For at least two decades, healthcare leaders have described collaboration between providers as essential for efficient and effective care delivery. The Institute of Medicine (IOM) has provided considerable evidence of the positive impact that interdisciplinary collaboration and teamwork can have on key dimensions of organizational performance (IOM, 2000, 2001, 2003, 2010). Yet, the ability to collaborate consistently, and in a way that ensures quality care, continues to elude us (Bensing, 2013; Martin, 2011; Orlovsky, 2013; Pohl, Barksdale, & Werner, 2013). This lack of interdisciplinary collaboration remains a significant challenge for healthcare executives, college deans, practicing nurses, physicians, and other healthcare professionals.
Rapid advances in biomedical knowledge and clinical technologies, continued economic pressures, consumer demands, and changes in the demographic characteristics of our communities have resulted in dramatic changes in healthcare delivery in recent decades. These changes require supportive work environments to achieve positive patient outcomes. Supportive work environments require communication, mutual respect, and collaboration between the various providers, as well as between providers and patients. Collaboration among nurses, physicians, and other members of the care team can improve the outcomes of care for patients (Engel & Prentice, 2013; IOM, 2010).
Sullivan (1998) has defined collaboration as “…a dynamic, transforming process of creating a power sharing partnership for pervasive application in healthcare practice, education, research, and organizational settings for the purposeful attention to needs and problems in order to achieve likely successful outcomes” (p.6). This definition seems simple enough. It suggests that professional providers will engage in two-way communication regarding patient conditions, with each individual sharing specific knowledge and understanding related to the situation at hand, in a way that will facilitate care decisions. The fact that this doesn’t always happen prompts us to ask, “What gets in the way?”
One might argue that the historical gender gap between medicine and nursing plays a role in this inability for physicians and nurses to collaborate despite the overwhelming evidence that it will make a difference in the outcomes of the individuals that we serve. Medicine continues to be a male-dominated profession, with 67.6% being male and 32.4% being female while nursing continues as a female-dominated profession (AMA, 2012; Strasser, 2012). These gender differences may continue to support gender bias and role expectations that are not conducive to collaborative behaviors.
There are deeply entrenched superior/subordinate relationships between medicine and nursing that will have to be moved aside in order for true collaborative practice partnerships to emerge (Corser, 2000; Ritter-Tietel, 2002; Stein, Watts, & Howell, 1990). It is difficult to have a power-sharing partnership when health professionals view their relationship in a hierarchical manner. More constructive dialogue regarding each discipline’s scope of practice and the interdependencies between the disciplines, as well as a sound basis for mutual trust and respect, will need to emerge in order for effective collaboration to occur.
Additionally, educational programs for medicine and nursing remain segregated, despite the report released in 2000 (thirteen years ago) by the Council on Graduate Medical Education (COGME) and the National Advisory Council on Nurse Education and Practice (NACNEP) which recommended interdisciplinary education and practice to enhance patient safety in contemporary healthcare settings. The report concluded that medicine and nursing often practice as two independent and parallel professions, thus preventing the establishment of the close and ongoing interdisciplinary collaboration and teamwork necessary for improving patient safety (COGME & NACNEP, 2000). The COGME- NACNEP recommendations for bridging the cultural and educational divide between the two disciplines addressed all aspects of healthcare education and practice, as well as licensing and credentialing systems, so as to facilitate the preparation of nurses and physicians who can function as effective members of interdisciplinary, collaborative-practice teams across a variety of diverse healthcare delivery settings.
One approach to bridging this interprofessional-collaboration gap could be the development of partnerships to facilitate the creation of interdisciplinary laboratories, sometimes called “collaboratories,” to enhance the ability of nurses and physicians to work together more effectively. These laboratories could serve as incubators for the development of new learning initiatives and conduct evaluations regarding the impact of these initiatives on patient safety and nurse-physician collaboration (COGME & NACNEP, 2000). Such collaboratories could focus on core content that is consistent with both roles, such as quality of care, patient safety, ethics, and leadership. Transforming the learning environment to accommodate active learning principles could facilitate the notion of working in teams by incorporating strategies, such as simulation, to mimic real-life scenarios that the students will encounter throughout their career. A major emphasis could be placed on systems thinking and identifying root causes, rather than traditional responses, for example placing individual blame.
Another approach could involve preparing graduates more effectively for the realities of collaborative practice in evolving, managed care environments by establishing interprofessional care models that reward the team rather than rewarding individual professionals. Developing a team reward system could entail behaviors and outcomes that are needed to be an effective member of the team. The system could apply to both job descriptions and performance evaluations. A structured bonus process could provide both monetary and nonmonetary rewards to the team for achieving identified and expected outcomes.
It is much easier for those entering the profession, than for those who have known only practice environments in which interprofessional collaboration is non-existent, to develop positive attitudes about collaboration. We believe that our best opportunities for a successful transition to collaborative practice are to begin the socialization of our students to a collaborative environment when they enroll in our colleges. This could begin with a joint course introducing students to interprofessional concepts and behaviors. However, students need interprofessional, educational experiences throughout their education. Such experiences could start by building trusting relationships between students/members of differing professions, progress to understanding and valuing each disciplines’ unique contribution to healthcare, and culminate in practicing together as partners to provide quality care.
Although accrediting bodies are mandating interprofessional education and collaboration, the question remains: How do we attain compliance with this standard? We recommend that nursing programs develop collaborative initiatives and joint experiences with other professions, while recognizing that the underlying issues of hierarchy, trust, valuing each other’s contributions, and sharing of power need to be addressed. Until this occurs, interprofessional collaboration will remain more of a goal than reality.
Karen Bankston, PhD, MSN, FACHE
Greer Glazer, RN, CNP, PhD, FAAN