The exact translation of word collaboration from Latin is together in labour. In dictionary, collaboration is defined as work with another or others on a project. However, Henneman et al (1995) stated that defining collaboration in practice is complex, vague, variable and difficult phenomenon where the term can be used inappropriately. According to Baggs and Schmitt (1988), collaboration in nursing and medicine are “nurses and physicians working together cooperatively, solving problems by sharing responsibility and making decisions to carry out patient care and treatment”. However, this definition was limited due to its meaning because this does not involve the significant contribution of other health care professionals.
Professional Partnership
In an environment constantly demanding adaptability, cost-effectiveness, and quality betterment, inter-professional collaboration assures re-examination because maximizing nurse-physician collaboration improves patient care and creates gratifying work roles. From personal experience as a sister in Cardiac Surgery Intensive Care Unit, patients require Level 3 care. Patients are mechanically ventilated and sedated on their admission. Most of the patients get extubated and transfer to ward within 48-72 hours but some stay back due to post- operative complications. Patient needs multidisciplinary team (MDT) approach and care during their recovery including Surgeon, anesthetist, Physicians, respiratory technicians, nurses, physiotherapist, dietician, occupational therapist (OT), Pharmacist, and speech and language therapist. As there are complications involved in a patients treatment and care, collaboration among MDT in the clinical practice area is very essential.
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Multidisciplinary team actually formed in 1950s and 1960s in order to meet the changes that occurring in the medicine there for able to meet patients social, psychological, rehabilitation and environmental needs (Brown 1982). Atwal and Caldwell (2002) conducted a large research study to evaluate how to improve Inter-professional collaboration through multidisciplinary integrated pathway (ICP). But this study found ICP did not improve MDT collaboration, however, this helped to improve the documentation. Another study conducted by Atwal and Caldwell (2006) found that there have been various argument regarding MDT existing in the surrounding however nurses described MDT as a complete myth or idealistic. According to Baggs and Schmitt (1988) collaboration here includes sharing of planning, decision making, problem solving, setting objectives taking responsibility, working co-operatively, communicating and more over coordinating each other.
Nature and Benefits of Collaboration
Collaboration has several dimensions. It can happen in both face-to-face appointments and via computerized communications such as voice mail and e-mail. It mainly encompasses swapping of outlooks and concepts that contemplates the viewpoints of all the collaborators. The term collaboration should not be misunderstood. Successful professional collaborative correlations require mutual respect and esteem. They also need trust and persistence. It parallely agrees with patient care quality. Collaboration between physicians and nurses is fruitful when role for patient well-being is divided and allocated. Professionalism is fortified when all members take admiration for successful collaboration which in-turn leads to high-quality patient care. Alas, the contribution of nursing towards the boundary limit is often not naive to spot out. Doctors have usually been sighted as the essential income generators for hospitals. Nevertheless, nurses are also significant makers of earnings. The variance in income and gender lead to consequences between the power balance of nurses and medical doctors. (Fagin,1992).
The remainder of this assignment focuses on categories of collaborative strategies, namely self-development, team-development, and communication-development strategies, which can intensify nurse-physician collaboration and associated positive patient and nurse outcomes.(refer)
Self-Development Strategies
A quota of discrete attributes sways the extent of co-operation between professionals in hospitals. Improving emotional maturity, apprehension of the outlooks of others, and evading sympathy fatigue are self-development behaviors that can increase interdisciplinary collaboration.
Team-Development Strategies
The one of the recent established organizational concepts is the Team development. Collaboration is vital for team growth and success; and advancing positive execution. Team development includes the following tasks: group formation, respectful arrangememts, dispute control, curtail of negative behaviours, and workplace outline to accelerate collaboration.(refer)
Communication-Development Strategies
A number of nurses and doctors have been tutored how to contact patients in complicated conditions where bad news has to be conveyed or difficult decisions must be formulated. (Quill and Townsend,1991). The strategies include to communicate effectively in emergencies and via electronically. Physicians and nurses fortified their communication skills in these circumstances.
Therapeutic Communities
Therapeutic community in UK is portrayed as bijou groups where decisions and options are framed involving the patient based on the views of shared duties, authority and evading reliance on professionals. Formidable leadership is needed to have a secured therapeutic community. In UK, this prototype is instigated within prison service. In USA, therapeutic community is used to depict user-runner cliques with a ranking framework and remuneration.
Key issues of collaborative partnership
The main issues underlying collaborative partnership between physicians and nurses when the attributes of partnership gives out negative impacts such as problems arising between trust in partners, respect for partners, joint working, teamwork and not trying to eliminate boundaries. The studies show that there are certain negative and supervisoral physician behaviour patterns and the nurses find it difficult to cope up with when they are in a partnership. Research have indicated that if nurse-physician co-operation is successful, it do intensify quality of care, ameliorate correspondence and organization of care, decrease patient morbidity and mortality, heighten patient contentment, and increase job satisfaction and retention. The issues underlying in a nurse-physician relationship were dissimilar and hierarchical in ranking, with physicians with an attitude as superiors and nurses as lower ranking subordinates. Nurses have to make counsels in a way that made their proposals appear to be initiated by the physicians.
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Nonetheless, nurses were taught that they are professionals and their bond between doctors is as a colleague, not submissive. Regrettably, the viewpoints of some physicians have been insensitive to change and some still view conveying out their command as the nurses’ foremost duty. However, the correlation between doctors and nurses in hospitals has never been a balanced one. The main differences in this partnership is contrasting levels of prestige and ranking, and distinct sides of the gender gap. The substantial differences between the two professions were on gratification with inter-departmental co-ordination, and doctors are more applauded for the work done and they take more credit; and nurses have more positive attitude towards patients than the doctors. For instance, a physician was more probably to prioritize on lab results and what measures to undertake, hardly recognizing the significance of the information contributed by nurses verbally. Because nursing and medicine demonstrate two different intellectuals with differing practice perspectives, disputes can be reckoned between them. The professional fraternization of doctors stresses “cure related” activities and that of nursing stresses “care related” behaviours. The last and the most important issue is lack of communication because it causes the safety of patients to be at a risky level due to lack of censorious data, misconceiving information, vague orders over the telephone, and fail to spot noticing changes in status. These issues have the possibilities which lead to grave damage or unpredicted death of patients. Effective clinical practice must emphasize not only on technological framework problems, but also on the human factor. By tackling these issues, health care consortiums have a chance to enhance their clinical results.
Critical Analysis of the collaborative partnership with the importance of individual professions
The critical analysis has been done and studied from the personal experience as a sister in Cardiac Intensive Unit. In the unit after the common hand over, sister-in-charge assign the patient and staff will take individual hand-over from the previous staff. Then ward-rounds are carried out by Anesthetic consultant, Surgical and anesthetist registrar along with nurse-in- charge. Then, decisions are made regarding patient management, discharge and transfer outs. Anesthetist gets irritated with registrar and nurses when adequate information was not given. As a unit team leader, main responsibility is to pass correct information to the doctors also involve the patient while discussing their treatment and care if they are awake.
Patient recovery and condition are normally discussed during hand-over and bedside nurse opinion has been taken into account while making decision. Patients are not being involved while discussing about their condition. Atwal and Caldwell (2006) commented about three types of team working in clinical practice. The first model excluding patient from all team meeting, the second model, consultant performing bedside round, discussing patient condition and asking how they are feeling? Third one including patient in the team meeting. In 2008, part of Essence of care I have undertaken a patient satisfaction survey in my unit. The main suggestion patients given through this audit was that, they have not been involved whilst discussing about their treatment and recovery. They also commented “Doctors and nurses stand at the end of the bed and talk, cannot listen what they are talking about, we are worried”. The things are changed now most of the doctors introduce self to the patient, discuss about their treatment, listen to them and explain whats happening with them. As a team leader in critical care, the responsibility as a sister is to delegate tasks effectively, prioritizing aspects of care, ensure team members are comfortable with the allocation, encourage team members and listening to them. It is important to know the patients entire clinical condition prior to the shift so that nurses can delegate the patients effectively to team members. At times, effective delegation is not possible due to staff shortage and skill mix. In such situation, sister-in-charge works along with them, as junior staffs are always hesitant to speak up because of fear, retaliation or lack of confidentiality.
Disagreements are common in decision making regarding patient management and treatment by surgical team and anesthetist in the unit. However, final decision has been taken by Consultant anesthetist since they have more power in the unit. Inter-professional working clearly recommends making considerable changes to this kind of practice by the power and status. Conflicts do occur sometimes between physiotherapist and nurses regarding time arrangement for mobilizing long term sick patient. Physiotherapists are coming to mobilize the patient but the staff may not be ready for that time due to their various role and responsibilities. When the staff disagrees with time they suggest them to do their own they may not be able to help later. This is due to the lack of understanding about each others role. Pritchard (1981) notes that, lack of awareness of roles leads to develop stereotypical attitudes within a MDT. One study conducted by Dally and Sim (2001) found that the physiotherapist doesnt understand the external pressure that nurses facing and the lack of awareness of their professional autonomy and decision making in rehabilitation. Nurses reported that, they often try to minimize conflicts but not always able to resolve disagreement in their satisfaction level as conflict is the one of the main barrier for collaboration (Allen 1997 and Thomas et al 2003). Lack of understanding on each others role and responsibilities are one of the main barriers in collaborative practice between the nurse and other medical practitioners. In order to have mutual respect and value to other professionals need achieving professional competence in your practice area (Bradford 1989 and Stichler 1995). Inter-professional education helps to develop role awareness, effective communication, mutual trust and respect (Barr et al and Freeth 2001).
In critical care, teamwork between MDT is very essential saying that Department Of Health in their NHS plan (2000) introduced the importance of implementing individual professional role in the team. There is remarkable evidence showing that, the team without an undefined role is an unsuccessful team. Every individual should be confident in their own professional role. They should also able to carry out their responsibility, exchange and receive information using their skills, knowledge and effective communication. DAmour and Oandasan (2005) stated that acquiring professional satisfaction is the most individual professional outcome. One of the main concerns in the health care system is that, not meeting the health needs (WHO 2002) of the older, sick and vulnerable people despite increasing the expenditure as nurses drive towards evidence-based practice, cost effective with increasing responsibility. Nurses are able to provide only what demanded of them than providing care (Litchfield 2002). Nurse should be able to make clinical judgment and decision making according to the situation for that critical thinking and education is important. It is essential to have staff development which helps providing up to date information, evidence-based practice research knowledge etc. Since NHS is under the cost cutting they are unable to provide enough funding for their own professionals for the development. Each member of the team contributes their knowledge, skills and experience to improve the patient care, so a therapeutic synergy is possible while working with other health care professions.
Summary and Conclusion
This report illustrates a fundamental model to document an effective collaborative practice. The core model is based on a framework or structure that consists of seven essential elements.: responsibility and accountability, co-ordination, communication, co-operation, autonomy, mutual trust and respect. The model includes a process for identifying the roles and functions of the nurses and physicians. The partnership between nurses and physicians is being studied using theoretical perspectives: team-working, partnership working, patient-professional collaboration, therapeutic communities and power differentials.
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