Maximizing nurse-physician collaboration holds promise for improving patient care and creating satisfying work roles. The purpose of this article is to describe strategies that will facilitate effective nurse-physician collaboration. First the nature and the benefits of collaborative communication will be reviewed. This review will be followed by a discussion of self-development, team-development, and communication-development strategies that can enhance nurse-physician collaboration.
Key words: collaboration, communication, conflict, health care, health care outcomes, interdisciplinary, professional socialization teamwork, workplace satisfaction
The rapid, relentless evolution of the health care system brings with it the need to periodically revisit important concepts. Nurse-physician collaboration is one such concept. In a climate constantly demanding efficiency, cost-effectiveness, and quality improvement, interprofessional collaboration warrants re-examination because maximizing nurse-physician collaboration holds promise for improving patient care and creating satisfying work roles.
Each health care profession has information the other needs to possess in order to practice successfully.
Collaboration is a complex process that requires intentional knowledge sharing and joint responsibility for patient care. Sometimes it occurs within long-term relationships between health professionals. Within long-term relationships, collaboration has a developmental trajectory that evolves over time as team members leave or join the group and/or organization structures change. On other occasions, collaboration between nurses and physicians may involve fleeting encounters in patient arenas. In these settings there is no second chance to collaborate effectively, and a given interaction may leave lasting positive or negative impressions on those involved or on those who witness a particular nurse-physician interaction. The volume of these fleeting professional encounters may be increasing, due in part both because primary care and specialty physicians spend less time on hospital wards than they once did (LeTourneau, 2004), and because many nurses work part time.
The challenge, then, is to make the most of all interactions in order to utilize the best knowledge and abilities of all health team members and produce positive patient outcomes. Each health care profession has information the other needs to possess in order to practice successfully. In the interest of safe patient care, neither profession can stand alone, making good collaboration skills essential. The purpose of this article is to review the nature and benefits of collaborative communication and to suggest self-development, team-development, and communication-development strategies that can enhance nurse-physician communication.
Nature and Benefits of Collaboration
Collaboration is multidimensional. It can occur in both face-to-face encounters and electronically via fast-paced interactions such as voice mail and e-mail. In whatever place or form, collaboration involves an exchange of views and ideas that considers the perspectives of all the collaborators, whether or not agreement is reached in the interaction (Coeling & Cukr, 1997). To reduce misunderstandings, it is also necessary to define what is not implied by the term "collaboration". It does not imply supervision, nor is it simply a one-way or two-way information exchange. Effective professional collaborative relationships require mutual respect (Kramer & Schmalenberg, 2003). They also necessitate trust and tenacity. In complex, sophisticated health care systems, collaboration is often difficult. Collaboration may seem idealistic and perhaps even unrealistic. However, Kramer and Schmalenberg (2003 ) state that collaborative partnerships are worth the effort because they result in better outcomes for patients as well as personal growth for collaborators.
Certain characteristics of nurse-physician relationships correlate directly with patient care quality (Kramer & Schmalenberg). Research carried out at fourteen hospitals which had achieved "Magnet" designation from the American Nurses Credentialing Center (ANCC) also indicated that healthy collaborative relationships between nurses and physicians were not only possible, but were directly linked to optimal patient outcomes (Kramer & Schmalenberg, 2003). Results of this ANCC study indicated a positive correlation between the quality of physician-nurse relationships, (as evidenced by measures of collegiality and collaboration), and the quality of patient care outcomes.
Despite the challenge of battling non-collaborative habits, true collaboration is vital not only for the benefit of patients, but also for the satisfaction of health care providers. Collaboration between physicians and nurses is rewarding when responsibility for patient well-being is shared. Professionalism is strengthened when all members take credit for group successes. Unfortunately the contribution of nursing toward the bottom line is often not easy to identify. Physicians have often been viewed as the primary generators of income for hospitals. However, nurses are also substantial revenue producers. The invisibility of nursing may occur because differences in income and gender have historically impacted the balance of power between nurses and physicians (Fagin, 1992).
Appreciation of the unique knowledge of contributing disciplines and a clear understanding of the unique contributions of nursing to care can demonstrate that nurses play an important role in achieving the positive patient outcomes that occur only through collaborative efforts. The remainder of this article will focus on three categories of collaborative strategies, namely self-development, team-development, and communication-development strategies, which can enhance nurse-physician collaboration and associated positive patient and nurse outcomes.
A number of individual characteristics can influence the degree of collaboration between professionals in health care settings. Goleman (1995) defined emotional intelligence as a maturation process involving mastering of one’s own emotions and recognizing those of others. Goleman added that achieving emotional maturity instills confidence and enhances one’s behavior within groups. Developing emotional maturity, understanding the perspective of others, and avoiding compassion fatigue are self-development behaviors that can enhance interdisciplinary collaboration.
Develop Emotional Maturity
Emotional maturity is foundational to effective collaboration. Mature team members are life-long learners (Malone & Morath, 2001), vigilant in identifying the latest best practices and in keeping their skills current. These leaders abandon perfectionist thinking and aim instead for constant improvement (Blickensderfer, 1996). They are persistently positive, humble, and willing to take responsibility for failures and try again. True leadership, according to De Pree (1989) is a matter of character, an art, belief or condition, rather than a set of things to do. There is always room for improvement in collaboration.
Self-confidence also influences collaboration effectiveness.
Individual differences can result in conflict, which if handled well can produce creative solutions. For example, those with Type A personalities are typically rewarded for their driven, competitive approach (Kai & Drinkwater, 2004). However, in the work setting these aggressive behaviors, if carefully channeled, can promote a spirit of cooperation. Self-confidence also influences collaboration effectiveness. Paradoxically, some people may cover their lack of confidence with bravado or forcefulness. Careful communication is necessary to move past the immediate behavior to examine the underlying issues. Ideally, physicians and nurses have matured as individuals so that they possess a balanced understanding of their professional contributions and limitations, and the contributions and limitations of others.
Understand the Perspectives of Others
The need for nurses and physicians to re-establish their common purpose and motivation is more important than ever before.
Early on, nurses and physicians are strongly influenced by the attitudes of their educators, the unique jargon of their own disciplines, and their professional cultural norms (Lindeke & Block, 1998). This professional socialization can present challenges to effective collaboration (Lindeke & Block, 2001). For example, nurses are typically socialized to press for consensus, which may make them appear tentative (Larson, 1999). In contrast, physicians often focus on justice issues and are intent on ruling out alternatives. Unfortunately, socializing students is typically discipline-specific and may not emphasize the strengths of other disciplines so as to strengthen collaboration skills. In the past, social concerns were common motivators of those aspiring to careers of both nursing and medicine. Currently, however, a business mentality tends to prevail in health care with a focus on patient volume and acuity (Milligan, Gilroy, Katz, Rodan, & Subramanian, 1999). This shift in the nature of health care may accentuate the differences between medicine and nursing. The need for nurses and physicians to re-establish their common purpose and motivation is more important than ever before.
Differences in socialization make collaboration difficult, but not impossible. Planned, strategically sequenced, educational experiences can shape attitudes and build communication skills of those new to their professions. Interdisciplinary service learning opportunities have proven to be effective in developing collaborative skills (Hojat et al., 2001; Sternas, O'Hare, Lehman, & Milligan, 1999). Another effective educational model is the Registered Nurse-Resident Physician Preceptorship Program at the University of Kentucky (Johnson, Norton, & Wilson, 1992) which pairs new residents with registered nurses for eight-hour orientation shifts. While working together on the nurses’ terms, the physicians directly encounter the unique functions, perspectives, and contributions of nursing. Importantly, though, no experiences in school will change behavior if students do not see effective collaboration in clinical practice. Leadership and role modeling are critical. A new culture of collaboration is needed that merges the unique strengths of each discipline to minimize energy wasted on turfism and territoriality.
Physicians and nurses do bring different perspectives to patient care. When unique disciplinary perspectives are valued, the uniqueness of each profession can be seen as an asset rather than a detriment to patient care (Pike, 1991). Interdisciplinary collaboration among individuals with different skill sets and knowledge bases may result in creative and practical solutions that would not otherwise occur. For these creative solutions to occur, professionals must avoid making assumptions about other professionals and take the time and effort to learn the other’s perspective. Through intentional discovery of what motivates each other as professionals, physicians and nurses can discover their common goals and collaborate in patient care, with patient well-being as the central focus.
Avoid Compassion Fatigue
Compassion fatigue and burnout can also pose barriers to effective communication. Patient care continually draws on the physical and emotional energies of health care professionals (Hojat, Fields, & Gonnella, 2003). If these professionals do not employ self-renewal strategies, they can become less effective over time. Compassion fatigue is triggered by the indirect trauma resulting from dealing with the tragedy of patient demise, viewing painful procedures, and experiencing the residual effects of exposure to human suffering (Maytum, Heiman, & Garwick, 2004).
Compassion fatigue and burnout can also pose barriers to effective communication.
If unrecognized and unaddressed, compassion fatigue may progress to burnout, a state with more severe, long-term symptoms that are difficult to reverse. Burnout has been described as a "syndrome of emotional exhaustion, depersonalization towards patients, and reduced sense of personal accomplishment" (Maslach, 1982, p.3). Communication with individuals who are experiencing compassion fatigue or burnout will be challenging and thus interdisciplinary collaboration can be difficult. To remain empathetic, motivated, and emotionally present in collaborative relationships, health care professionals must personally recognize the effects of compassion fatigue. Timely lifestyle changes and self-care measures are critical to prevent these negative states that work to the detriment of effective collaboration.
Team development is one of today’s most popular organizational concepts. Collaboration is essential for team development and ongoing positive performance. For example, Larson and LaFasto (1989) included a collaborative climate as one of their eight essential characteristics of team excellence. Their later work demonstrated that collaborative climates embody safe communication of and rewards for collaboration, problem-solving behaviors, and management of negative behaviors (LaFasto & Larson, 2001). Team development includes the following tasks: team building, respectful negotiation, conflict management, containment of negative behaviors, and workplace design to facilitate collaboration.
Build the Team
Collaboration requires intentional team building.
Collaboration requires intentional team building. Collaborative practice is not a process involving side-by-side efforts; rather it is a drawing together of the valued contributions of all team members to reach the best possible solutions. Collaboration involves developing shared meanings (not simply information exchange) and building trust, which takes time and patience. Through the competence and commitment of collaborative group members, valuable partnerships are created. Developing a shared language between team members that reflects the diversity of contributing disciplines helps to build the team. A common goal of patient well-being also enhances team unity. First, however, collaborators must agree on a definition of patient well-being (Zwarenstein & Reeves, 2002). This definition may vary from patient to patient. Patients (and their families when feasible) must be viewed as full participants in the group process so they can articulate what well-being means to them. Maintaining a patient focus creates common ground between team members.
How collaborative relationships are negotiated has a direct impact on outcomes. Unequal power and authority influences interdisciplinary collaboration. One way to balance power and authority might be to drop titles and use given names to neutralize the deleterious effects of an unequal playing field. Additionally, nurses must learn to contribute to teams from positions of strength. Beck-Kritek (1994) describes this as "negotiating at an uneven table." Nurses need not strive for dominance on teams. In fact, such striving can be counterproductive. Rather they can exude strength, innovation, and integrity in collaboration (Beck-Kritek). Nurses negotiate from a position of strength when they recognize the substantial power they do possess, remain confident in their expertise, and create their own freedom to make meaningful contributions (Eisenhardt, Kahwajy, & Burgeois III, 1997).
From the start, team members must define which tasks can be done individually, which must be worked on together, and what the expectations are for joint interactions (Zwarenstein & Reeves, 2002). It is best to function and negotiate within hierarchical structures and respect the chain of command. It is never wise to jump over levels of authority to be expedient. When mutual goals and respect are woven into the fabric of a workplace, issues of hierarchy become secondary to the sharing of knowledge by competent group members.
Manage Conflict Wisely
Cohesiveness and joint problem solving are the desired results of collaborative teamwork. However, nurses and physicians will not always agree. There must be the freedom to disagree. In fact, when managed correctly, conflict is actually a desirable element. Without it, the trap of groupthink can occur, in which case creative, contradictory solutions are suppressed in the interest of maintaining consensus and peaceful relationships.
Healthy conflict is a sign that diverse ideas are welcome at the table.
It is important, however, to quickly identify when achieving consensus has become unrealistic. When this occurs, communication difficulties must be analyzed, openness fostered, and inclusive language incorporated. Focusing on the facts versus opinions helps preserve unity. Often the best strategy is for the most senior member to receive group input and make a decision. Encouraging productive conflict without destroying group cohesiveness requires mature team members and humble, practiced leadership.
Avoid Negative Behaviors
It takes only one difficult personality to cast a pall of dominance, negativity, or distraction that derails collaborative efforts. Fortunately, productivity and positivity can counteract debilitating influences and restore team productivity if there is consistent, courageous, and deliberate leadership. Team-leaders must be mature, must value consensus, and must be unwilling to settle for less than productive dialogue.
One strategy to encourage positive teamwork is to avoid the blame game. Nurses must stop blaming others for problems that exist in nursing (Easson-Bruno, 2003). It is counterproductive and unprofessional to blame physicians, administrators, organizations, or other nurses for the frustrating and disappointing aspects of present-day nursing. Acting like an oppressed group will not encourage others to respect and trust nurses (Roberts, 1999). Willingness and courage to share the load of responsibility for patient outcomes will infuse the collaborative process with trust and respect. Nurses create momentum when they are confident in their contributions and secure in their identities. To project strength and competence, nurses can emulate nurse heroes, utilize nurse mentors, and become skilled role models themselves who can effectively lead the next generation of nurses.
...be frank while remaining flexible and open-minded.
What do you do when you disagree and need to "make your case?" Assertiveness is a great asset in these situations (Blickensderfer, 1996). Question care decisions calmly and directly. Refuse to play the doctor-nurse game (Stein, Watts, & Howell, 1990) by using disclaimers that rob you of due credit for your contributions (Blickensderfer). Avoid tag questions, such as "You might think differently, but...", which erode the respect of others. Instead, be frank while remaining flexible and open-minded.
Design Facilities for Collaboration
Facility design can directly impact teamwork. Research has shown that space allotment in the practice site influences productivity, work attitudes, confidentiality, and the professional image of health care
Comfortable and inviting spaces facilitate team discussions...
Design factors to consider include privacy, noise control, seating space, and convenience. The following suggestions help to ensure the space needed for effective teamwork. First, anticipate space and equipment needs. Negotiate for them, giving priority not just to patient/family space but also to space needed for interdisciplinary interaction, including conferencing and consulting. Secondly, articulate space needs clearly. Ambiguity is an obstacle for timely change. Finally, enhance the existing space. Comfortable and inviting spaces facilitate team discussions as well as conferences with patients and families.
Many nurses and physicians have been taught how to communicate with patients in difficult circumstances where bad news has to be delivered or difficult decisions must be made (Quill & Townsend, 1991). However, since September 11, 2001, much has been written about the urgent need for effective communication between individuals in situations demanding quick responses, such as crisis situations or, in today's fast-paced world, electronic communication (Schuster, Stein & Jaycox, 2001). Physicians and nurses would do well to reflect on and strengthen their communication skills in these situations.
Communicate Effectively in Emergencies
Collaborative interactions are most effective and rewarding when they are efficient. When information is exchanged in emergency situations, for instance, it is critical to prioritize, to leave out peripheral data, and to provide current information. Henry (2000) offers tips for communicating in emergencies. These tips include: getting the facts from informed sources, not blowing issues out of proportion, responding promptly and calmly, and divulging only what others need to know and ethically ought to know. Following up on issues later and debriefing about processes and outcomes will also enhance collaborative efforts and relationships that deal with emergencies and crises.
Use Electronic Communication Thoughtfully
Much communication now is electronic via e-mail, voicemail, or fax. The following suggestions from the University of Minnesota School of Nursing (2004) are helpful for these modes of communication:
- Project openness with a friendly, courteous tone
- Evaluate the content of received messages before reacting because messages are sometimes composed in haste and might not reflect the sender’s intent
- Clarify your understanding of messages, being sure to critique the message itself and not the sender
- Send messages with only pertinent details, paying attention to what the receiver will find useful and avoiding jargon
- Summarize issues without being overly repetitious; be as brief as possible
When communication is precise and unencumbered by unnecessary detail, collaborators are more likely to perceive interactions as beneficial.
Mature, motivated health care professional teams must work together to thrive...
Attention to the bottom-line is encroaching on the humanitarian focus of patient care. Interdisciplinary collaboration can help to keep patient well-being central in spite of economic pressures. Mature, motivated health care professional teams must work together to thrive by fostering self-awareness and preventing burnout. Effective, collaborative partners will waste little time posturing and will instead focus their attention on issues of importance (Eisenhardt et al., 1997). Leaders of collaborative teams will be optimistic and positive, inspiring hope in others when change is unsettling. Using the variety of strategies presented in this article can enhance interdisciplinary collaboration and promote quality patient care in an era of decreased resources and enhanced expectations.
Linda L. Lindeke PhD, RN, CNP
Dr. Lindeke is an Associate Professor at the University of Minnesota in the School of Nursing. She has specialized in pediatrics for over 30 years, including 25 years in advanced nursing practice as a Pediatric Nurse Practitioner. She has taught and developed nursing curriculum in a variety of institutions, and has provided continuing education for many audiences over the years. Her current position is in the Center for Children with Special Health Care Needs, in Minneapolis, MN, teaching didactic and clinical courses. She practices in both a high risk Neonatal Intensive Care Unit follow-up interdisciplinary clinic in the Academic Health Center and in the emergency room at Children's Hospital and Clinic in Minneapolis. Her research areas focus on health and developmental outcomes following high-risk birth and barriers to advanced practice nursing. She is active on numerous pediatric policy committees and nurse practitioner task forces regionally and nationally.
Ann M. Sieckert, BAN
Ann Sieckert is a registered nurse in pediatrics at North Memorial Medical Center, Robbinsdale, MN and a master’s student in the Center for Children with Special Health Care Needs/Pediatric Nurse Practitioner area of studies. She is interested in interdisciplinary collaboration in the workplace, the lived experiences of children and families facing chronic sorrow, and the possibility of experiencing joy in the midst of difficult circumstances.
Article published January 31, 2005
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