Karen Bankston, PhD, MSN, FACHE
Greer Glazer, RN, CNP, PhD, FAAN
Citation: Bankston, K., Glazer, G., (November 4, 2013) "Legislative: Interprofessional Collaboration: What’s Taking So Long?" OJIN: The Online Journal of Issues in Nursing Vol. 19 No. 1.
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
Dr. Bankston is the Associate Dean for Clinical Practice, Partnership, and Community Engagement in the College of Nursing at the University of Cincinnati in Cincinnati, OH. She is responsible for establishing and maintaining partnerships with other disciplines to develop innovative clinical experiences and community engagement activities for students and faculty at the College of Nursing. Her activities include seeking, obtaining, and administering public and private funds, grants, and contracts, leading to relationships that facilitate clinical initiatives and community projects. Dr. Bankston has held previous administrative positions in a variety of agencies, including Long Term Care/Rehabilitation (Chief Executive Officer), a large healthcare system (Senior Vice President), and a large academic hospital (Chief Operating Officer and Chief Nursing Officer). In her 37 years of nursing experience, she has found it exciting to transform the environment and the future of healthcare delivery. She received her AAS degree from Youngstown State University in Youngstown, OH, her BSN and MSN degrees from Kent State University in Kent, OH, and her PhD from the University of Cincinnati in Cincinnati, OH.
Greer Glazer, RN, CNP, PhD, FAAN
Dr. Greer Glazer is Dean and Professor in the College of Nursing at the University of Cincinnati Academic Health Center in Cincinnati, OH. Dr. Glazer was previously Dean and Professor, College of Nursing and Health Sciences, at the University of Massachusetts in Boston, MA and has held a variety of academic positions at Kent State University in Kent, OH, Case Western Reserve University (CWRU) in Cleveland, OH, University Hospitals of Cleveland, and Tel Aviv University in Israel. She received her BSN from the University of Michigan in Ann Arbor, MI and her MSN with a focus in maternal/newborn nursing and PhD degrees from CWRU.
Dr. Glazer has served as Chairperson of the Political Action Committee of the American Nurses Association. She was a Fulbright Scholar to Israel and a Fulbright Selection Committee/Committee Chair for the Israel and Egypt regions. She has also received the Massachusetts Association of Registered Nurses, Excellence in Nursing Education Award; the Frances Payne Bolton School of Nursing (CWRU) Alumni of the Year Award; and the Dorothy A. Cornelius Ohio Nurses’ Association Award. Dr. Glazer has also been a member of the RWJ Executive Nurse Fellows’ Program.
Dr. Glazer’s research has focused on women’s health issues and barriers to the provision and utilization of prenatal healthcare services for African-American women. Recent publications have focused on minority underrepresentation in nursing and cancer health disparities. She also recently completed a United States Department of Education grant seeking to educate nurse scholars who are underrepresented minorities. Dr. Glazer is widely published in her field, is in great demand as a public speaker, and has appeared on numerous radio and television programs.
American Medical Association. (2012). Women physicians’ congress: A profile and history of women in medicine. Retrieved from www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/women-physicians-congress/women-medicine-history.page
Bensing, K. (2013). Collaboration in healthcare. Retrieved from http://nursing.advanceweb.com/article/collaboration-in-healthcare-2.aspx
Council on Graduate Medical Education & National Advisory Council on Nurse Education and Practice. (2000). Collaborative education to ensure patient safety: A report on the joint COGME-NACNEP meeting on the implications of the IOM report. Washington D.C.: U.S.
Corser, W. D. (2000). The contemporary nurse-physician relationship: Insights from scholars outside the two professions. Nursing Outlook, 48(6), 263-268.
Engel, J. & Prentice, D. (2013). The ethics of interprofessional collaboration. Nursing Ethics, 20(4), 426-435.
Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, D.C.: National Academy Press.
Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, D.C.: National Academy Press.
Institute of Medicine. (2003). Keeping patients safe: Transforming the work environment of nurses. Washington, D.C.: National Academy Press.
Institute of Medicine (2010). The future of nursing leading change, advancing health. Washington, D.C.: National Academy Press.
Martin, K.L. (2011, January 13). Trendspotter: If health reform demands teamwork, when does it start? [Web log] Retrieved from www.physicianspractice.com/blog/trendspotter-if-health-reform-demands-teamwork-when-does-it-start
Orlovsky, C. (2013, June 25). Study reports poor communication among health care workers. Retrieved from www.pedagogy-inc.com/Home/News/Study-Reports-Poor-Communication-Among-Health-Care.aspx?cmp=H3&goback=.gde_700187_member_253199189
Pohl, J., Barksdale, D. & Werner, K. (2013, June 18). The latest data on primary care nurse practitioners and physicians: Can we afford to waste our workforce? [Web log] Retrieved from http://healthaffairs.org/blog/2013/06/18/the-latest-data-on-primary-care-nurse-practitioners-and-physicians-can-we-afford-to-waste-our-workforce/
Ritter-Tietel, J. (2002). The impact of restructuring on professional nursing practice. Journal of Nursing Administration, 32(1), 31-41.
Stein, L. I., Watts, D. T., & Howell, T. (1990). The doctor-nurse game revisited. The New England Journal of Medicine, 322(8), 546-549.
Strasser, A. (2012, Dec. 5). Despite growing number of female doctors and lawyers, women’s pay still lags behind. Think Progress. Retrieved from http://thinkprogress.org/economy/2012/12/05/1284131/women-pay-gap-persists/?mobile=n
Sullivan, T. J. (1998). Collaboration: A health care imperative. New York, NY: McGraw Hill Professional.
© 2013 OJIN: The Online Journal of Issues in Nursing
Article published November 4, 2013