Teamwork and Collaboration in Nursing Practice

Running head: TYPE SHORT TITLE IN ALL CAPS Title in Upper and Lower Case Your Name Chamberlain College of Nursing Course Number: Course Name Term Month and Year 1 TYPE SHORT TITLE IN ALL CAPS 2 Title of your Paper in Upper and Lower Case (Centered, not Bold) Type your introduction. Although the first paragraph after the paper title is the introduction, no heading labeled Introduction is used. Refer to your assignment guidelines for the headings to be used for the body of the paper. See the APA file in Doc Sharing for additional resources. Level 1 Paper Heading (Bold and centered) Begin to type the body of your paper here. Use as many paragraphs as needed to cover the content appropriately. Level 2 Heading (if required) (Bold and starts at left margin) Type additional content here. Next Level 2 Heading Continue to add support for your purpose. Next Level 1 Heading Use as many headings as necessary to organize your paper. Short papers may only have first-level headings. Teamwork and Collaboration in Nursing Practice

Longer papers may require more organizational detail. See your APA manual for instructions on formatting multiple levels of headings. Conclusion Papers should end with a conclusion or summary. The assignment directions will specify which is required. It should be concise and contain little or no detail. No matter how much space is left on the page, the references always start on a separate page (insert a page break). TYPE SHORT TITLE IN ALL CAPS References (centered, not bold) Type your references in alphabetical order here using hanging indents. See your APA Manual and the resources in your APA folder in Doc Sharing for reference formatting. 3 Research for Practice Working Together Toward a Common Goal: A Grounded Theory of NursePhysician Collaboration Lori Fewster-Thuente ffective nurse-physician collaboration is essential to superior patient care. The lack of effective collaboration has been cited as the root cause of over 70% of major medical errors (The Joint Commission, 2014) and costs the Centers for Medicare & Medicaid Services over $4 billion annually (U.S. Department of Health and Human Services, 2010). Teamwork and Collaboration in Nursing Practice

To achieve optimal patient outcomes, health care providers need and want to collaborate but often do not know how to do so effectively (Dow, Blue, Konrad, Earnest, & Reeves, 2013). The process of collaboration must be understood fully to build a curriculum by which to teach providers. Inherent to understanding the process is a unified definition of collaboration. The literature reflects a great disparity in the definitions of collaboration (O’Leary et al., 2010; Tschannen & Kalisch, 2009), which has resulted in inconsistencies and discrepancies. Physicians have defined collaboration as nurses acting as assistants to physicians and fulfilling orders (Dillon, Noble, & Kaplan, 2009; Garber, Madigan, Click, & Firzpatrick, 2009) or providing physicians with complete and accurate patient information (Tang, Chan, Zhou, & Liaw, 2013). Nurses have defined collaboration as physicians listening to the nurse’s information and opinion and helping to formulate a plan of care (Johnson & Kring, 2012). The inconsistencies in providers’ definitions of collaboration reflect the challenges inherent to the study of nurse-physician collaboration and collaboration itself (Rose, 2011). Although collaboration has been studied extensively (O’Leary et al., E 356 Working together toward a common goal is an empirically derived theory that can guide education and practice to improve patient outcomes while saving money and lives. Grounded theory was used to explore nurses’ and physicians’ experiences with collaboration in order to understand the process intrinsically. 2011; Tschannen & Kalisch, 2009), the conceptual and theoretical basis for understanding and practicing collaboration remains underdeveloped and imprecise. An inductively derived theory of the collaboration process as defined by nurses and physicians could not be found in the literature. The purpose of this study was to theorize collaboration as a basic social process occurring between nurses and physicians. Literature Review Teamwork and Collaboration in Nursing Practice

The literature search for this study was conducted within CINAHL and PubMed for the years 2009-2015. Exploration of the literature focused on barriers to and outcomes of collaboration, and interventions to improve collaboration. Barriers to nurse-physician collaboration may prevent collaboration from occurring. Major barriers are the patriarchal relationship between nurses and physicians (Johnson & Kring, 2012; O’Leary et al., 2010), lack of interprofessional education (Clarke & Hassmiller, 2013; Interprofessional Education Collaborative Expert Panel (IECEP), 2011), proximity (O’Leary et al., 2010), and locating the provider within the organization (O’Leary et al., 2009). Patri- archal relationships remain the largest barrier, along with differences in perceptions of collaboration (Johnson & Kring, 2012). O’Leary and co-authors (2010) surveyed nurses and physicians (N=159) on four inpatient units. Providers were asked to give their ratings of communication and collaboration with team members as well as identify barriers to collaboration. Physicians rated collaboration with nurses as high or very high, while nurses indicated collaboration with physicians was lacking. Nurses also noted identifying the patient’s physician, as well as the patriarchal nature of the role, as barriers. Physicians determined nurse proximity to be a barrier. A descriptive survey conducted by Johnson and Kring (2012) included nurses (N=170) from medical-surgical and intensive care units in assessment of their perceptions of collaboration with physicians. Nurses from both units agreed concerning their satisfaction with nurse-physician relationships (p=0.11). However, intensive care nurses found physicians to be more patriarchal than did medical-surgical nurses (p=0.056). The IECEP report (as cited in Clark & Hassmiller, 2013) discussed lack of interprofessional education Lori Fewster-Thuente, PhD, RN, is Assistant Professor, DePaul University School of Nursing, and Assistant Director, DePaul University School of Nursing’s Master’s Entry into Nurse Practice Program, Chicago, IL. September-October 2015 • Vol. 24/No. Teamwork and Collaboration in Nursing Practice

5 Working Together Toward a Common Goal: A Grounded Theory of Nurse-Physician Collaboration Introduction The results are presented from a grounded theory study that theorized nurse physician collaboration as a basic social process in which groups are formed and changed in harmony. Effective collaboration is essential to superior patient care and outcomes but a lack of theoretical basis for collaboration has hampered the study of collaboration and the optimization of patient care. Purpose The purpose of this study was to theorize collaboration as a basic social process occurring between nurses and physicians. Method Grounded theory was used to explore nurses’ and physicians’ experiences with collaboration to understand the process intrinsically. Following Institutional Review Board approval, 15 nurses and 7 resident physicians from various units within an academic medical center participated in face-to-face interviews regarding their experiences of collaboration. Data collection and constant comparison analysis continued concurrently until saturation was reached in the core and subsequent categories. Findings The basic social process of nurse-physician collaboration that emerged includes the core category of working together toward a common goal. It describes how nurses and physicians collaborate for patient care. The seven stages in the process are something needs our attention, knowing who to talk to, finding the right person, coming together, exchanging ideas and information, making it happen, and monitoring progress. Conclusion Working together toward a common goal is an empirically derived theory that can guide education and practice to improve patient outcomes, while saving money and lives. as a barrier to collaboration. Four core competencies were identified for incorporation into education: values and ethics for interprofessional practice, roles and responsibilities, interprofessional communication, and teams and teamwork. Teamwork and Collaboration in Nursing Practice

Physical location of the provider can be a barrier to communication and collaboration (O’Leary et al., 2009). An interventional study was conducted in which physicians were localized to specific units to assess if communication and collaboration between the two professions increased. Nurses and physicians agreed communication and collaboration increased in the areas of planned tests and anticipated length of stay (LOS) (68% vs. 50%; p<0.001 and 74% vs. 61%; p<0.001, respectively). Overcoming barriers to nursephysician collaboration is critical due to the impact on patient outcomes. Health care leaders, now realizing the need for collaboration, are employing various interventions to teach providers how to collaborate. Interdisciplinary rounds (O’Leary et al., 2011; Segel et al., 2010) have been studied to achieve patient outcomes, such as decreased LOS and subsequently lower cost. Simulation (Dillon et al., 2009; Maxson et al., 2011) is another common intervention to teach collaboration to students and licensed providers. An experimental study by O’Leary and colleagues (2011) assessed 49 nurses’ ratings of teamwork and communication following an intervention of structured interprofes- September-October 2015 • Vol. 24/No. 5 sional rounds. These ratings were compared with patient data on LOS and cost. Although nurses rated teamwork and communication higher on the interventional unit (80% vs. 54%; p=0.05), no difference was found in cost or LOS. A shorter LOS, as evidenced by earlier discharge, was found by Segel and co-authors (2010) after implementing interprofessional rounding on an obstetrics unit. Findings on the experimental unit indicated 45% more patients (p=0.03) than the control unit were discharged by the goal time. Dillon and associates (2009) incorporated simulation of a mock code into the curriculum of nursing and medical students to teach collaboration. Using a pre-test/posttest design, researchers asked students to provide their perceptions of interdisciplinary collaboration. The medical students’ post-test scores were statistically significant (p<0.05) for the factors of collaboration and nurse autonomy. The nursing students’ scores revealed an increase in collaboration but the increase was not significant. Interprofessional simulation also was used by Maxson and colleagues (2011) to teach providers (19 nurses, 9 physicians) collaboration. Teamwork and Collaboration in Nursing Practice

Pretest findings indicated physicians perceived open communication existed (p=0.04); nursing opinions were considered in decision making for the patient (p=0.02). Post-test scores demonstrated significant improvement (p<0.002) by nurses and physicians. Varied findings in the literature suggest a great deal of work remains to be done. Researchers must understand the process of collaboration so providers can become familiar with steps in the process. Thus, the purpose of this study was to conceptualize collaboration as a basic social process. Methods Design As collaboration is believed to be a basic social process in which groups are formed and changed in 357 Research for Practice harmony, grounded theory was used to conceptualize collaboration. Grounded theory (Glaser, 1998) allows the researcher to develop a theory that offers an explanation about the main concern of the population under study. Data Collection and Participants This study was conducted at a major academic medical center in a large city in the midwestern United States. The university and hospital Institutional Review Boards approved the study. Participants were recruited via emails from the chief nursing officer and the chief hospitalist. Informed consent was obtained following a brief discussion of the risks and benefits of participation. Confidentiality was assured as personal identifiers were not used. Data were collected on-site via single, individual, face-to-face interviews in which participants were asked open-ended questions regarding their perceptions and experiences with nurse-physician collaboration. The interviews were audio recorded and transcribed verbatim. The audiotapes and transcripts were kept in a locked drawer in the researcher’s locked office. Memos were kept by the researcher and also used as data. Sample Demographics The purposive sample consisted of 22 participants: 12 clinical nurses, three advanced practice nurses, and seven resident physicians. Attending physicians were not included because nurses primarily collaborate with resident physicians at the study site. Demographic data were collected by the researcher at the start of the interview and described in aggregate form, including level of education, unit, role, experience, and tenure on the unit. Years of experience ranged from 4 to 35 (average 21.4 years). Teamwork and Collaboration in Nursing Practice

Average experience on the current unit was 6 years. Physician participants were first-, second-, or third-year residents. Nursing education ranged from associate degree (n=1) to doctorate of nursing practice (n=1), although most participants held a 358 baccalaureate (n=11) or a master’s degree (n=2). Each participant worked on a different unit. Data Analysis Data analysis requires theoretical sampling, data collection, and analysis to occur concurrently. Through reading and rereading the transcripts, the researcher coded the data by selecting substantive words that conceptualized the data. A total of 956 initial codes emerged from the transcripts and were compared against each other for relevance (align with the core concern), fit (have a place among the other codes), and workability (explain and interpret the behavior). They then were categorized as themes emerged. Final concepts and categories were identified through focused coding. Theoretical sampling continued until saturation in each category was reached. Comparison of the categories continued until a parsimonious basic social process was developed Trustworthiness To assure reliability and truthfulness of the findings, a colleague experienced in grounded theory independently analyzed the data to ensure a credible interpretation. Both sets of findings were compared side by side throughout the analysis; differences were discussed and agreement reached. Data were compared constantly against the researcher’s memos for further accuracy. Use of the participants’ words provided final certainty to the results derived. Teamwork and Collaboration in Nursing Practice

‘Theory of Nurse Physician Collaboration – Working Together Toward a Common Goal Working together toward a common goal conceptualized nurse-physician collaboration as a basic social process that occurs in two major parts: forming the group and creating harmony. Forming the group included the following stages: something needs our attention, knowing who to talk to, finding the right person, and coming together. Creating harmony included exchanging ideas and infor- mation, making it happen, and monitoring process. Participants believed they were or needed to be unified in their actions toward the patient. This belief was evidenced by participants’ comments: “Collaboration is all the health care providers working toward one common goal that they all agree on, to provide the best patient outcome.” “Collaboration takes place for us to understand that we all work together for one common goal, for the patient.” Forming the Group Participants believed collaboration involves two or more people from different professions discussing a patient problem (forming a group), and together determining the patient’s treatment and care, and providing that care (harmony). A second belief was that patients are the reason for collaboration. Participants suggested the common goal equated to the best outcome for the patient, as one resident said, “The purpose of collaboration is providing the best patient care.” Working together to achieve the goal was necessary and desired by participants, who found value and meaning in the process. No discussion occurred of a hierarchy or an “us against them” mentality. The collaboration process can be linear with a start and end point (the group is formed and harmony is achieved), or loop back to the beginning if the patient goal is not achieved or a subsequent issue arises. A stage may be skipped if it is not necessary (e.g., the person needing to be found when a patient issue occurs might be standing next to the provider who realized the issue) but the stages must transition in this order for collaboration to occur. If the process is stopped at any stage, collaboration does not occur (the group is not formed) and a negative outcome for the patient may result (disharmony). Something Needs Our Attention The process begins with the first stage and is the purpose of the collaboration. “Something” is a patient medical issue. Nurse and physician September-October 2015 • Vol. 24/No. 5 Working Together Toward a Common Goal: A Grounded Theory of Nurse-Physician Collaboration participants spoke of collaboration occurring due to a patient’s complex medical problem that cannot be addressed by a single provider. Teamwork and Collaboration in Nursing Practice

A nurse gave an example: “Collaboration is needed when you have a multifaceted problem and no one person can take care of all those needs.” Health care providers must work within their scope of practice. Participants encountered patient problems beyond their scope and recognized involvement of other providers was necessary. One of the nurses said, “I had a bad fetal strip so I talked with the doctor. We decided to do an emergency C-section and the baby was fine.” As health care has become specialized, providers must recognize the expertise and knowledge of one or more disciplines are essential to start the collaboration process and result in optimal care as evidenced by this example: “We had a patient who was in heart failure, so we needed to work together to improve their clinical status.” Once a patient requires the attention of another provider, collaboration transitions to the next stage to resolve the issue. Knowing Who to Talk to Additional providers are sought to help the initial provider when a patient does not feel comfortable or if the provider recognizes a problem out of his or her scope of practice. Knowledge of what role is needed requires previous experience with the type of patient problem as stated by a nurse: “A physician needed assistance setting up home nursing care. They needed additional help from other team members whose expertise was different from their own.” The initial provider must know the role, responsibilities, and scope of practice of each type of provider to know who to contact. Both nurses and physicians said, “We know our roles, what to expect from each other, and we help each other.” In addition to seeking others, participants were sought themselves for having the right knowledge and experience. Teamwork and Collaboration in Nursing Practice

Physicians sought nurses for the patient-specific knowledge and experience essential to decision making, as evidenced by one resident’s comment: “The nurse knew the patient better than I did. So I asked her, for this particular patient, should we give him medicine A or B, and she said definitely B because he would never take A in that method.” Without nursing knowledge, an incorrect decision or error could be made or patient care delayed. Participants often understood what role was needed but did not know who was filling the role at that time because providers work in shifts. Breakdown in the collaboration process could occur if considerable time was required to determine who was in the role at that time, and participants were concerned this could result in a negative patient outcome. Finding the Right Person Knowing where providers are located accelerates the process, an important fac … Teamwork and Collaboration in Nursing Practice