included in the analysis, the studies had to be original research or articles from peer-reviewed journals. Thus, dissertations, theses, or news reports were excluded from the analysis. A comprehensive computerized review of the literature was performed to identify prose in the selected domains related to the concept of collaboration within the context of NP-MD collaborative practice. The discussions of the concept of collaboration in regards to NPs and MDs started in the literature in the early 1980s and increased in the 1990s and even more so up to the present time. Therefore, a broad time frame was selected, 1980–2011, to allow for the emergence and significant changes of the meaning of the concept to develop over time. An electronic search of databases, such as Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, Medscape, and Cochrane, was done. The search was performed using all literature indexed under the subject heading of nurse-physician collaboration. The search produced 666 articles in CINAHL, 1089 in PubMed, and 3 in Cochrane. A secondary search on NPphysician collaboration produced four articles in CINAHL, four articles in PubMed, and zero articles in Cochrane. A third search was conducted in CINAHAL, PubMed, and
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Cochrane using the term collaborative practice. This search demonstrated 3167 articles in CINAHAL, 7921 articles in PubMed, and 9 articles in Cochrane. After narrowing this search to articles pertaining to NP, 129 articles in CINAHAL and 406 articles in PubMed were found. Medscape articles are searchable online from 1990 to present. Using the subject heading of nurse-physician collaboration, 696 references were found. A search in Medscape using the term NP-physician collaboration revealed 300 references and another 258 references on NP-physician collaborative practice. There are other surrogate terms (Table 1) for the concept of collaboration and the search using these terms alone in CINHAL demonstrated >12,000 articles, when this search was narrowed to include NP and physician, results demonstrated 134 articles, mostly overlapping previous searches. With such a large yield of articles to choose from with discussions on the concept of collaboration, the sample was derived from articles that were found (a) by using the search terms: nurse-physician collaboration, NP-physician collaboration, or NP-physician collaborative practice, (b) to have collaboration defined and to be relevant to NP-MD collaborative practice, (c) to have discussions of NP-MD collaborative communications, or (d) to have models or discussions regarding the impact on NPMD collaborative practice on healthcare outcomes. The overall search provided a total of 17 studies (Table S1). Of these, there were seven qualitative, eight quantitative, and one mixed method designs from the fields of medicine and nursing, and one qualitative method design from the field of pharmacology. Furthermore, there were two included conceptual analysis and 12 published review articles on the topic of NP-MD collaboration. After the sample was chosen, the published reports were read at least twice to categorize the related concepts and surrogate terms, definitions, attributes, antecedents, and consequences. Similarities and differences of the concept of collaboration with the chosen context were identified and contrasted to make known an operational definition of the concept and to describe the major aspects of the concept.
Critical analysis of the literature Surrogate terms and related concepts Surrogate terms are words that are used interchangeably to express a concept’s characteristics (Tofthagen & Fagerstrom, 2010). Recognizing surrogate terms prior to starting the formal analysis is necessary because every concept is a part of an association of similar concepts and doing so gives perspective to help convey meaning to the concept of concern (Cypress, 2011). 403
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Table 1 Surrogate terms, antecedents, attributes, and consequences of collaboration within the context of NP-MD collaborative practice Surrogate terms Collaborative communication, open communication, sharing of communication, nurse- or NP-physician interaction, consultation, teamwork, and partnerships
Antecedents
Attributes
Consequences
Individual readiness (prior experience), understanding and acceptance of one another’s role and expertise, confidence in each other’s ability, effective group dynamics, communication skills, respect, and trust, environment support of team orientation
Work together cooperatively in a joint adventure, open communication, individuals view themselves as members of a team and contribute to a common goal, shared responsibility and accountability for outcomes, participants offer their expertise and are acknowledged and respected by other team members for their contribution to the process, power is shared in a nonhierarchical relationship, shared planning, problem solving, and decision making, working together cooperatively and coordinating care jointly, assertiveness, autonomy, approachability with consistent consultation, and trust
Advance role integration, foster role clarity, autonomy, and develop trust and respect from both patients and colleagues of NP, reduce healthcare costs and improve patient outcome, improved strategic alliances, improved productivity for both physicians and organizations, noncollaborative work environments contribute to dissatisfaction, job strain, lack of respect, negative behaviors, and role confusion
The selected studies and review articles used common surrogate terms in conveying the concept of collaboration. Communication itself is a method by which the exchange of ideas is transferred between individuals and the term by itself does not contain the exact attributes of collaboration. However, sharing of communication, open communication, and collaborative communication are terms with the same attributes and are used interchangeably with collaboration (Cypress, 2011). Collaborative practice is used interchangeably with collaboration. Moreover, collaboration is often used interchangeably with the terms consultation (a meeting for deliberation, discussion, or decision), teamwork (cooperative or coordinated efforts of a group acting as a team for a common goal), and partnerships (an association of two or more people conducting a business; retrieved online from http://dictionary.reference.com/). It is imperative to discern the concept of collaboration from related terms because although related terms may have something in common with the concept, they do not possess the same characteristics (Tofthagen & Fagerstrom, 2010). The term relationship implies a state of being connected, associated, or involved (retrieved online from http://dictionary.reference.com/). While the term relationship alone has no association to and does not have similar attributes with collaboration, the term collabora404
tive relationship between the NP and MD, which consists of mutual problem solving and accountability, has the same attributes to NP-MD collaborative practice (Kuebler & Bruera, 2000). Additionally, collaboration is often defined in relation to conflict resolution. The terms accommodating, assertive, corporative, and avoidance refer to varying degrees of conflict resolution. Although collaboration denotes some of the attributes of conflict resolution, such as individuals being both assertive and corporative, it does not have the characteristics of individuals being accommodating (unassertive) or displaying avoidance. Thus, although related in some ways, the characteristics of conflict resolution are dissimilar to those of collaboration (Henneman et al., 1995). Also, collaboration does not imply supervision (to direct or oversee performance). Although this term may be related to some NP and MD work relationships, it does not share the same attributes with collaboration (Lindeke & Sieckert, 2005; retrieved online from http://dictionary.reference.com/).
Definitions Collaboration has been defined as a true partnership in which both sides value each other’s power with acknowledgment and acceptance of combined and
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separate fields of responsibility and activity. Moreover, where those involved collectively safeguard the rightful interests and the unity of goals that is acknowledged by each party (Dougherty & Larson, 2005). Thus, collaboration is a manner of working together, with mutual action and planning, which includes shared decision making and communication. It is an interaction with eager cooperation on the basis of mutual authority and power with joint responsibility for the outcome (Dougherty & Larson, 2005; Lamb & Napodano, 1984; Taylor, 2009). Collaboration incorporates the individual point of views and proficiency of team participants on behalf of imparting excellence in patient care (O’Brien, Martin, Heyworth, & Meyer, 2009). Collaborative practice between NPs and MDs is defined as a process through which these providers work concurrently toward a mission of exceptional patient care, implying team members work collegially and cohesively and strive for a common goal (Hallas, Butz, & Gitterman, 2004; Martin, O’Brien, Heyworth, & Meyer, 2005; Norsen, Opladen, & Quinn, 1995). Likewise, it is an interdisciplinary course of action for decision making and communication so as to facilitate the individual skills and knowledge of the healthcare providers. It is an interaction in an atmosphere in which there is a sharing of knowledge and expertise with complementary practice styles, open communication, and mutual trust and respect. Moreover, these providers consult as needed to positively influence the patient care provided to reach the collective goal of achieving quality (Bailey Jones, & Way, 2006; Hallas et al., 2004; Makowsky et al., 2009; Martin et al., 2005; Nelson, King, & Brodine, 2008; Vazirani et al., 2005). The collaborative interaction focuses not only on quality of patient care and outcomes, but also on a relationship that enhances professionalism and mutual understanding (Neale, 1999). Similarly, collaborative communication has been defined as MDs and nurses working in cooperation, mutually accountable for conflict management, problem solving, communication, coordination, and decision making in effort to enhance patient outcomes (Boyle & Kochinda, 2004).
Antecedents Antecedents are contextual features of a concept and are phenomena or events that precede instances of the occurrence of the concept (Cypress, 2011; Tofthagen & Fagerstrom, 2010). The findings of the investigation indicate that instances of the concept of collaboration within the context of NP-MD collaborative practice are preceded by both personal and environmental factors and these were more obvious in the qualitative research studies
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selected for this examination. The extent and breadth of antecedents that have to transpire prior to the incidence of collaboration may well justify healthcare leader’s and clinician’s lack of achievement in promoting collaborative practice (Clarin, 2007; Henneman et al., 1995; Lindeke & Sieckert, 2005). Personal factors. A variety of personal factors have been expressed as previous circumstances to collaboration. These antecedents relate to uniqueness of the group, team, or individuals and convey the readiness of a team member to engage in this manner of interpersonal behavior. This inclination may be the product of a number of factors, such as maturity, prior experience working in similar situations, and educational preparation (Henneman et al., 1995; Lindeke & Sieckert, 2005). Successful group dynamics plays a crucial position in the process of collaboration. Included in the ability to maintain effective group dynamics is the combination of excellent communication and interpersonal skills. These interpersonal skills include approachability, mutual trust and respect, sharing and listening skills, and verbal message skills. In addition, problem solving and conflict management skills are required (Bailey et al., 2006; Boyle & Kochinda, 2004; Goldman, Meuser, Rogers, Lawrie, & Reeves, 2010; Hallas et al., 2004; Henneman et al., 1995; O’Brien et al., 2009). The ability to communicate openly and effectively is a key antecedent to effective collaboration (Clarin, 2007; Lindeke & Sieckert, 2005; Martin et al., 2005; Todd, Resnick, Stuhlemmer, Morris, & Mullen, 2004). Open communication requires that NPs and MDs listen to each other’s points of view, while being self-confident in conveying their own perspective. It is by way of communication that NPs and MDs express their contributions to managing and evaluating patient care (Boyle & Kochinda, 2004; Henneman et al., 1995). A component of open communication is effective social skills that incorporate a comprehension and adjustment of each other’s work styles and limitations. Open communication permits these team members to constructively negotiate together and operates as a means for conveying other important antecedents to collaboration, such as reciprocated respect, trust, and sharing (Boyle & Kochinda, 2004; Henneman et al., 1995; O’Brien et al., 2009). Conflict management skills and problem solving are other important antecedent to collaboration and are the abilities of NPs and MDs to actively convey information to ensure that available expertise are used in conflict negotiation so the best feasible resolution is realized (Boyle & Kochinda, 2004; Kuebler & Bruera, 2000; Martin et al., 2005; Nelson et al., 2008). Collaboration incorporates mutually compatible solutions with recognition 405
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and concern of both disciplines (Maylone, Ranieri, Griffin, McNulty, & Fitzpatrick, 2010). Approachability is an important antecedent to collaboration in so much as NPs and MDs both value approachable partners and the ease in accepting and conveying information is essential for collaboration to happen (Martin et al., 2005; O’Brien et al., 2009). Both endorse the merit of listening, which involves concentration, hearing, comprehension, remembering, and considered retorts to guarantee information is integrated into the workflow. Furthermore, both value verbal message skills as important precursors to collaboration. Verbal message proficiency involves corollary capabilities, including multitasking, time managing, follow-up, and the ability to report, synthesize, and organize findings (O’Brien et al., 2009). Collaboration between NPs and MDs requires many types of sharing, including shared knowledge, values, responsibility, and vision (Hallas et al., 2004; Henneman et al., 1995; Linkeke & Sieckert; 2005). Most importantly is a shared dedication of those clinicians concerned to put effort into the relationship (Henneman et al., 1995; Martin et al., 2005). In any team activity, respect for, and acknowledgment of, each other’s experience and judgment is a prerequisite to collaborative practice (Almost & Laschinger, 2002, Bailey et al., 2006; Hallas et al., 2004; Makowsky et al., 2009; Martin & Coniglio, 1996; Martin et al., 2005). This respect necessitates that each discipline have a basic level of understanding of each others’ expertise and roles and a acknowledgment for the body of knowledge, abilities, proficiency, and uniqueness of each discipline (Henneman et al., 1995). Additionally, self-confidence and recognizing the limitations of one’s own role is essential to collaboration. This self-assurance is often the result of prior recognition of worth from other team members and feelings of proficiency in one’s field of expertise and knowing when to seek consultation (Copnell et al., 2004; Hallas et al., 2004; Henneman et al., 1995; Herrmann & Zabramski, 2005). The opportunity to seek expert consultation between providers must be legitimate and the consultant must have confidence in the person seeking the consultation (Kuebler & Bruera, 2000). Similarly, role clarity and knowledge of each disciplines scope of practice are necessary components of collaboration (Bailey et al., 2006; Burgess & Purkis, 2010; Goldman et al., 2010; Makowsky et al., 2009; Martin et al., 2005; Taylor, 2009; Vazirani et al., 2005). One of the hurdles to successful collaboration among NPs and MDs includes lack of MD understanding of the NP scope of practice and role. MDs should be familiar with the NP’s scope of practice to suitably allocate duties of patient 406
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management (Clarin, 2007). A transparent understanding regarding the NP scope of practice is essential because of the issue of practicing within scope as it defines the legal parameters for a written collaborative agreement (Norsen et al., 1995). Clinical competence is necessary for effective collaboration (Bailey et al., 2006; Hallas et al., 2004). Competency refers to collaborators remaining up to date with medical guidelines and knowledgeable about the other disciplines profession, as well as certifications and educational requirements (Hallas et al., 2004). Moreover, trust between the NP and MD is an essential precursor to collaboration (Almost & Laschinger, 2002; Hallas et al., 2004). Trust requires that individuals search out knowing one another in the course of sharing and communicating ideas. However, trust, similar to respect, is gained over the course of time (Bailey et al, 2006; Henneman et al., 1995; Martin et al., 2005), making it also a consequence of collaboration. Furthermore, MDs’ perceived hierarchal medical framework creates an obstacle to effective collaboration with NPs and can be understood by NPs as a lack of respect. This perception, along with not completely understanding the concept of collaboration with NPs, is unfavorable to any shared endeavor. MDs’ understanding of collaboration may not mirror that of NPs. MDs tend to view collaboration as NPs practicing dependently under them. On the other hand, NPs tend to view collaboration as an autonomous role, consulting when needed (Clarin, 2007; Taylor, 2009). Further personal factors essential to collaboration are willingness to cooperate and coordinate care collegially, autonomy, responsibility for outcomes (Bailey et al., 2006, Neale, 1999), and accountability for one’s own actions (Kuebler & Bruera, 2000). Reluctance to accept each other’s uniqueness and contributions toward patient care could be explained by lack of knowledge, previous unsuccessful experiences, and poor role modeling (Martin & Coniglio, 1996). Ineffective communication, inflated egos, unassertive nurses, and aggressive MDs can contribute to failure in collaborative practice (Neale, 1999). Environmental factors. Collaboration calls for an atmosphere supportive of a team direction (Bailey et al., 2006; Henneman et al., 1995). Clinicians are strongly persuaded by the opinions of their educators, professional culture and norms, and the distinctive lingo of their own profession. These differences in socialization can make collaboration difficult to occur. In clinical practice, leadership and role modeling of collaborative practice skills are critical. A new culture of collaboration is considered necessary at the organizational level to merge the unique strengths of each profession to decrease energy
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exhausted on territoriality and control issues (Henneman et al., 1995; Lindeke & Sieckert, 2005). An organization that promotes team development, including team structure, reverent consideration, conflict negotiation, and control of unconstructive behaviors, is essential for collaboration to occur. Likewise, organizational leaders that support collaborative practice promote a shared vision and a devotion to common objectives. These leaders offer a unified direction to a team, yet foster resourcefulness and independence in decision making (Henneman et al., 1995; Lindeke & Sieckert, 2005). Facility design can directly impact collaboration by improving collaboration when space is allotted in the practice sites to enhance formal and informal interactions among team members. Factors related to design include privacy, noise control, seating space, and convenience (Goldman et al., 2010; Lindeke & Sieckert, 2005). These antecedents are detailed in Table 1.
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which is the bond that unites the other attributes insomuch as without trust the other attributes are hampered (Avery, 1995; Boyle & Kochinda, 2004; Dougherty & Larson, 2005; Goldman et al., 2010; Lamb & Napodano, 1984; Lindeke & Sieckert, 2005; Makowsky et al., 2009; Martin & Coniglio, 1996; Martin et al., 2005; Meyer & Miers, 2005; Neale, 1999; Nelson et al., 2008; Norsen et al., 1995; O’Brien et al., 2009; Rodts, 2008; Taylor, 2009). The data analysis revealed that effective NP-MD collaboration is characterized by both individuals working together as a team in a collegial relationship in an environment where there is open communication, mutual respect and trust, sharing of clinical expertise and knowledge, and consultation as needed to meet the shared goal of achieving excellent patient care. These attributes are detailed in Table 1.
Consequences Attributes of the concept Attributes are clusters of characteristics that allow for identification of situations that can be categorized under the concept (Tofthagen & Fagerstrom, 2010). The attributes constitute the real definition of the concept as opposed to the dictionary definition and allow the concept to be set apart from other concepts. The detection of the attributes of the concept denotes the primary accomplishment of the concept analysis and the process identifies characteristics without which collaboration cannot occur (Cypress, 2010; Henneman et al., 1995). The identification and analysis of the attributes of collaboration in the context of NP-MD collaborative practice yielded a number of dimensions of the concept. They include but are not limited to the following: (a) interactions where professionals work together cooperatively in a joint adventure, (b) sharing of and open communication, (c) individuals view themselves as members of a team and contribute to a common goal with willingness and openness to learn from others, (d) shared responsibility and accountability for outcomes, (e) participants offer their expertise and are acknowledged and respected by other team members for their contribution to the process, (f) power is shared in a nonhierarchical relationship based on the knowledge and expertise, versus role or title, (g) shared planning, problem solving, and decision making, (h) working together cooperatively and coordinating care jointly, (i) assertiveness where individuals on the team support their views with confidence, (j) autonomy in which individual team members carry out the plan of care as a compliment to team work, (k) team member approachability with consistent consultation and interaction regarding patient needs, and (l) trust
The complexity of collaboration makes it difficult to distinguish consequences of collaboration from antecedents to collaboration, that is, one could make a case that only in a situation where collaboration is present could these processes take place, which would classify them as consequences. Yet, the case could be made that these processes must exist prior to collaboration beginning, which categorizes them as antecedents. For example, collaboration has been shown to advance role integration, foster role clarity, autonomy, and develop trust and respect from both patients and colleagues of NPs (Burgess & Purkis, 2010). Yet, as discussed earlier, trust, respect, autonomy, and role clarity were also antecedents to collaboration. Furthermore, collaboration has been said to generate team capacity, which again has been illustrated to be an antecedent to collaboration (Bailey et al., 2006; Burgess & Purkis, 2010). Individuals who participate in collaboration gain from the encouraging and supportive environment it produces by substantiating the distinctive and vital role of team member, by emphasizing opinions of competency, confidence, and worth. Possibly the most important part of collaborative practice is the ability the process has to promote collegial relationships and enhance mutual respect among professionals. When the nature of collaboration is cyclical in this way (respect→collaboration→greater respect), it ensures the sustained use and success of interpersonal interaction (Henneman et al., 1995). Benefits. Collaboration has been shown to have a number of benefits. Collaborative alliances between the NP and healthcare leaders has served to advance the NP role and promote strategic alliances to collectively remedy start-up problems of practices, develop needed 407
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infrastructure and policies, and negotiate resources for improving patient care (Burgess & Purkis, 2010). Inside the milieu of collaborative practice, NPs encounter greater occasions to make use of their knowledge and skills, thus being able to more directly influence the quality of patient care (Martin et al., 2005). Collaborative practice has been reported by NPs to enhance holistic client-centered care (Burgess & Purkis, 2010) and to reduce healthcare cost and improve patient outcomes (Cowan et al., 2006; Meyer & Miers, 2005; Sennour, Counsell, Jones, & Weiner, 2009). Collaborative communication has been shown to increase opinions of nursing leaders and improve problem-solving tasks. Nurses’ reports lower personal stress despite perceiving significantly more situation stress and ability to meet family demands, technical aspects of care, and job satisfaction (Boyle & Kochinda, 2004). For MDs, collaborative practice may allow more time for meeting increased demands for consultations and to devote to complex cases (Martin et al., 2005). Economically, collaborative practice between NPs and MDs derives financial benefits because of the ability to see an increased number of patients with an increased accessibility to the practice for patients, referring MDs, and other members of the healthcare team (Martin & Coniglio, 1996). Collaboration among NPs and physician assistants (PAs) with attending MDs and residents has also been found to increase patient approval in care delivery as well as satisfaction of attending staff and residents. More significantly, patient care outcomes were comparable to the resident service and the NP and PA service had reduced length of stays (Todd et al., 2004). Likewise, the addition of an NP to the team, along with initiation of multidisciplinary rounding and the appointment of a hospitalist director in one facility, was shown to increase collaboration and communication between MDs and nurses. This effort produced a decrease in overall costs and length of stay without a reduction in quality of life or satisfaction among patients between the two groups studied (Vazirani et al., 2005). Institutions that encourage collaboration also profit in several ways. Collaboration promotes greatest efficiency as team members use their abilities and expertise in a supportive and noncompetitive manner. Retention and commitment of team members is improved when team members perceive that their contributions are respected and they are able to share in decision making and planning (Henneman et al., 1995; Martin & Miers, 1996). Moreover, achievement of this goal frequently translates into a decreased length of hospital stays because of coordinated care provided by the NP and MD (Martin & Miers, 1996). The NP receives numerous additional benefits to collaborative practice. The NP can perform in a truly au408
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tonomous style, utilizing the expertise distinctive to the NP role, which can contribute to increased job satisfaction, personal and professional growth and development, and the satisfaction of being able to provide patients excellent care (Almost & Laschinger, 2002; Martin & Coniglio, 1996). Successful NPs and MDs who establish collaborative practice arrangements both can benefit from learning that occurs by both individuals exchanging their knowledge and experiences of ways to improve patient care (Norse et al., 1995). Both NPs and MDs acknowledge learning as a consequence of collaboration; however, MDs tend to relate while NPs could learn from them, they tend not to concede learning as a reciprocal feature of their working relationship (Martin et al., 2005). Sharing knowledge and ideas has not yet reached the point where MDs consistently view NPs as valuable in regard to exchanging expert knowledge (Hallas et al., 2004). Negative consequences. Negative consequences of ineffective collaboration include fragmented care, poor patient outcomes, and patient discontentment. Sharing of information is a key aspect of any conflict-resolution method and lack of such collaboration within the NP and MD partnership could ultimately affect patient care (Martin et al., 2005). Noncollaborative work environments may be a factor in role discontentment and tension for clinicians in charge of assuring quality patient care (Almost & Laschinger, 2002; O’Brien et al., 2009) and role confusion of healthcare team members and, more broadly, the public (Neale, 1999). Furthermore, noncollaborative work environments can contribute to lack of respect of partners, territorial and control issues, undesirable attitudes and behaviors, and competency issues. Thus, thwarting the development of successful collaborative practice relationships (Burgess & Purkis, 2010; Clarin, 2007; Hallas et al., 2004; Maylone et al., 2010). Consequences of collaboration are detailed in Table 1.
Proposed operational definition Based on the definitions and attributes identified in this review, the following operational definition is proposed: Collaboration is defined within the context of NP-MD collaborative practice as an interaction in which both individuals work as a team in a collegial relationship in an environment where there is mutual trust and respect and open communication. It is an interaction in which both individuals share knowledge and clinical expertise, decision making, and problem solving. In addition, it is an interaction in which both parties consult when needed to meet the shared goals of achieving excellent patient care and improved patient outcomes.
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Exemplar case The purpose of the exemplar case is to offer a practical demonstration of the concept in a relevant context to illustrate the characteristics of the concept to enhance clarity and effective application of the concept of interest (Tofthagen & Fagerstrom, 2010). The exemplar case of collaboration within the context of NP-MD collaborative practice was found in the literature and was described by Lamb and Napodano (1984) as follows. The NP interviews an elderly woman with a recent development of fatigue. This woman has a past medical history of obesity and noninsulin dependent diabetes mellitus. The NP gathers the history and does a physical exam, orders laboratory data, and recognizes there has been no change in the patient’s report of her diet, activity level, or any objective changes in her diabetic control, blood counts, or thyroid status. This woman does not seem more depressed than prior meetings with the NP and the NP is not able to discover a reason to explain the symptom of fatigue. Therefore, the NP involves the MD for assistance in finding additional potential causes for the fatigue. This interaction is scored as collaborative. As requested by the NP, the MD questions the patient along with the NP. The MD’s process of gathering additional information in this instance merely adds to the data already gathered by the NP and therefore is not considered to be collaborative. However, in later discussions, the two clinicians recognize that the women answered remarkably different to each of them, and placed a different importance on specific symptoms and used dissimilar nonverbal gestures during the interaction with each of them. This assessment of the history data by the clinicians with the detection of a distinctive pattern of communication with the patient leads to a new differential diagnosis based on the assimilation of the data from both interviews and viewpoints. As a result, this interaction is counted as collaborative.
Implications for research and practice This analysis has brought to light that collaboration is foundational to NP practice, yet, collaboration is cultivated by a broad context of healthcare culture. Organizational efforts to effectively promote collaboration between NPs and MDs are needed. Organizations should host routine educational sessions for team members teaching effective communication skills, problem-solving skills, and verbal message skills to improve collaborative practices in their facilities. Research is needed to determine what interventions are useful in promoting interdisciplinary collaboration between NPs and MDs and to describe their perceptions’ of the meaning of collaboration.
Research has shown that both NPs and MDs concur on the language related to collaboration, but hold a different view with regard to the invariants, which characterize its achievement (O’Brien et al., 2009). Research is needed to determine what NPs and MDs expect from one another to collaborate effectively. Qualitative methods may be an effective means in increasing an understanding of collaboration between NPs and MDs. Education of both the public and MDs regarding the roles of NPs is warranted to help change misconceptions of subordination and promote a collaborative practice (Neale, 1999).
Summary and conclusions This concept analysis has demonstrated that collaboration is a multifaceted, complicated process that obliges commitment to all of those involved. Within the context of NP and MD collaborative practice, patience, nurturing, and time are needed to develop a rapport where collaboration can take place (Henneman et al., 1995, Lamb & Napodano, 1984). A rare chance occurs for NPs who work with other individuals who are encouraging and experienced about collaborative practice. It allows NPs to work autonomously, utilizing the expertise and experiences distinctive to their role, allowing for them to be creative, effective, and productive while providing quality care to their patients (Almost & Laschinger, 2002).
Acknowledgments Dr. Clelia Lima, FNP-BC, MSN, DNP, is personally acknowledged for her contribution to this manuscript in the form of unpaid editorial assistance.
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Supporting Information Additional Supporting Information may be found in the online version of this article at the publisher’s web site: Table S1. Features of studies included for concept analysis.
