HEALTH POLICY AND SYSTEMS
Interdisciplinary Communication and Collaboration Among Physicians, Nurses, and Unlicensed Assistive Personnel Gwendolyn Lancaster, EdD, MSN, RN, CCRN1 , Stephanie Kolakowsky-Hayner, PhD2 , Joann Kovacich, PhD3 , & Nancy Greer-Williams, PhD, MPH4 1 Assistant Nursing Care Coordinator, Omicron Delta, Mount Sinai St. Luke’s Hospital, New York, NY 2 Director of Rehabilitation Research, Santa Clara Valley Medical Center, San Jose, CA 3 Associate Professor, School of Advanced Studies, University of Phoenix, AZ 4 Assistant Professor, University of Arkansas for Medical Sciences, Little Rock, AR
Key words Collaboration, interdisciplinary communication, nurses, patient safety, physicians, teamwork, unlicensed assistive personnel Correspondence Dr. Gwendolyn Lancaster, 269 W 121st St., Apt 1, New York, NY 10027. E-mail: [email protected] Accepted: January 25, 2015 doi: 10.1111/jnu.12130
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Abstract Purpose: Historically, health care has primarily focused on physician, nurse, and allied healthcare provider triads. Using a phenomenological approach, this study explores the potential for hospital-based interdisciplinary care provided by physicians, nurses, and unlicensed assistive personnel (UAPs). Design: This phenomenological study used a purposive nonprobability, criterion-based, convenience sample from a metropolitan hospital. Theoretical Foundation: Malhotra’s (1981) Schutzian lifeworld phenomenological orchestra study provided the theoretical basis for the conductorless orchestra model, which guided this study. In an orchestra, each member sees and hears the musical score from a different vantage point or perspective and has a different stock of knowledge or talent; however, members work together to produce a cohesive performance. Like the orchestra, individual talents and perspectives of physicians, nurses, and UAPs can be collaboratively blended to create a symphony: enhanced patient-centered care. Methods: Qualitative semistructured face-to-face, individual interviews were carefully transcribed and coded with the aid of NVivo 9, a qualitative data analysis software program, to discover emergent patterns and themes. Findings: The study suggests that most of the time physicians, nurses, and UAPs operate as separate healthcare providers who barely speak to each other. Physicians see themselves as the primary patient care decision makers. Many physicians acknowledge the importance of nurses’ knowledge and expertise. On the other hand, the study indicates a hierarchical, subservient relationship among nurses and UAPs. Physicians and nurses tend to work together or consult each other at times, but UAPs are rarely included in any type of meaningful patient discussion. Conclusions: Since physicians, nurses, and UAPs each provide portions of patient care, coordination of the various treatments and interventions provided is critical to prevent errors and fragmentation of care. Tensions, misunderstandings, and conflicts caused by differences of opinions and interests can interfere with effective interdisciplinary communications and collaboration. Improving patient safety in the hospital requires addressing the current hierarchical professional structure inherent in healthcare delivery. A hospital patient care model based on the conductorless orchestra model would mitigate hierarchy; recognize physician, nurse, and UAP contributions to care; promote improved communication and collaboration; and enhance patient safety.
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Clinical Relevance: Study results provide additional information supporting interdisciplinary communication and collaboration education and training among physicians, nurses, and UAPs to support positive patient care outcomes.
The negative impact of medical errors on patient safety is a serious problem. Medical errors are a major cause of death in the United States. Nearly 100,000 patients die annually due to medical errors (Ross, 2008). According to reports from healthcare accrediting agencies like the Joint Commission, poor communication among healthcare professionals is one of the most common causes of patient care errors (Siegele, 2009; Tschannen et al., 2011). Studies link efficient communication and dynamic collaboration to improved patient outcomes, while poor communication and collaboration are linked to negative consequences such as medical mistakes (Aston, Shi, ˆ Galway, & Crisp, 2005). Bullot, With increasing regulatory and public demands and workloads amid decreasing resources, collaboration and cooperation among healthcare providers is essential for patient safety. Since physicians, nurses, and unlicensed assistive personnel (UAPs) each provide a portion of hospital-based patient care, coordination of the various treatments and interventions they provide is critical to preventing errors. Collaboration occurs when providers with different knowledge and skills interact to synergistically and constructively influence patient care (Nelson, King, & Brodine, 2008; Ross, 2008; Vazirani, Hays, Shapiro, & Cowan, 2005). Collaboration involves “direct and open communication, respect for different perspectives, and mutual responsibility for problem solving” (Stein-Parbury & Liaschenko, 2007, p. 471). Lack of cooperation and collaboration hampers efficiency and quality (Hofmarcher, Oxley, & Rusticelli, 2007). Subsequently, it is essential that physicians, nurses, and UAPs find ways to work together to meet increasingly complex patient care needs. Working together is complicated and challenging. Bringing various perspectives into the decision-making process and differences of opinions can affect understanding in clinical situations (Stein-Parbury & Liaschenko, 2007). Different perspectives and priorities among the disciplines may present a barrier to collaboration that prevents them from capitalizing on their interdependence (Siegele, 2009). The National Joint Practice Commission formed in 1971 and, supported by the American Nurses Association and the American Medical Association, recognized the detrimental effects of nurse-physician conflict on patient care (Schmalenberg & Kramer, 2009). Nurse-nurse and nurse-UAP conflict can also contribute to negative patient care outcomes. 276
While the expertise of physicians, nurses, and UAPs as individual practitioners are important to safe patient care, good interdisciplinary relationships are equally important to high-quality patient care. Interdisciplinary collaboration can be effective when the professionals involved have a clear understanding of each other’s roles (O’Toole & Kirkpatrick, 2007). This qualitative, phenomenological study explored the research question: How do physicians, nurses, and UAPs perceive their own individual role and each other’s roles in patient care and interdisciplinary communication and collaboration? The goal of the study was to gain a greater understanding of interdisciplinary communication and collaboration among physicians, nurses, and UAPs, which can be used to enhance patient safety.
Theoretical Framework The Schutzian lifeworld phenomenological orchestra study described by Malhotra (1981) and the conductorless orchestra (Bartolovich, 2007; Khodyakov, 2007) provided a theoretical model for the study. The orchestra study illustrates how an orchestra’s final symphony performance is made up of more than the sum of its parts or orchestra members. While members may have a shared stock of knowledge, they also have individual experiences or stocks of knowledge and view a phenomenon (the music) from slightly different angles or perspectives. The musicians in the orchestra hear certain parts of the music being played but do not hear the entire musical piece while they are playing (Malhotra, 1981). Stock of knowledge refers to the learning and experiences that accumulate into social guidelines of appropriate behavior that enable groups or individuals to think about and interpret the world (Yu & Kwan, 2008). The different experiences and perspectives of individual orchestra members may affect the overall performance if they are not coordinated. The orchestra study shows that the various member perspectives can come together to create a cohesive final performance. While traditionally orchestras have a conductor that leads the group, directly oversees the musicians, and decides what, how, and when music is played (Seifter, 2001), Malhotra noted that a conductor is not an absolutely essential component of an orchestra. The conductor model fosters a rigid hierarchical approach to the musical performance, which presents a barrier to Journal of Nursing Scholarship, 2015; 47:3, 275–284. C 2015 Sigma Theta Tau International
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interdisciplinary communication and collaboration. However, the conductorless orchestra model recognizes that physicians, nurses, and UAPs (individual musicians) each see patient care from slightly different perspectives and each provider brings to bear his or her own stock of knowledge about patient-centered care (the musical score), which affects how he or she approaches or interprets the patient’s needs. The conductorless model flattens hierarchy, invites every member to participate in decisions, demonstrates willingness to change, promotes open communication, and encourages all members to give their best performance (Khodyakov, 2007). To produce a cohesive performance, orchestra members must have a working understanding of how each individual member contributes to a particular music score. Each orchestra member steps into the lead, using his or her talents as the score (patient care needs) indicates. The musicians engage in a joint interpretive project based on their individual and collective stock of knowledge; they remain perceptive to each other’s roles and functions; and they coach each other while playing the notes as the composer (patient) wrote them (Bartolovich, 2007; Malhotra, 1981). In some hospitals, there is a disconnection between physicians’, nurses’, and UAPs’ (orchestra members’) interpretations of patient care (the music). Through collaboration, skilled communication, and a respectful work environment, partnerships can develop that promote optimal patient care (successful performance of the musical score; Dietrich et al., 2010).
Methods The study was conducted at a major metropolitan hospital center located in New York City. Approval for the study was obtained from the hospital’s Institutional Review Board (IRB), and written authorization was obtained to use the hospital premises for the study. In addition, union leaders were informed of the study, and their support for member involvement was obtained. Validity and reliability are critical concepts in research. Validity is a measure of the truth or accuracy of a claim or proposition (Burns & Grove, 2005; Cooper & Schindler, 2003). Reliability refers to the consistency and accuracy of a measurement tool in gauging the study phenomenon (Neuman, 2003), and describes how well an instrument will produce similar results under different circumstances, assuming nothing else is changed. There are two major types of validity: internal and external. Internal validity indicates that there are no errors in the research design, and external validity is largely a measure of whether the research makes sense beyond the confines of the data collected (Cooper & Schindler, 2003). In qualitative Journal of Nursing Scholarship, 2015; 47:3, 275–284. C 2015 Sigma Theta Tau International
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research, ensuring validity and reliability involves conducting studies in an ethical manner (Merriam, 2009). In phenomenological research, external validity is judged in terms of meaningful coherence between results, data, and the techniques by which findings are reached (Garza, 2007). Credibility, confirmability, and transferability are the concepts used in qualitative research to evaluate internal and external validity. Credibility is comparable to internal validity, confirmability is comparable to objectivity, and transferability is comparable to generalizability found in quantitative research (Merriam, 2009). Credibility, confirmability, and transferability concerns are addressed through careful attention to a study’s conceptualization and how data are collected, analyzed, and interpreted, and the way findings are presented (Cooper & Schindler, 2003; Merriam, 2009). The hospital’s IRB reviewed all aspects of the study prior to granting permission to perform the study, which insured that the study design, data collection, and data analysis were consistent. Also, informed consent was obtained in accordance with the ethical principles of the National Commission for the Protection of Human Subjects of Biomedical Research, which protects research subjects from abuse (Burns & Grove, 2005). Tape-recording the semistructured interviews and triple checking transcripts and notes against the original audiotape recordings minimized loss or misinterpretation, thereby enhancing the believability and trustworthiness of the research findings and preventing spurious incorrect study conclusions (Salkind, 2003). In addition, all study procedures were discussed openly with participants, and participants were encouraged to ask questions and informed that their participation was strictly voluntary; they could withdraw at any time without penalty. The study did not pose any predictable harm to participants. However, the fear of reprisals might have been a real or perceived stressor for participants since the primary researcher also worked at the hospital and was known by many of the participants. Fear of reprisal was mitigated by making every effort to maintain confidentiality and by making participants as comfortable as possible. No names or identifying information was used in any notes or reports. Fictional names were randomly selected from a list of Jane Does (female) and John Does (male) numbered from 1 to 15 and assigned to each participant (i.e., MD John Doe 1 or Jane Doe 1). A code log of assigned names was developed. The code log, personal information, history, and experiences were kept in a database on a private password-protected laptop computer. Data collection involved qualitative semistructured interviews using an interview guide to maintain focus (Table 1). The qualitative interview is the primary 277
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Table 1. Interview Guide: Understanding Interdisciplinary Communication Among Physicians, Nurses, and Unlicensed Assistive Personnel Date: Introductory information
Question 1
Question 2
Question 3
Question 4 Question 5
Question 6 Question 7 Question 8
Question 9
Question 10 Closing
Welcome and introduce self to participants. Thank them for taking time to participate. Remind participants of the purpose of the interview, procedures to ensure confidentiality, informed consent, and the length of the interview. Explain that the questions are open-ended and designed to stimulate conversation. Encourage participants to speak whatever comes to mind. Inform participants when recording. Tell me a little about yourself (i.e., age, position, education, years of service, experience). How do you describe your role as a physician, nurse, or nursing attendant (depending on the participant) in patient care? What are your thoughts on the role of physicians, nurses, and nursing attendants (depending on the participant)? How do these roles affect patient safety? Describe how you believe others view your role (physicians, nurses, or nursing attendants). How do you define/describe communication? How do you define/describe interdisciplinary collaboration? How do you think interdisciplinary communication and collaboration affect patient safety? Describe your thoughts about interdisciplinary communication and collaboration now. Does it exist and to what extent? Describe an ideal example of interdisciplinary communication and collaboration. Thank you for your participation and candor.
method used to uncover the essence or basic underlying structure of meaning of an experience (Merriam, 2009). Interviews were tape-recorded with participants’ express permission and carefully transcribed to ensure accuracy of data collection. Note taking was used in conjunction with the tape recordings to record participants’ initial reactions, record the researcher’s reactions to what the participant said, or to pace the interview (Merriam, 2009). Data consisted of the words participants used to describe their perceptions and experiences. Participants were expected to speak freely and honestly. In-depth personal interviews elicit stories, thoughts, and feelings about the study phenomenon and are consistent with an intimate focus on one person’s experience, thereby
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providing context for understanding the meaning behind the person’s behavior (Smith, Flowers, & Larkin, 2009). The interviewer plays a dynamic role in controlling bias in the data collection process. Through the process of phenomenological reduction, the interviewer must acknowledge and put aside prior beliefs about the phenomenon of interest so as not to interfere with seeing the true essence of the phenomenon (Merriam, 2009). Performing the epoch, in which the researcher abstains from making suppositions and clears his or her mind, allows the researcher to listen with genuine curiosity, be open to new ideas, and see an object or phenomenon as it truly appears (Moustakas, 1994). To minimize potential negative effects of familiarity, the interviewer remained mindful of the study’s purpose, strove to curb personal biases about physician, nurse, and UAP interactions, and kept an open mind by listening intently to participant expressions and feelings and refraining from interjecting personal opinions. In addition, interviews were privately conducted and study participants chose the time and place of the interviews to maximize participant comfort and facilitate intimate conversation. The population for the qualitative phenomenological inquiry consisted of a nonprobability purposive sample of willing physicians (interns, residents, and attending physicians), and nurses and UAPs with at least 1 year of work experience at the hospital center. Nonprobability sampling is the method of choice in qualitative research since statistical generalization is not the primary goal (Merriam, 2009). A hospital-wide invitation was posted on the hospital’s internal intranet homepage, flyers were posted on patient care units, and information was presented at medical grand round meetings. An average sample size of 20 to 50 participants is adequate for qualitative studies (Mason, 2010). The final sample size was determined by the number of responses to the invitation to participate and on how quickly data saturation occurred during the interview process. Saturation generally refers to reaching a point where further data collection (conducting additional interviews) becomes counterproductive and new information does not necessarily add substantively to the overall story (Mason, 2010). Nurses readily volunteered for study participation, but physician and UAP recruitment proceeded more slowly. Ultimately, study participants included 12 physicians, 13 nurses, and 11 UAPs. Physician participants were involved in direct patient care, regardless of title (intern, resident, attending) or specialty. The majority of physicians were male attending physicians. The nurses and UAPs were mainly female. All participants were at least 18 years old and consisted of males and females of varying ethnicities.
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The interviewer piloted the interview guide prior to beginning the study to ensure that the questions elicited the type of information that would address the research question. Piloting strengthens study reliability and confirmability by helping the researcher ensure participant comprehension, determine the amount of interview structure needed, refine questions, and determine if participants are willing to talk about the research topic (Luck & Rose, 2007; Smith et al., 2009). The interviews were carefully transcribed, coded, and examined for patterns and themes with the help of NVivo 9 (QSR International Pty Ltd, Victoria, Australia), a computer-assisted qualitative data analysis software, which provided tools to help code, organize, and analyze the large amount of raw data collected. Interview notes were used to verify context of the data, ensure that nothing was excluded or missed, and enhance understanding of the emerging themes. The interviewer generated a list of provisional codes based on the research question, literature review, and interview guide (see Table 1) prior to beginning data collection. Then pattern or inferential coding was used to identify ˜ 2009). Provisional categories emergent themes (Saldana, for the study included (a) roles in patient care, (b) others’ views of a role, (c) communication, (d) collaboration or teamwork, (e) conflict, (f) patient safety, and (g) ideal interdisciplinary communication and collaboration. Each category was further subdivided to represent physician, nurse, and UAP perceptions. The preliminary coded responses were then reexamined and compared looking ˜ 2009). The for recurring themes or patterns (Saldana, researcher selected chunks of text and applied codes to them, and retrieved all similarly coded text without losing the data’s context. Recurring themes determined when data saturation occurred.
Findings The study suggests that a physician-nurse hierarchy exists, but may be changing. Physicians see themselves as the primary patient care decision makers, but many physicians advocate for and seek out nurse input. Nonetheless, some nurses reported that physicians order them around. Physicians and UAPs in this study admitted that they have very little contact with each other, whereas nurses and UAPs had a more significant relationship, which UAPs described as uncooperative and hierarchical. Perceptions among nurses and UAPs differ as to the reason for the negativity.
Roles in Patient Care Five of the physicians described the physician’s role as medical plan managers, or decision makers, or Journal of Nursing Scholarship, 2015; 47:3, 275–284. C 2015 Sigma Theta Tau International
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coordinators who care for all aspects of the patient. Three physicians described the physician as a teacher. According to MD John Doe 10, “The physician has the ultimate responsibility for all the inner workings of what’s going on with the patient.” MD Jane Doe 3, an outlier, stated, “I see the physician as a conductor . . . I see the nurse as the first violinist because they are the first on the scene and lead the group in doing everything.” When asked about the physician’s role, five nurses said physicians make a diagnosis and are not on the floor very long: “Honestly, when I see them on the floor, it’s just for a few minutes” (RN Jane Doe 11). Four nurses said physicians write orders and make treatment decisions. Seven UAPs noted that physicians examine patients and make diagnoses or plans. Three nurses stated that some physicians are arrogant, abrupt, and short tempered. RN Jane Doe 3 pumped out her chest and said, “Some doctors have this ‘I am the doctor’ persona so you have to listen to me. . . . It’s like I am nobody?” Then she shrugged her shoulders and laughed. Five nurses said they love nursing and described their role as a compassionate care provider, which includes giving medication, taking care of all of the patients’ needs, following physicians’ orders, and sometimes questioning orders. One nurse said, “It is a lot of work.” RN Jane Doe 11 said the nurse’s role is like being a waitress: I see myself as a waitress juggling things. Each patient is a person coming in to eat at the restaurant. I have to get them what they need at certain times and then I still have orders from my boss to carry out certain things. The restaurant boss can be the doctor, the nurse manager, the assistant nursing care coordinator, or it can be the patient. Three nurses mentioned that part of their role includes delegating to nursing attendants. Seven physicians stated that nurses are an integral part of patient care and protecting patients; nurses pay attention to details the physician may not be aware of because they spend more time with the patients. Four physicians noted that nurses do things like give medications, collect blood samples, take vital signs, and alert them to changes in the patients’ conditions. MD Jane Doe 4 reflected, “If you didn’t have your nurses around, you would not know what is going on with your patients.” When UAPs were asked to describe the nurse’s role, four stated that nurses take care of the whole patient, including dispensing medications. Four UAPs noted that some nurses are not helpful with patient care, such as cleaning patients. Three UAPs said the nurse role is similar to the UAP role. “A nurse is somebody who takes care of a patient like a CNA [UAP]. . . . Almost the same work plus they do 279
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medication” (UAP Jane Doe 3). One UAP stated, “Technically the physician is the head of the team, but the nurse is the actual head because once the physician does his part, he is gone.” Another UAP said nurses just follow doctors’ orders. When asked about the UAP role, five UAPs stated they love their jobs. However, UAP Jane Doe 11’s comments represent the general consensus among UAPs: I am here to make sure patients are comfortable . . . make sure they feel welcome. . . . I come in the mornings and go to each room, making sure that they can feed themselves . . . sit them up, make sure they eat, make sure they’re dry, cleaned and just talk to them . . . I assist the nurse. Most physicians did not comment about the UAP role in patient care. Three physicians and six nurses said UAPs assist the nurses and assist patients with daily needs. Two physicians admitted they were not sure what a UAP does. Five nurses made comments similar to RN Jane Doe 11: They [UAPs] are an extra hand . . . listening to them is important. . . . One came and grabbed me saying the patient was eating but then it seemed like she could not catch her breath. I went right away . . . the patient was choking. RN Jane Doe 2 took it a step further, stating, “They [UAPs] have a difficult role . . . they are a support system for us . . . I couldn’t work without them.” However, five other nurses said sometimes it is difficult to work with UAPs. RN John Doe 1 offered an explanation for the difficulty: They [UAPs] feel like they’re . . . on like the lowest rank I guess . . . I don’t want to say that . . . [he laughed uncomfortably, paused, then resumed speaking]. . . . So I think they already feel they are in the lowest rank and I think they don’t want another person telling them what to do. . . . They already have a lot of work to do and I guess after a while it wears you down.
Others’ Views of Provider Roles Participants were asked to describe what members of the other disciplines thought of that participant’s role. Four physicians believed that nurses see physicians as the major decision makers who write orders. Two physicians said nurses respect them and look to them for guidance. On the other hand, MD Jane Doe 7 stated, “You kind of grow to appreciate how much information and knowledge you gain from what nurses know about a specific case, it’s a medical view, but it’s a different cut of the same view.” MD Jane Doe 4 stated it slightly differently: 280
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“Nurses know some things to do with the systems but not to the degree that the doctors would have to know.” Almost all physicians just shrugged their shoulders when asked what UAPs thought of the physician role. When asked about how physicians view the nurse’s role, seven nurses said they believed physicians thought they were superior to nurses and tended to order nurses around. According to RN Jane Doe 3, “I had a doctor tell me the other day, ‘I am the doctor; you are the nurse.’ Like he was commanding me.” RN John Doe 1, who worked in the critical care and medical-surgical area, had a slightly different view: “I believe that physicians in the intensive care unit (ICU) listen to and value nurses’ opinions more than on the medical-surgical unit.” When asked about how UAPs view the nurse’s role, four nurses stated that UAPs think nurses believe they are superior to UAPs. When UAPs were asked how nurses view the UAP role, the majority of UAPs agreed with UAP Jane Doe 11: “Some nurses feel like you’re just there to clean, and run errands. . . . Some nurses look down their noses and boss you.” Physicians and UAPs stated they have little, if any, interaction.
Communication Physicians, nurses, and UAPs all said that communication is critical in health care. The general consensus among physicians was that good communication helps avoid patient care mistakes. MD John Doe 6 noted: Communication is essential in any field. In medicine, it is particularly important because you delegate work on behalf of the patient. You have to be clear on your assessments and management plan, and this has to be laid out very carefully to the patient, your colleagues, to nursing staff, and aides who are participating in care. Six physicians and eight nurses stated communication should be mainly a verbal face-to-face two-way interaction. UAPs mainly described communication as “talk to a person.” The majority of physicians, nurses, and UAPs also noted that how something is said is just as important as what is said. Six UAPs said communication with nurses should be respectful. According to UAP Jane Doe 7, “Communication is welcoming yourself to the person you’re working with . . . good morning . . . a smile.” Three physicians noted written communication is important and is often inadequate among physicians. Three UAPs said they try to keep to themselves and do not speak much; they only speak to nurses when it is necessary. Journal of Nursing Scholarship, 2015; 47:3, 275–284. C 2015 Sigma Theta Tau International
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Collaboration and Teamwork When asked about their thoughts on collaboration/teamwork, six physicians stated that taking the time to build physician-nurse relationships enables clear communication and helps to ensure that patient information is not missed. Five physicians and four nurses said that the meetings that the hospital called “interdisciplinary” in which the physician, nurse, and social worker discuss patients’ discharge readiness are sometimes helpful. UAPs are not typically included in those established meetings. On the other hand, seven UAPs stated it is important for nurses to work with them and help them with patients’ personal care. UAP Jane Doe 7 stated, Sometimes while the call bell is ringing, you’ll have a patient that needs total care, but your hands are too dirty. You can’t run to catch that bell. So, someone else can; it could be the RN, the manager, the doctor, or anybody; it’s a team. Four UAPs also thought that getting reports from nurses was important to teamwork and patient care. Three physicians noted that knowing the staff and keeping the nurses informed of changes to patients’ care plan is important. Two of the physicians noted a hierarchy among physicians. According to MD John Doe 8, “As an intern you don’t have a large role in the decision-making process of the patient. The major decisions are made by the attending [physician] and resident [physician], which are passed on to the juniors.”
Conflict Physicians, nurses, and UAPs stated that poor communication could cause conflict. Five attending physicians mentioned that it bothered them when another physician (consult, intern, or resident) did not inform them of a change in their patient’s condition. Five UAPs and six nurses noted conflict with each other. For example, UAP Jane Doe 6 reflected, “I asked about a patient’s diet and the nurse said in front of the patient’s family, ‘Just give him the food!’ I felt so disrespected, but I didn’t say anything.” UAP Jane Doe 8 stated that a nurse told her, “I don’t do nursing attendant work.” On the other hand, RN Jane Doe 3 noted, “When I was in nursing school, they said ‘listen to your [UAPs] good because sometimes they save you or they can sink you’.”
Patient Safety Physicians, nurses, and UAPs all stated that their roles are important to patient safety. Most physicians and nurses stated that communication is important to Journal of Nursing Scholarship, 2015; 47:3, 275–284. C 2015 Sigma Theta Tau International
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avoiding mistakes like medication errors, while UAPs mainly focused on preventing patient falls. MD John Doe 9 relayed an outlying experience with another physician that deeply affected him: The message was [verbally] relayed to my fellow [another physician] to apply wet to dry dressings for 2 days . . . the message was [supposedly] relayed to the residents . . . 5 days later, the patient had the same gauze . . . the patient bled when the gauze was removed . . . I should have spoken directly to the resident . . . I think it is on the physician to make sure everybody understands.
Ideal Communication and Collaboration Five physicians and four nurses noted that ideal collaboration involves making rounds with the physicians, nurses, and social workers. Five nurses said that it is important for physicians to at least inform them of changes to the patient care plans or orders. Most UAPs stressed the importance of having nurses help with patients’ personal needs and to give UAPs verbal reports on patients. UAP John Doe 2 took it a step further, “It [ideal teamwork] is the involvement of all who partake in the care of a patient, no matter what your position is. All roles must be considered important and critical to patient care.”
Implications for Practice Meeting today’s increasingly complicated dynamic healthcare needs requires a variety of healthcare providers. No one provider can meet all patient needs. Yet, when a variety of providers are involved in patient care, there is a possibility of fragmented care. Fragmentation of care contributes to medical mistakes (Retchin, 2008; Weinberg, 2002). Interprofessional collaboration, which allows providers to build an understanding that reflects both independent and shared decision making, prevents fragmentation and increases effectiveness of healthcare delivery (Thiele & Barraclough, 2007). Reeves and Lewin (2004) noted that lack of time for team building, confused roles, effects of professional socialization, and power and status differentials block interprofessional collaboration. A professional group’s perception of how they should work with other professions influences their interpretation of collaboration (Rodger, Mickan, Marinac, & Woddyatt, 2005). Therefore, building a cohesive interprofessional healthcare team begins with gaining an understanding of the individual members. The stories told by the physicians, nurses, and UAPs in the study provided insights into how they define their individual roles and the roles of members of the other 281
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disciplines. Study results suggest a multidisciplinaryinterdisciplinary triad among physicians, nurses, and UAPs. Most of the time physicians, nurses, and UAPs operated as separate healthcare providers who barely spoke to each other. Physicians and nurses occasionally dialogued, but UAPs were rarely included in any meaningful patient dialogue. Valuable patient information might be missed when healthcare providers do not communicate with each other. This study’s results also indicate that a hierarchical relationship exists in the hospital setting. Physicians, nurses, and UAPs tend to see the physician as the person in charge. Study findings support those of Scherer and Fitzpatrick (2008) and Weinberg (2002), which suggest that enhancing patient safety should begin by changing the dysfunctional hierarchical hospital culture, aligning healthcare providers’ perceptions, attitudes, knowledge, and skills, and acknowledging the importance of communication and collaboration. Successful collaborative interaction includes nonhierarchical control among mutually respectful equals (Stupak & Stupak, 2006; Taylor, 2009). In a conductorless orchestra, the leadership role rotates so that everyone experiences being a leader and a follower; there is no hierarchical control (Jagd, 2010). Each member of the team steps up, using his or her stock of knowledge based on the patient’s needs. In the past, researchers described the physician-nurse relationship as a game that nurses played in which they did not confront physicians directly about patient care issues; they made subtle suggestions (Davies, Salvage, & Smith, 1999; Stein, 1968). Reeves, Nelson, and Zwarenstein (2008) noted that over time, nurses rebelled and sought a more professional, well-educated, independent, and skilled image. This study yielded similar results that suggest the old subservient relationship between physicians and nurses has improved. Many physicians acknowledge the importance of nurses’ knowledge and expertise. On the other hand, the study found a toxic nurse-UAP relationship. UAPs currently struggle for the same respect and recognition from nurses that nurses seek from physicians.
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will provide opportunities to gain professional respect, which is an essential condition for changes needed to make health care safe (Leape et al., 2012). Online problem-based learning case studies can offer busy providers anywhere and anytime access to test their interdisciplinary knowledge and promote patient-centered care by allowing providers to explore the impact of each team member’s contributions to patient care (Vroman & Kovacich, 2002). Communication technology can be creatively incorporated as an adjunct to face-to-face meetings to keep all team providers informed.
Conclusions Interprofessional collaboration, which allows providers to build an understanding that reflects both independent and shared decision making, prevents fragmentation and increases effectiveness of healthcare delivery (Thiele & Barraclough, 2007). Inadequate communication and a dictatorial, authoritative arrangement among healthcare providers foster hostility, frustration, and distrust, which hinder collaboration and jeopardize quality patient care (Burke, Boal, & Mitchell, 2004; Sopow, 2006; Thiele & Barraclough, 2007). Furthermore, collaboration, communication, and coordination of care are limited in hierarchical hospital structures because isolated professionalism causes territorial issues (Kenaszchuk, MacMillan, van Soeren, & Reeves, 2011). Adoption of a hospital patient care system based on the conductorless orchestra model would mitigate hierarchy and recognize physician, nurse, and UAP contributions to care, improve communication and collaboration, and enhance patient safety.
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Education and Professional Development To increase interdisciplinary communication and collaboration, education and training opportunities should be offered to increase knowledge about different healthcare providers’ roles and functions (Hague & Kovacich, 2007; Kovacich, Cook, Pelletier, & Weaver, 1997). Interprofessional programs that allow healthcare professionals to learn together should be developed. Learning together 282
American Medical Association Journal of Ethics: http://virtualmentor.ama-assn.org/2013/06/ecas3-1306.html American Nurses Association Principles: http:// www.nursingworld.org/principles Joint Commission National Patient Safety Goals: http://www.jointcommission.org/standards_ information/npsgs.aspx
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Luck, A. M., & Rose, M. L. (2007). Interviewing people with aphasia: Insights into method adjustments from a pilot study. Aphasiology, 21(2), 208–224. doi:10.1080/02687030601065470 Malhotra, V. (1981). The social accomplishment of music in a symphony orchestra: A phenomenological analysis. Qualitative Sociology, 4(2), 102–124. Mason, M. (2010). Sample size and saturation in PhD studies using qualitative interviews. Qualitative Social Research, 11(3), 1–19. Merriam, S. B. (2009). Qualitative research: A guide to design and implementation. San Francisco, CA: Jossey-Bass. Moustakas, C. (1994). Phenomenological research methods. Thousand Oaks, CA: Sage. Nelson, G., King, M., & Brodine, S. (2008). Nurse-physician collaboration on medical units. MedSurg Nursing, 17(1), 35–40. Neuman, W. L. (2003). Social research methods: Qualitative and quantitative approaches (5th ed.). Boston, MA: Allyn & Bacon. O’Toole, C., & Kirkpatrick, V. (2007). Building collaboration between professionals in health and education through interdisciplinary training. Child Language Teaching and Therapy, 23(3), 325–352. Reeves, S., & Lewin, S. (2004). Interprofessional collaboration in the hospital: Strategies and meanings. Journal of Health Services Research & Policy, 9(4), 218–225. Reeves, S., Nelson, S., & Zwarenstein, M. (2008). The doctor-nurse game in the age of interprofessional care: A view from Canada. Nursing Inquiry, 15(1), 1–2. Retchin, S. M. (2008). A conceptual framework for interprofessional and co-managed care. Academic Medicine, 83(10), 929–933. Rodger, S., Mickan, S., Marinac, J., & Woddyatt, G. (2005). Enhancing teamwork among allied health students: Evaluation of an interprofessional workshop. Journal of Allied Health, 34(4), 230–235. Ross, J. (2008). Collaboration: Integrating pharmacy and information technology into a barcode medication administration system implementation. Caring Newsletter, 23(1), 1–9. ˜ J. (2009). The coding manual for qualitative researchers. Saldana, Los Angeles, CA: Sage Publications. Salkind, N. J. (2003). Exploring research (5th ed.). Upper Saddle River, NJ: Prentice Hall. Scherer, D., & Fitzpatrick, J. J. (2008). Perceptions of patient safety culture among physicians and RNs in the perioperative area. Association of Operating Room Nurses Journal, 87(1), 163–175. Schmalenberg, C., & Kramer, M. (2009). Nurse-physician relationships in hospitals: 20,000 nurses tell their story. Critical Care Nurse, 29(1), 74–83. doi:10.4037/ccn2009436 Seifter, H. (2001). The conductor-less orchestra. Leader to Leader Journal, 21. Retrieved from http://www.leader toleader.org/knowledgecenter/journal.aspx?ArticleID=110 283
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Siegele, P. (2009). Enhancing outcomes in a surgical intensive care unit by implementing daily goals. Critical Care Nurse, 29(6), 58–69. Smith, J. A., Flowers, P., & Larkin, M. (2009). Interpretive phenomenology analysis: Theory, method and research. Los Angeles, CA: Sage. Sopow, E. (2006). The impact of culture and climate on change programs. Strategic Communication Management, 10(6), 14–18. Stein, L. I. (1968). The doctor-nurse game. The American Journal of Nursing, 68(1), 101–105. Stein-Parbury, J., & Liaschenko, J. (2007). Understanding collaboration between nurses and physicians as knowledge at work. American Journal of Critical Care, 16(5), 470–478. Stupak, R. J., & Stupak, K. N. (2006). Finding organizational reality in paradise: A team of two. Public Administration Quarterly, 30(1), 11–21. Taylor, C. (2009). Attitudes toward physician-nurse collaboration in anesthesia. American Association of Nurse Anesthetists (AANA), 77(5), 343–348. Thiele, A., & Barraclough, A. (2007). The framework for physical therapist and physician assistant partnership:
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Interprofessional education and collaborative patient-centered care. Journal of Physical Therapy Education, 21(3), 47–52. Tschannen, D., Keenan, G., Aebersold, M., Kocan, M. J., Lundy, F., & Averhart, V. (2011). Implications of nurse-physician relations: Report of a successful intervention. Nursing Economics, 29(3), 127–135. Vazirani, S., Hays, R. D., Shapiro, M. F., & 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. Vroman, K., & Kovacich, J. (2002). Computer-mediated interdisciplinary teams: Theory and reality. Journal of Interprofessional Care, 16(2), 159–170. Weinberg, J. K. (2002). Medical error and patient safety: Understanding cultures in conflict. Law & Policy, 24(2), 93–114. Yu, F. T., & Kwan, D. S. M. (2008). Social construction of national identity: Taiwanese versus Chinese consciousness. Social Identities, 14(1), 33–52. doi:10.1080/135046701848 515
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Interdisciplinary Communication and Collaboration Among Physicians, Nurses, and Unlicensed Assistive Personnel Gwendolyn Lancaster, EdD, MSN, RN, CCRN1 , Stephanie Kolakowsky-Hayner, PhD2 , Joann Kovacich, PhD3 , & Nancy Greer-Williams, PhD, MPH4 1 Assistant Nursing Care Coordinator, Omicron Delta, Mount Sinai St. Luke’s Hospital, New York, NY 2 Director of Rehabilitation Research, Santa Clara Valley Medical Center, San Jose, CA 3 Associate Professor, School of Advanced Studies, University of Phoenix, AZ 4 Assistant Professor, University of Arkansas for Medical Sciences, Little Rock, AR
Key words Collaboration, interdisciplinary communication, nurses, patient safety, physicians, teamwork, unlicensed assistive personnel Correspondence Dr. Gwendolyn Lancaster, 269 W 121st St., Apt 1, New York, NY 10027. E-mail: [email protected] Accepted: January 25, 2015 doi: 10.1111/jnu.12130
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Abstract Purpose: Historically, health care has primarily focused on physician, nurse, and allied healthcare provider triads. Using a phenomenological approach, this study explores the potential for hospital-based interdisciplinary care provided by physicians, nurses, and unlicensed assistive personnel (UAPs). Design: This phenomenological study used a purposive nonprobability, criterion-based, convenience sample from a metropolitan hospital. Theoretical Foundation: Malhotra’s (1981) Schutzian lifeworld phenomenological orchestra study provided the theoretical basis for the conductorless orchestra model, which guided this study. In an orchestra, each member sees and hears the musical score from a different vantage point or perspective and has a different stock of knowledge or talent; however, members work together to produce a cohesive performance. Like the orchestra, individual talents and perspectives of physicians, nurses, and UAPs can be collaboratively blended to create a symphony: enhanced patient-centered care. Methods: Qualitative semistructured face-to-face, individual interviews were carefully transcribed and coded with the aid of NVivo 9, a qualitative data analysis software program, to discover emergent patterns and themes. Findings: The study suggests that most of the time physicians, nurses, and UAPs operate as separate healthcare providers who barely speak to each other. Physicians see themselves as the primary patient care decision makers. Many physicians acknowledge the importance of nurses’ knowledge and expertise. On the other hand, the study indicates a hierarchical, subservient relationship among nurses and UAPs. Physicians and nurses tend to work together or consult each other at times, but UAPs are rarely included in any type of meaningful patient discussion. Conclusions: Since physicians, nurses, and UAPs each provide portions of patient care, coordination of the various treatments and interventions provided is critical to prevent errors and fragmentation of care. Tensions, misunderstandings, and conflicts caused by differences of opinions and interests can interfere with effective interdisciplinary communications and collaboration. Improving patient safety in the hospital requires addressing the current hierarchical professional structure inherent in healthcare delivery. A hospital patient care model based on the conductorless orchestra model would mitigate hierarchy; recognize physician, nurse, and UAP contributions to care; promote improved communication and collaboration; and enhance patient safety.
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Clinical Relevance: Study results provide additional information supporting interdisciplinary communication and collaboration education and training among physicians, nurses, and UAPs to support positive patient care outcomes.
The negative impact of medical errors on patient safety is a serious problem. Medical errors are a major cause of death in the United States. Nearly 100,000 patients die annually due to medical errors (Ross, 2008). According to reports from healthcare accrediting agencies like the Joint Commission, poor communication among healthcare professionals is one of the most common causes of patient care errors (Siegele, 2009; Tschannen et al., 2011). Studies link efficient communication and dynamic collaboration to improved patient outcomes, while poor communication and collaboration are linked to negative consequences such as medical mistakes (Aston, Shi, ˆ Galway, & Crisp, 2005). Bullot, With increasing regulatory and public demands and workloads amid decreasing resources, collaboration and cooperation among healthcare providers is essential for patient safety. Since physicians, nurses, and unlicensed assistive personnel (UAPs) each provide a portion of hospital-based patient care, coordination of the various treatments and interventions they provide is critical to preventing errors. Collaboration occurs when providers with different knowledge and skills interact to synergistically and constructively influence patient care (Nelson, King, & Brodine, 2008; Ross, 2008; Vazirani, Hays, Shapiro, & Cowan, 2005). Collaboration involves “direct and open communication, respect for different perspectives, and mutual responsibility for problem solving” (Stein-Parbury & Liaschenko, 2007, p. 471). Lack of cooperation and collaboration hampers efficiency and quality (Hofmarcher, Oxley, & Rusticelli, 2007). Subsequently, it is essential that physicians, nurses, and UAPs find ways to work together to meet increasingly complex patient care needs. Working together is complicated and challenging. Bringing various perspectives into the decision-making process and differences of opinions can affect understanding in clinical situations (Stein-Parbury & Liaschenko, 2007). Different perspectives and priorities among the disciplines may present a barrier to collaboration that prevents them from capitalizing on their interdependence (Siegele, 2009). The National Joint Practice Commission formed in 1971 and, supported by the American Nurses Association and the American Medical Association, recognized the detrimental effects of nurse-physician conflict on patient care (Schmalenberg & Kramer, 2009). Nurse-nurse and nurse-UAP conflict can also contribute to negative patient care outcomes. 276
While the expertise of physicians, nurses, and UAPs as individual practitioners are important to safe patient care, good interdisciplinary relationships are equally important to high-quality patient care. Interdisciplinary collaboration can be effective when the professionals involved have a clear understanding of each other’s roles (O’Toole & Kirkpatrick, 2007). This qualitative, phenomenological study explored the research question: How do physicians, nurses, and UAPs perceive their own individual role and each other’s roles in patient care and interdisciplinary communication and collaboration? The goal of the study was to gain a greater understanding of interdisciplinary communication and collaboration among physicians, nurses, and UAPs, which can be used to enhance patient safety.
Theoretical Framework The Schutzian lifeworld phenomenological orchestra study described by Malhotra (1981) and the conductorless orchestra (Bartolovich, 2007; Khodyakov, 2007) provided a theoretical model for the study. The orchestra study illustrates how an orchestra’s final symphony performance is made up of more than the sum of its parts or orchestra members. While members may have a shared stock of knowledge, they also have individual experiences or stocks of knowledge and view a phenomenon (the music) from slightly different angles or perspectives. The musicians in the orchestra hear certain parts of the music being played but do not hear the entire musical piece while they are playing (Malhotra, 1981). Stock of knowledge refers to the learning and experiences that accumulate into social guidelines of appropriate behavior that enable groups or individuals to think about and interpret the world (Yu & Kwan, 2008). The different experiences and perspectives of individual orchestra members may affect the overall performance if they are not coordinated. The orchestra study shows that the various member perspectives can come together to create a cohesive final performance. While traditionally orchestras have a conductor that leads the group, directly oversees the musicians, and decides what, how, and when music is played (Seifter, 2001), Malhotra noted that a conductor is not an absolutely essential component of an orchestra. The conductor model fosters a rigid hierarchical approach to the musical performance, which presents a barrier to Journal of Nursing Scholarship, 2015; 47:3, 275–284. C 2015 Sigma Theta Tau International
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interdisciplinary communication and collaboration. However, the conductorless orchestra model recognizes that physicians, nurses, and UAPs (individual musicians) each see patient care from slightly different perspectives and each provider brings to bear his or her own stock of knowledge about patient-centered care (the musical score), which affects how he or she approaches or interprets the patient’s needs. The conductorless model flattens hierarchy, invites every member to participate in decisions, demonstrates willingness to change, promotes open communication, and encourages all members to give their best performance (Khodyakov, 2007). To produce a cohesive performance, orchestra members must have a working understanding of how each individual member contributes to a particular music score. Each orchestra member steps into the lead, using his or her talents as the score (patient care needs) indicates. The musicians engage in a joint interpretive project based on their individual and collective stock of knowledge; they remain perceptive to each other’s roles and functions; and they coach each other while playing the notes as the composer (patient) wrote them (Bartolovich, 2007; Malhotra, 1981). In some hospitals, there is a disconnection between physicians’, nurses’, and UAPs’ (orchestra members’) interpretations of patient care (the music). Through collaboration, skilled communication, and a respectful work environment, partnerships can develop that promote optimal patient care (successful performance of the musical score; Dietrich et al., 2010).
Methods The study was conducted at a major metropolitan hospital center located in New York City. Approval for the study was obtained from the hospital’s Institutional Review Board (IRB), and written authorization was obtained to use the hospital premises for the study. In addition, union leaders were informed of the study, and their support for member involvement was obtained. Validity and reliability are critical concepts in research. Validity is a measure of the truth or accuracy of a claim or proposition (Burns & Grove, 2005; Cooper & Schindler, 2003). Reliability refers to the consistency and accuracy of a measurement tool in gauging the study phenomenon (Neuman, 2003), and describes how well an instrument will produce similar results under different circumstances, assuming nothing else is changed. There are two major types of validity: internal and external. Internal validity indicates that there are no errors in the research design, and external validity is largely a measure of whether the research makes sense beyond the confines of the data collected (Cooper & Schindler, 2003). In qualitative Journal of Nursing Scholarship, 2015; 47:3, 275–284. C 2015 Sigma Theta Tau International
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research, ensuring validity and reliability involves conducting studies in an ethical manner (Merriam, 2009). In phenomenological research, external validity is judged in terms of meaningful coherence between results, data, and the techniques by which findings are reached (Garza, 2007). Credibility, confirmability, and transferability are the concepts used in qualitative research to evaluate internal and external validity. Credibility is comparable to internal validity, confirmability is comparable to objectivity, and transferability is comparable to generalizability found in quantitative research (Merriam, 2009). Credibility, confirmability, and transferability concerns are addressed through careful attention to a study’s conceptualization and how data are collected, analyzed, and interpreted, and the way findings are presented (Cooper & Schindler, 2003; Merriam, 2009). The hospital’s IRB reviewed all aspects of the study prior to granting permission to perform the study, which insured that the study design, data collection, and data analysis were consistent. Also, informed consent was obtained in accordance with the ethical principles of the National Commission for the Protection of Human Subjects of Biomedical Research, which protects research subjects from abuse (Burns & Grove, 2005). Tape-recording the semistructured interviews and triple checking transcripts and notes against the original audiotape recordings minimized loss or misinterpretation, thereby enhancing the believability and trustworthiness of the research findings and preventing spurious incorrect study conclusions (Salkind, 2003). In addition, all study procedures were discussed openly with participants, and participants were encouraged to ask questions and informed that their participation was strictly voluntary; they could withdraw at any time without penalty. The study did not pose any predictable harm to participants. However, the fear of reprisals might have been a real or perceived stressor for participants since the primary researcher also worked at the hospital and was known by many of the participants. Fear of reprisal was mitigated by making every effort to maintain confidentiality and by making participants as comfortable as possible. No names or identifying information was used in any notes or reports. Fictional names were randomly selected from a list of Jane Does (female) and John Does (male) numbered from 1 to 15 and assigned to each participant (i.e., MD John Doe 1 or Jane Doe 1). A code log of assigned names was developed. The code log, personal information, history, and experiences were kept in a database on a private password-protected laptop computer. Data collection involved qualitative semistructured interviews using an interview guide to maintain focus (Table 1). The qualitative interview is the primary 277
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Table 1. Interview Guide: Understanding Interdisciplinary Communication Among Physicians, Nurses, and Unlicensed Assistive Personnel Date: Introductory information
Question 1
Question 2
Question 3
Question 4 Question 5
Question 6 Question 7 Question 8
Question 9
Question 10 Closing
Welcome and introduce self to participants. Thank them for taking time to participate. Remind participants of the purpose of the interview, procedures to ensure confidentiality, informed consent, and the length of the interview. Explain that the questions are open-ended and designed to stimulate conversation. Encourage participants to speak whatever comes to mind. Inform participants when recording. Tell me a little about yourself (i.e., age, position, education, years of service, experience). How do you describe your role as a physician, nurse, or nursing attendant (depending on the participant) in patient care? What are your thoughts on the role of physicians, nurses, and nursing attendants (depending on the participant)? How do these roles affect patient safety? Describe how you believe others view your role (physicians, nurses, or nursing attendants). How do you define/describe communication? How do you define/describe interdisciplinary collaboration? How do you think interdisciplinary communication and collaboration affect patient safety? Describe your thoughts about interdisciplinary communication and collaboration now. Does it exist and to what extent? Describe an ideal example of interdisciplinary communication and collaboration. Thank you for your participation and candor.
method used to uncover the essence or basic underlying structure of meaning of an experience (Merriam, 2009). Interviews were tape-recorded with participants’ express permission and carefully transcribed to ensure accuracy of data collection. Note taking was used in conjunction with the tape recordings to record participants’ initial reactions, record the researcher’s reactions to what the participant said, or to pace the interview (Merriam, 2009). Data consisted of the words participants used to describe their perceptions and experiences. Participants were expected to speak freely and honestly. In-depth personal interviews elicit stories, thoughts, and feelings about the study phenomenon and are consistent with an intimate focus on one person’s experience, thereby
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providing context for understanding the meaning behind the person’s behavior (Smith, Flowers, & Larkin, 2009). The interviewer plays a dynamic role in controlling bias in the data collection process. Through the process of phenomenological reduction, the interviewer must acknowledge and put aside prior beliefs about the phenomenon of interest so as not to interfere with seeing the true essence of the phenomenon (Merriam, 2009). Performing the epoch, in which the researcher abstains from making suppositions and clears his or her mind, allows the researcher to listen with genuine curiosity, be open to new ideas, and see an object or phenomenon as it truly appears (Moustakas, 1994). To minimize potential negative effects of familiarity, the interviewer remained mindful of the study’s purpose, strove to curb personal biases about physician, nurse, and UAP interactions, and kept an open mind by listening intently to participant expressions and feelings and refraining from interjecting personal opinions. In addition, interviews were privately conducted and study participants chose the time and place of the interviews to maximize participant comfort and facilitate intimate conversation. The population for the qualitative phenomenological inquiry consisted of a nonprobability purposive sample of willing physicians (interns, residents, and attending physicians), and nurses and UAPs with at least 1 year of work experience at the hospital center. Nonprobability sampling is the method of choice in qualitative research since statistical generalization is not the primary goal (Merriam, 2009). A hospital-wide invitation was posted on the hospital’s internal intranet homepage, flyers were posted on patient care units, and information was presented at medical grand round meetings. An average sample size of 20 to 50 participants is adequate for qualitative studies (Mason, 2010). The final sample size was determined by the number of responses to the invitation to participate and on how quickly data saturation occurred during the interview process. Saturation generally refers to reaching a point where further data collection (conducting additional interviews) becomes counterproductive and new information does not necessarily add substantively to the overall story (Mason, 2010). Nurses readily volunteered for study participation, but physician and UAP recruitment proceeded more slowly. Ultimately, study participants included 12 physicians, 13 nurses, and 11 UAPs. Physician participants were involved in direct patient care, regardless of title (intern, resident, attending) or specialty. The majority of physicians were male attending physicians. The nurses and UAPs were mainly female. All participants were at least 18 years old and consisted of males and females of varying ethnicities.
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The interviewer piloted the interview guide prior to beginning the study to ensure that the questions elicited the type of information that would address the research question. Piloting strengthens study reliability and confirmability by helping the researcher ensure participant comprehension, determine the amount of interview structure needed, refine questions, and determine if participants are willing to talk about the research topic (Luck & Rose, 2007; Smith et al., 2009). The interviews were carefully transcribed, coded, and examined for patterns and themes with the help of NVivo 9 (QSR International Pty Ltd, Victoria, Australia), a computer-assisted qualitative data analysis software, which provided tools to help code, organize, and analyze the large amount of raw data collected. Interview notes were used to verify context of the data, ensure that nothing was excluded or missed, and enhance understanding of the emerging themes. The interviewer generated a list of provisional codes based on the research question, literature review, and interview guide (see Table 1) prior to beginning data collection. Then pattern or inferential coding was used to identify ˜ 2009). Provisional categories emergent themes (Saldana, for the study included (a) roles in patient care, (b) others’ views of a role, (c) communication, (d) collaboration or teamwork, (e) conflict, (f) patient safety, and (g) ideal interdisciplinary communication and collaboration. Each category was further subdivided to represent physician, nurse, and UAP perceptions. The preliminary coded responses were then reexamined and compared looking ˜ 2009). The for recurring themes or patterns (Saldana, researcher selected chunks of text and applied codes to them, and retrieved all similarly coded text without losing the data’s context. Recurring themes determined when data saturation occurred.
Findings The study suggests that a physician-nurse hierarchy exists, but may be changing. Physicians see themselves as the primary patient care decision makers, but many physicians advocate for and seek out nurse input. Nonetheless, some nurses reported that physicians order them around. Physicians and UAPs in this study admitted that they have very little contact with each other, whereas nurses and UAPs had a more significant relationship, which UAPs described as uncooperative and hierarchical. Perceptions among nurses and UAPs differ as to the reason for the negativity.
Roles in Patient Care Five of the physicians described the physician’s role as medical plan managers, or decision makers, or Journal of Nursing Scholarship, 2015; 47:3, 275–284. C 2015 Sigma Theta Tau International
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coordinators who care for all aspects of the patient. Three physicians described the physician as a teacher. According to MD John Doe 10, “The physician has the ultimate responsibility for all the inner workings of what’s going on with the patient.” MD Jane Doe 3, an outlier, stated, “I see the physician as a conductor . . . I see the nurse as the first violinist because they are the first on the scene and lead the group in doing everything.” When asked about the physician’s role, five nurses said physicians make a diagnosis and are not on the floor very long: “Honestly, when I see them on the floor, it’s just for a few minutes” (RN Jane Doe 11). Four nurses said physicians write orders and make treatment decisions. Seven UAPs noted that physicians examine patients and make diagnoses or plans. Three nurses stated that some physicians are arrogant, abrupt, and short tempered. RN Jane Doe 3 pumped out her chest and said, “Some doctors have this ‘I am the doctor’ persona so you have to listen to me. . . . It’s like I am nobody?” Then she shrugged her shoulders and laughed. Five nurses said they love nursing and described their role as a compassionate care provider, which includes giving medication, taking care of all of the patients’ needs, following physicians’ orders, and sometimes questioning orders. One nurse said, “It is a lot of work.” RN Jane Doe 11 said the nurse’s role is like being a waitress: I see myself as a waitress juggling things. Each patient is a person coming in to eat at the restaurant. I have to get them what they need at certain times and then I still have orders from my boss to carry out certain things. The restaurant boss can be the doctor, the nurse manager, the assistant nursing care coordinator, or it can be the patient. Three nurses mentioned that part of their role includes delegating to nursing attendants. Seven physicians stated that nurses are an integral part of patient care and protecting patients; nurses pay attention to details the physician may not be aware of because they spend more time with the patients. Four physicians noted that nurses do things like give medications, collect blood samples, take vital signs, and alert them to changes in the patients’ conditions. MD Jane Doe 4 reflected, “If you didn’t have your nurses around, you would not know what is going on with your patients.” When UAPs were asked to describe the nurse’s role, four stated that nurses take care of the whole patient, including dispensing medications. Four UAPs noted that some nurses are not helpful with patient care, such as cleaning patients. Three UAPs said the nurse role is similar to the UAP role. “A nurse is somebody who takes care of a patient like a CNA [UAP]. . . . Almost the same work plus they do 279
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medication” (UAP Jane Doe 3). One UAP stated, “Technically the physician is the head of the team, but the nurse is the actual head because once the physician does his part, he is gone.” Another UAP said nurses just follow doctors’ orders. When asked about the UAP role, five UAPs stated they love their jobs. However, UAP Jane Doe 11’s comments represent the general consensus among UAPs: I am here to make sure patients are comfortable . . . make sure they feel welcome. . . . I come in the mornings and go to each room, making sure that they can feed themselves . . . sit them up, make sure they eat, make sure they’re dry, cleaned and just talk to them . . . I assist the nurse. Most physicians did not comment about the UAP role in patient care. Three physicians and six nurses said UAPs assist the nurses and assist patients with daily needs. Two physicians admitted they were not sure what a UAP does. Five nurses made comments similar to RN Jane Doe 11: They [UAPs] are an extra hand . . . listening to them is important. . . . One came and grabbed me saying the patient was eating but then it seemed like she could not catch her breath. I went right away . . . the patient was choking. RN Jane Doe 2 took it a step further, stating, “They [UAPs] have a difficult role . . . they are a support system for us . . . I couldn’t work without them.” However, five other nurses said sometimes it is difficult to work with UAPs. RN John Doe 1 offered an explanation for the difficulty: They [UAPs] feel like they’re . . . on like the lowest rank I guess . . . I don’t want to say that . . . [he laughed uncomfortably, paused, then resumed speaking]. . . . So I think they already feel they are in the lowest rank and I think they don’t want another person telling them what to do. . . . They already have a lot of work to do and I guess after a while it wears you down.
Others’ Views of Provider Roles Participants were asked to describe what members of the other disciplines thought of that participant’s role. Four physicians believed that nurses see physicians as the major decision makers who write orders. Two physicians said nurses respect them and look to them for guidance. On the other hand, MD Jane Doe 7 stated, “You kind of grow to appreciate how much information and knowledge you gain from what nurses know about a specific case, it’s a medical view, but it’s a different cut of the same view.” MD Jane Doe 4 stated it slightly differently: 280
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“Nurses know some things to do with the systems but not to the degree that the doctors would have to know.” Almost all physicians just shrugged their shoulders when asked what UAPs thought of the physician role. When asked about how physicians view the nurse’s role, seven nurses said they believed physicians thought they were superior to nurses and tended to order nurses around. According to RN Jane Doe 3, “I had a doctor tell me the other day, ‘I am the doctor; you are the nurse.’ Like he was commanding me.” RN John Doe 1, who worked in the critical care and medical-surgical area, had a slightly different view: “I believe that physicians in the intensive care unit (ICU) listen to and value nurses’ opinions more than on the medical-surgical unit.” When asked about how UAPs view the nurse’s role, four nurses stated that UAPs think nurses believe they are superior to UAPs. When UAPs were asked how nurses view the UAP role, the majority of UAPs agreed with UAP Jane Doe 11: “Some nurses feel like you’re just there to clean, and run errands. . . . Some nurses look down their noses and boss you.” Physicians and UAPs stated they have little, if any, interaction.
Communication Physicians, nurses, and UAPs all said that communication is critical in health care. The general consensus among physicians was that good communication helps avoid patient care mistakes. MD John Doe 6 noted: Communication is essential in any field. In medicine, it is particularly important because you delegate work on behalf of the patient. You have to be clear on your assessments and management plan, and this has to be laid out very carefully to the patient, your colleagues, to nursing staff, and aides who are participating in care. Six physicians and eight nurses stated communication should be mainly a verbal face-to-face two-way interaction. UAPs mainly described communication as “talk to a person.” The majority of physicians, nurses, and UAPs also noted that how something is said is just as important as what is said. Six UAPs said communication with nurses should be respectful. According to UAP Jane Doe 7, “Communication is welcoming yourself to the person you’re working with . . . good morning . . . a smile.” Three physicians noted written communication is important and is often inadequate among physicians. Three UAPs said they try to keep to themselves and do not speak much; they only speak to nurses when it is necessary. Journal of Nursing Scholarship, 2015; 47:3, 275–284. C 2015 Sigma Theta Tau International
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Collaboration and Teamwork When asked about their thoughts on collaboration/teamwork, six physicians stated that taking the time to build physician-nurse relationships enables clear communication and helps to ensure that patient information is not missed. Five physicians and four nurses said that the meetings that the hospital called “interdisciplinary” in which the physician, nurse, and social worker discuss patients’ discharge readiness are sometimes helpful. UAPs are not typically included in those established meetings. On the other hand, seven UAPs stated it is important for nurses to work with them and help them with patients’ personal care. UAP Jane Doe 7 stated, Sometimes while the call bell is ringing, you’ll have a patient that needs total care, but your hands are too dirty. You can’t run to catch that bell. So, someone else can; it could be the RN, the manager, the doctor, or anybody; it’s a team. Four UAPs also thought that getting reports from nurses was important to teamwork and patient care. Three physicians noted that knowing the staff and keeping the nurses informed of changes to patients’ care plan is important. Two of the physicians noted a hierarchy among physicians. According to MD John Doe 8, “As an intern you don’t have a large role in the decision-making process of the patient. The major decisions are made by the attending [physician] and resident [physician], which are passed on to the juniors.”
Conflict Physicians, nurses, and UAPs stated that poor communication could cause conflict. Five attending physicians mentioned that it bothered them when another physician (consult, intern, or resident) did not inform them of a change in their patient’s condition. Five UAPs and six nurses noted conflict with each other. For example, UAP Jane Doe 6 reflected, “I asked about a patient’s diet and the nurse said in front of the patient’s family, ‘Just give him the food!’ I felt so disrespected, but I didn’t say anything.” UAP Jane Doe 8 stated that a nurse told her, “I don’t do nursing attendant work.” On the other hand, RN Jane Doe 3 noted, “When I was in nursing school, they said ‘listen to your [UAPs] good because sometimes they save you or they can sink you’.”
Patient Safety Physicians, nurses, and UAPs all stated that their roles are important to patient safety. Most physicians and nurses stated that communication is important to Journal of Nursing Scholarship, 2015; 47:3, 275–284. C 2015 Sigma Theta Tau International
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avoiding mistakes like medication errors, while UAPs mainly focused on preventing patient falls. MD John Doe 9 relayed an outlying experience with another physician that deeply affected him: The message was [verbally] relayed to my fellow [another physician] to apply wet to dry dressings for 2 days . . . the message was [supposedly] relayed to the residents . . . 5 days later, the patient had the same gauze . . . the patient bled when the gauze was removed . . . I should have spoken directly to the resident . . . I think it is on the physician to make sure everybody understands.
Ideal Communication and Collaboration Five physicians and four nurses noted that ideal collaboration involves making rounds with the physicians, nurses, and social workers. Five nurses said that it is important for physicians to at least inform them of changes to the patient care plans or orders. Most UAPs stressed the importance of having nurses help with patients’ personal needs and to give UAPs verbal reports on patients. UAP John Doe 2 took it a step further, “It [ideal teamwork] is the involvement of all who partake in the care of a patient, no matter what your position is. All roles must be considered important and critical to patient care.”
Implications for Practice Meeting today’s increasingly complicated dynamic healthcare needs requires a variety of healthcare providers. No one provider can meet all patient needs. Yet, when a variety of providers are involved in patient care, there is a possibility of fragmented care. Fragmentation of care contributes to medical mistakes (Retchin, 2008; Weinberg, 2002). Interprofessional collaboration, which allows providers to build an understanding that reflects both independent and shared decision making, prevents fragmentation and increases effectiveness of healthcare delivery (Thiele & Barraclough, 2007). Reeves and Lewin (2004) noted that lack of time for team building, confused roles, effects of professional socialization, and power and status differentials block interprofessional collaboration. A professional group’s perception of how they should work with other professions influences their interpretation of collaboration (Rodger, Mickan, Marinac, & Woddyatt, 2005). Therefore, building a cohesive interprofessional healthcare team begins with gaining an understanding of the individual members. The stories told by the physicians, nurses, and UAPs in the study provided insights into how they define their individual roles and the roles of members of the other 281
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disciplines. Study results suggest a multidisciplinaryinterdisciplinary triad among physicians, nurses, and UAPs. Most of the time physicians, nurses, and UAPs operated as separate healthcare providers who barely spoke to each other. Physicians and nurses occasionally dialogued, but UAPs were rarely included in any meaningful patient dialogue. Valuable patient information might be missed when healthcare providers do not communicate with each other. This study’s results also indicate that a hierarchical relationship exists in the hospital setting. Physicians, nurses, and UAPs tend to see the physician as the person in charge. Study findings support those of Scherer and Fitzpatrick (2008) and Weinberg (2002), which suggest that enhancing patient safety should begin by changing the dysfunctional hierarchical hospital culture, aligning healthcare providers’ perceptions, attitudes, knowledge, and skills, and acknowledging the importance of communication and collaboration. Successful collaborative interaction includes nonhierarchical control among mutually respectful equals (Stupak & Stupak, 2006; Taylor, 2009). In a conductorless orchestra, the leadership role rotates so that everyone experiences being a leader and a follower; there is no hierarchical control (Jagd, 2010). Each member of the team steps up, using his or her stock of knowledge based on the patient’s needs. In the past, researchers described the physician-nurse relationship as a game that nurses played in which they did not confront physicians directly about patient care issues; they made subtle suggestions (Davies, Salvage, & Smith, 1999; Stein, 1968). Reeves, Nelson, and Zwarenstein (2008) noted that over time, nurses rebelled and sought a more professional, well-educated, independent, and skilled image. This study yielded similar results that suggest the old subservient relationship between physicians and nurses has improved. Many physicians acknowledge the importance of nurses’ knowledge and expertise. On the other hand, the study found a toxic nurse-UAP relationship. UAPs currently struggle for the same respect and recognition from nurses that nurses seek from physicians.
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will provide opportunities to gain professional respect, which is an essential condition for changes needed to make health care safe (Leape et al., 2012). Online problem-based learning case studies can offer busy providers anywhere and anytime access to test their interdisciplinary knowledge and promote patient-centered care by allowing providers to explore the impact of each team member’s contributions to patient care (Vroman & Kovacich, 2002). Communication technology can be creatively incorporated as an adjunct to face-to-face meetings to keep all team providers informed.
Conclusions Interprofessional collaboration, which allows providers to build an understanding that reflects both independent and shared decision making, prevents fragmentation and increases effectiveness of healthcare delivery (Thiele & Barraclough, 2007). Inadequate communication and a dictatorial, authoritative arrangement among healthcare providers foster hostility, frustration, and distrust, which hinder collaboration and jeopardize quality patient care (Burke, Boal, & Mitchell, 2004; Sopow, 2006; Thiele & Barraclough, 2007). Furthermore, collaboration, communication, and coordination of care are limited in hierarchical hospital structures because isolated professionalism causes territorial issues (Kenaszchuk, MacMillan, van Soeren, & Reeves, 2011). Adoption of a hospital patient care system based on the conductorless orchestra model would mitigate hierarchy and recognize physician, nurse, and UAP contributions to care, improve communication and collaboration, and enhance patient safety.
Clinical Resources
r r r
Education and Professional Development To increase interdisciplinary communication and collaboration, education and training opportunities should be offered to increase knowledge about different healthcare providers’ roles and functions (Hague & Kovacich, 2007; Kovacich, Cook, Pelletier, & Weaver, 1997). Interprofessional programs that allow healthcare professionals to learn together should be developed. Learning together 282
American Medical Association Journal of Ethics: http://virtualmentor.ama-assn.org/2013/06/ecas3-1306.html American Nurses Association Principles: http:// www.nursingworld.org/principles Joint Commission National Patient Safety Goals: http://www.jointcommission.org/standards_ information/npsgs.aspx
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