Overview: Partnerships and Collaboration: What Skills are Needed?

The Cochrane Collection is the world’s foremost collection of summary and meta-analytic reports of interventional research in health care. At least 6 years ago the topic of nurse-physician collaboration was introduced by Zwarenstein and Bryant (1998). Each year since then they have re-visited the topic. They have since found two randomized controlled trials (RCTs) of interventions to increase collaboration and reported their outcomes. In subsequent years to date, no further studies met the Cochrane criteria of an RCT, so they continue to report the same two studies (Zwarenstein & Bryant, 2004).

However, there are other research studies, not RCTs, that, in their consistent findings, support the importance of collaboration in delivering health care. Dating back to the late 1970s there are descriptive and quasi-experimental studies demonstrating either improved patient outcomes or improved provider quality of work life or both (Alt-White, Charns, & Strayer, 1983; Baggs & Ryan, 1990; Baggs, Ryan, Phelps, Richeson, & Johnson, 1992; Baggs et al., 1997; Baggs et al., 1999; Feiger & Schmitt, 1979; Knaus, Draper, Wagner, & Zimmerman, 1986; Mitchell, Armstrong, Simpson, & Lentz, 1989; Shortell et al., 1994; Zimmerman et al., 1993). There also have been interventional studies, but lacking aspects of randomization or strict control, demonstrating similar positive results (Ahrens, Yancey, & Kollef, 2003; Boyle, 2004; Campbell, 1996; Koerner & Armstrong, 1984; Lilly et al., 2000; Lilly, Sonna, Haley, & Massaro, 2003; Rubenstein et al., 1984).

All this evidence supports the importance of collaboration, as do the authors of each of the articles included in this issue. In the first article Gardner notes that a major difficulty with collaboration is that many descriptions of it emphasize egalitarian relationships in a health care system where there is a hierarchical structure. She identifies the skills and values required to collaborate effectively and formulates 10 lessons to help care providers practice collaboration by sharing responsibility, knowledge, and power even within a hierarchical structure. Throughout she emphasizes that collaboration is both a process and an outcome.

Boswell and Cannon identify networking, leadership, and vision as the key behaviors associated with collaboration. Networking, defined as identification and mobilization of resources, is the first and most crucial of these elements. Leadership requires inspiration of stakeholders to transform practice. Vision is the identification of shared purpose. They provide examples from their own experiences of collaborative endeavors within particular geographic areas.

Ross, King, and Firth describe a technique to assist individual practitioners to see how they could change their behaviors in practice settings to reflect on and increase interdisciplinary practices. The paper focuses on use of the process, derived from phenomenology, personal construct psychology, social network method, and the Salmon Line technique. In a case study they demonstrate how a practitioner was encouraged to graphically represent her community health practice, then to re-examine her model in light of the key bi-polar dimension of good versus poor collaboration. They conclude by saying how this technique has been useful in their own interdisciplinary educational settings.

Lindeke and Sieckert review the research evidence for collaboration, particularly from Magnet Hospital studies, and note the importance of interdisciplinary educational experiences. They, too, present strategies to enhance collaboration. Three of these strategies emphasize self-development, five are focused on team development, and two address communicating in fast-paced situations. These authors have identified several key issues related to collaboration in today’s health care settings. One of these is that collaboration does not always mean a standing team, but is important even in brief interactions, which are not always face-to-face. The sections on designing facilities and use of electronic communication bring new insights to the longstanding conversation on collaboration.

The final article, by Hinton Walker and Elberson, emphasizes the need for collaboration to move beyond individual health care settings into larger partnerships, including global ones, using new technologies. They stress the importance of the leader in organizations in setting the stage for change and collaboration based on the three collaborative principles of relationships, understanding the perspectives of others, and shared decision making. This work can begin with attention to language, for example changing debate to dialogue and either/or to both/and. The second step is to assess new technology for collaboration and find ways to integrate it into the organization. Hinton Walker and Elberson end with a brief identification of key technologies including document and file sharing, streaming, document collaboration, and distance learning.

While much of what is presented in these articles is a re-emphasis on work previously written on collaboration, several themes emerge. At the beginning is interdisciplinary education, with nascent providers of various professions learning together both about substance and about the perspectives of each other’s professions. In the process of professional work, there is the need to consider multiple perspectives and to communicate thoughtfully, not only in traditional teams, during interdisciplinary rounds, and in telephone communications but using new forms of technology. There is a need to look beyond one’s immediate setting to the larger organization and to other organizations. Leaders need to consider how to support and reward collaborative endeavors for better patient outcomes and to recruit and retain providers. More interventional research is needed, when possible. RCTs, to add to Zwarenstein’s summaries, when not, work like that of Lilly and Boyle. Talking about collaboration is fulfilling, but investigating concrete ways to support it is crucial.

Judith Gedney Baggs, PhD, RN, FAAN
E-mail: Judith_Baggs@URMC.Rochester.edu

Dr. Baggs received her PhD in nursing from the University of Rochester and was inducted as a Fellow of the American Academy of Nursing in 2002. Her research program has focused on nurse-physician collaboration in the intensive care unit as a way of improving patient and provider outcomes. Most recently, her research program has included patients, families, and other care providers as collaborators in decision making at the end of life. Dr. Baggs has published a number of articles related to collaboration in critical care settings and has been federally funded by the National Institute of Nursing Research (NINR) to conduct research exploring collaboration in practice. She has also chaired the Science Study Section of NINR.

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