Collaboration 3 The nurse mangers role in creating a collaborative work environment The nurse manager is vital in creating an environment where nurse-physician collaboration can occur and is the expected norm. It is she, who clarifies the vision of collaboration, sets an example of and practices as a role model for collaboration. The nurse manager also supports and makes necessary changes in the environment to bring together all the elements that are necessary to facilitating effective nurse-physician collaboration. Many authors (Alpert, Goldman, Kilroy, & Pike, 1992; Baggs & Schmitt, 1997; Betts, 1994; Evans, 1994; Evans & Carlson, 1993; Keenan, Cooke, & Hillis, 1998; Jones, 1994) have indicated that nurse-physician collaboration is not widespread and a number of barriers exist. The following will discuss the necessary ingredients for creating a nursing unit that is conducive to nurse-physician collaboration and supported through transformational leadership.
The first important barrier according to (Keenan et al., (1998) is concerned with how nurses and physicians have not been socialized to collaborate with each other and do not believe they are expected to do so. Nurse and physicians have traditionally operated under the paradigm of physician dominance and the physician's viewpoint prevails on patient care issues. Collaboration, on the other hand, involves mutual respect for each other's opinions as well as possible contributions by the other party in optimizing patient care. Collaboration (Gray, 1989) requires that parties, who see different aspects of a problem, communicate together and constructively explore their differences in search of solutions that go beyond their own limited vision of what is possible. Many researchers have argued (Betts 1994; Evans & Carlson, 1993; Hansen et al., 1999; Watts et al., 1995) Collaboration 4 that nurses and physicians should collaborate to address patient care issues, because consideration of both the professions concerns is important to the development of high quality patient care.
Additionally, effective nurse-physician collaboration has been linked to many positive outcomes over the years, all of which are necessary in today's rapidly changing health care environment. One study by (Baggs & Schmitt, 1997) found several major positive outcomes form nurses and physicians working together, they were described as improving patient care, feeling better in the job, and controlling costs. In another study (Alpert et al., 1992) also found that collaboration among physicians and nurses led to increased functional status for patients and a decreased time from admission to discharge. Along with improved patient outcomes, nurse-physician collaboration has several other reasons why it has become significant in today's health care environment. Several examples of which are, as identified by (Jones, 1994) the cost containment effort, changing roles for nurses and physicians, the Joint Commission on Accreditation of Health Care Organizations focus on total quality management, and emphasis by professional organizations and investigators have focused attention on this area. The challenge of creating an environment for patient care in which collaboration is the norm can be difficult and belongs to the domain of the nurse manager.
In order to create a collaborative work environment several conditions must be achieved and several natural barriers to nurse-physician collaboration must be overcome. In creating this environment for collaborative practice, (Evans, 1994) identified several more barriers to overcome. She expresses that the most difficult to overcome is the time-honored tradition of the nurse-physician hierarchy of relationships, which encourages a tendency Collaboration 5 toward superior-subordinate mentality. Keenan et al. (1998) found that nurses expect the physicians to manage conflict with a dominant / superior attitude. They also found that nurses are oriented towards being passive in conflict situations with physicians.
A second barrier to collaboration is a lack of understanding of the scope of each other's practice, roles, and responsibilities. Evans (1994) feels that one cannot appreciate the contribution of another individual if one has only limited understanding of the dimensions of that individual's practice. It is equally true that appreciation of one's own contribution is blurred if the understanding of one's own role is limited. A third constraint to collaborative practice might be related to this perceived constraint on effective communication. Although there might be individual differences causing restraint in communication, the organizational and bureaucratic hierarchies of most hospitals hinders lines of communication. Several final factors cited by (Evans, 1994) as barriers to collaborative practice include immaturity of both physician and nurse groups, coupled with unassertive nurse behavior and aggressive physician behaviors.
Factors that promoted collaboration between nurse and physicians were identified by (Keenan et al, 1998). She explained that nurse education was sighted as one of the most outstanding variables that promoted collaboration. The more educated a nurse was the more likely they were to take action in disagreements with physicians. Additionally, when nurses expected physicians to collaborate and to not exhibit strong aggressive behaviors or controversial styles, they were more likely to approach and discuss patient conditions with them. Researchers also found that male nurse were more likely than female nurses to confront physicians and not avoid dominant or aggressive behavior. Collaboration 6 Expectations for physicians to collaborate and to not handle situations aggressively appeared to be a stronger predictor of nurse-physician collaboration than any expected normative beliefs.
The first step a nurse manager should take in the process of achieving a practice environment that facilitates collaboration is to conduct an assessment of the presence or absence of barriers leading to collaborative practice. According to (Evans, 1994), the environmental and role variables to assess include role identification and the professional maturity of both the nurses and physicians, communication patterns, and the flexibility of the organizational structure. By assessing the work environment for barriers and facilitators to collaborative practice, the nurse manager can achieve a general idea of how ready the unit is to begin a collaborative practice. The next step would be to plan an effective way to initiate a collaborative practice model of delivering health care on the unit. This can be done by establishing what is called a Joint Practice Committee, and including nurses and physicians to be a part of this work group.
Its purpose would be to examine the needs assessment results of the unit's readiness for collaborative practice, designing, implementing, and evaluating the process of transforming the unit. This step is an integral part of the process of establishing a collaborative practice and was identified by the National Joint Practice Commission (NJPC) as a necessary element in the process. The NJPC began in 1971 and the commission was dissolved in 1981. The commission's wor resulted in the publication of guidelines for collaborative practice in hospitals. The NJPC defines a joint-practice committee with a composition of equal number of nurses and physicians who monitor the Collaboration 7 inter-professional relationships and recommend appropriate strategies to support and maintain those relationships. The NJPC identifies four other structural elements necessary for a collaborative practice as primary nursing, integrated patient care records, joint patient care reviews, and emphasis on and support of nurse independent clinical decision making.
These elements are an important cornerstone for creating a successful collaborative practice unit. In addition, several other factors have been identified by the NJPC as beneficial to maintaining an effective support systems when developing a collaborative practice such as appropriate staffing, committed medical leadership, standardized clinical protocols, and most importantly communication. Although a successful collaborative practice model has is a planned event. According to (Evans, 1994), it is important to realize that a collaborative relationship cannot be legislated, dictated, or mandated by anyone.
It must be agreed upon and accepted by individuals who share responsibility for patient care outcomes. The third step in the process would be to empower the nursing staff with beliefs that fulfill their higher order of needs such as achievement, self-actualization, concern for others, and affiliation. Because of nursing's normative behavior as passive, caring, and subservient the staff must learn to overcome expectations to identify with this role expectation. The nurse manager must support, coach, and instill a sense of empowerment into her staff in order for them to depart from those stereotypes. The idea is to fill the nursing staff with a sense of self-confidence and to lose thoughts of self-doubt, inequality, and subservience.
To implement this new paradigm of nurse empowerment can be a challenge for the nurse manager within any typical hospital. That is Collaboration 8 why it is important to choose the correct style of leadership to guide the staff through this process of empowering or transforming. The leadership model best suited for this type of task and the most congruent with empowerment is the transformational model. Transformational leadership is a process in which leaders seek to shape and alter the goals of followers. Cassidy & Ko roll (1994) describe the process as incorporating the dimensions of leader, follower, and situation. The leader motivates followers by identifying and clarifying motives, values, and goals that contribute to enhancing shared leadership and autonomy.
Transformational leaders are usually charismatic so they enhance energy and drive people towards a common vision and shifting the focus of control from leaders to followers. It is the transformational nurse manager that will be able to empower her workers to facilitate nurse-physician collaboration, for the common good of the patient. The nurse manager using transformational leadership would set the direction for the rest of the unit to follow. She would be able to charismatically appeal to the medical staff as well as the nursing staff and create collaboration beyond the daily frustrations of arguing about to which domain a certain patient care issues belong. Further more the nurse manager would have to work hard at decreasing the seeds of distrust and disrespect that have been planted between our colleagues in medicine, and vice versa with nursing.
Corley (1998) described several behaviors that the transformation nurse manager would need to exhibit in supporting her staff in such a role transition. The behaviors are as follows: stimulate creativity, establish an environment that facilitates team work and learning, implement change, motivate staff to assume increased responsibility, help Collaboration 9 develop employees' awareness of organizational goals, delegate responsibility appropriately, communicate openly and directly with staff, and collaborate with peers. The significance of these behaviors in facilitating empowerment is seen as fundamental to creating collaborative practice environment. The final step in the process is to evaluate its effectiveness.
In order to provide a clear and concise evaluation of the collaborative process one must look at all structural elements and all indicators of collaboration as previously discussed. Once accurate measures are identified and assessed the collaborative practice committee can discuss their outcomes and effectiveness. Over time, nurses and physicians may be able to articulate more clearly the changes in their practice and beliefs that have been affected by collaborating on patient care. Several of these key areas to examine would be: length of stay, patient and provider satisfaction, number of return visits, and changes in supply costs. Improvements in any of these areas could be due to favorable results from collaborative practice between nurses and physicians. In conclusion, many problems related to nurse physician collaboration are typically blamed on physicians.
However the reality is that many of the barriers can be traced back to nursing as well. Collaboration is a process by which members of various disciplines share their expertise. Accomplishing this requires that these individuals understand and appreciate what it is that each professional domain contributes to the 'whole'; . The nurse manger plays a pivotal role in establishing an environment that is conducive to collaboration among the disciplines. Although it is a difficult road to follow the benefits of an effective collaborative unit out-weigh the difficulties of establishing Collaboration 10 such a practice. However, the nurse manager has an excellent vehicle for which to begin her journey and that is the use of transformation leadership, an empowering tool for change.
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