COLLABORATION ISSUES IN NURSING

INTRODUCTION

Changing models of health care have created a need for modification of traditional roles. Nurses
and physicians have been especially affected by these changes and work more collaboratively as
colleagues.

Collaboration is a process in which two or more individuals work together jointly influencing one
another, for the attainment of goal. The word collaboration implies working together for the greater good,
but it actually encompasses far more. Several preconditions must be in place for collaboration to
be successful. Collaborative health care practices facilitate better patient outcomes. The health
team works as a group utilizing individual skills and talents to reach the highest of patient care
standards. A multidisciplinary plan of care should be decided by all of the team members.
Individual disciplines must be willing to work together, have the same objectives and goals, and
provide a plan of care which is individualized to the patient needs. A multidisciplinary approach
to care sounds simple in theory, but collaboration of different skill levels and expertise has its problems.

MEANING OF COLLABORATION:

The word “collaboration” is derived from Latin word “Co” and “Labor” which means to “work
together”. That means the interaction among two or more individuals, which can encompass a
variety of actions such as communication, information sharing, coordination, cooperation,
problem solving, and negotiation.

Collaboration means a collegial working relationship with another health care provider in the
provision of (to supply) patient care, collaborative practice requires (many include) the
discussion of patient diagnosis and cooperation in the management and delivery of care .each
collaborator is available to the other for consultation either in person or by communication
device, but need not be physically present on the premises at the time actions are performed. The
patient designated health care provider is responsible for the over all direction and management
of patient care (ANA, 1992).

“Collaboration is an intricate concept with multiple attributes. It is defined in a variety of ways,

many of them explicitly referring to interdisciplinary collaboration” (Henneman, Lee, &
Cohen, 1995).

“Attributes identified by several nurse authors include sharing of planning, making decisions,
solving problems, setting goals, assuming responsibility, working together cooperatively,
communicating, and coordinating openly”
(Baggs & Schmitt, 1988).

“Collaboration as a mutually beneficial and well defined relationship entered into by two or
more organizations to achieve common goal”
(Murray and Monsey ,2001)

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"Collaboration is the most formal inter organizational relationship involving shared authority
and responsibility for planning, implementation, and evaluation of a joint effort
(Hord, 1986).

Related concepts, such as cooperation, joint practice, and collegiality, are often used as
substitutes. They share some, but not all, of collaboration’s attributes. Baggs and Schmitt (1988)
reframe the relationship between collaboration and teamwork by defining collaboration as the
most important aspect of team care, but certainly not the only dimension. The description of
collaboration as a dynamic process resulting from developmental group stages and as an
outcome, producing a synthesis of different perspectives more accurately reflects the reality that
collaboration evolves in partnerships and in teams. The overlap between team/group process and
collaboration is related to the nature of collaboration as a developmental process. Teamwork and
collaboration are often used synonymously.

Much of the literature on collaboration describes what it should look like as an outcome, but
little is written describing how to approach the developmental process of collaboration. Effects
of Collaboration (Abramson & Mizrahi 1996).

Improved patient outcomes

Reduced length of stay
Cost savings
Increased nursing job satisfaction and retention
Improved teamwork
PRINCIPLES OF COLLABORATION-A STATE OF ART
1. A stands for Assets, attitudes and values that each potential partner brings
2. Accountability to each other
3. Agreements to be mutual and documented
4. Acknowledgement of each others contributions
5. Achievements -monitored
R stands for;
Reciprocal benefits
Respect for each partners
Responsibilities –well defined and agreed upon
i) T stands for;
(1) Time and timing
(2) Tact and talent
(3) Trust

Collaborative Health Care: Virginia Henderson(1991,)one of the pioneers of nursing ,defines

collaborative care as ―a partnership relationship between doctors ,nurses and other health care
providers with patients and their families‖ .It is a process by which health care professionals
work together with clients to achieve quality health care outcomes. Mutual respect and a true
sharing of both power and control are essential elements .Ideally collaboration becomes a

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dynamic, interactive process in which clients (individual, groups, communities)confer with
physicians, nurses and other health care providers to meet their health objectives .more recently
published executive Summary from (ANA1998)relished in nursing trends and issues described
collaboration as intrinsic to nursing as follows,

 Nurses and physicians working together and indigently assessing,diagnosing,caring for

consumers by preparing patients histories conducting physical and psychosocial
assessments, and reviving and discussing their cases with other health professionals to
determine the changing health status of each clients.
 To provide effective and comprehensive care, nurses, physicians, and other heath care
professionals must collaborate with each other. No group can claim total authority over
the other.
 The different areas of professional competence exhibited by each profession, when
combined, provide a continuum of care that the consumer has come to expect.

Collaborative Practice Models Propose To Achieve The Following Objectives:

Provide client- directed and centered care using multi deciplinary, integrated,
participative framework.
Enhance continuity across the continuum of care, from wellness and prevention, pre
hospitalization through an acute episode of illness to transfer or discharge and recovery
or rehabilitation.
Improves clients and family satisfaction with care.
Provide quality, cost-effective, research-based care that is outcome driven.
Promote mutual respect, communication and understanding between client(s) and
members of health care team.
Create synergy among clients and providers, in which the sum of their efforts is greater
than the parts.
Provide opportunity to address and solve system related to issue and problem.
Develop interdependedt relationships and understanding among providers and clients.

Characteristics Of Effective Collaboration Include:

Common purpose and goals identified at the outset

i. Clinical competence of each provider.

ii. Interpersonal competence.
iii. Humor.
iv. Trust.
v. Valuing and respecting diverse, complementary knowledge.

The Nurse as a Collaborator:

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 With client: Acknowledges supports and encourages client‘s active involvement in
health care decision.
Encourages a sense of client autonomy and an equal position with other members of the
health care team. Help clients set mutually agreed upon goals and objectives for health
care. Provides client consultation in a collaborative fashion.
With peers: Shares personal expertise with other nurses and elicits the expertise of
others to ensure quality client care. Develops a sense of trust and mutual respect with
peers that regimes their unique contributions.
With other health care professionals: Recognizes the contribution that each member of
the interdisciplinary team can make by virtue of his or her expertise and view of the
situation. Listens to each individual‘s view. Shares health care responsibilities in
exploring options, setting goals, and making decisions with clients and families.
Participates in collaborative interdisciplinary research to increase knowledge of a clinical
problem or situation.
With professional nursing organizations: Seeks out opportunities to collaborate with
and within organizations. Serves on committees in state (or provincial),national and
international nursing organizations or specialty groups. Supports professional
organizational in political action to create solutions for professional and health care
concern
With legislator: Offers experts opinions on legislative initiatives related to health care.
Collaborative with health care providers and consumers on health care legislation to best
serve the needs of the public.

TYPES OF COLLABORATION :

Interdisciplinary
Multidisciplinary
Trans disciplinary
Inter professional collaboration

1. Interdisciplinary collaboration- it is the term used to indicate the combining of two or

more disciplines, professions, departments, or the like, usually in regard to practice ,research,
education and theory.

2.Multidisciplinary collaboration- refers to independent work and decision making, such

as when disciplines work side-by-side on a problem.

3.Transdisciplinary collaboration- efforts involve multiple disciplines sharing together

their knowledge and skills across traditional disciplinary boundaries in accomplishing tasks
or goals. Trans disciplinary efforts effects reflects a process by which individuals work
together to develop a shared conceptual framework that integrates and extends discipline
specific theories, concepts, and methods to address a common problems.

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4. Inter professional collaboration-has been described as involving “ interaction of two or
more disciplines involving professionals who work together , with intention, mutual respect
and commitments for the sake of a more adequate response to a human problem” .

Factors leading to the need for increased collegiality and collaboration: World wide there
are a number of significant influence on health and health care that will require international
collaboration. The World Health Organization (WHO) sets an objective that they hoped all
people would achieve by the year 2000, a level of health that would permit them to lead
socially and economically productive lives. A number of factors influence the provision of
health care: They are:-

Consumer Wants and Needs: Health care consumers are demanding comprehensive,
holistic and compassionate health care that is also affordable. Clients expect that
health care providers will view each person as a bio psycho social whole and respond
to his or her individual needs. They want expert, humanistic care that integrate that
available technology and provides information and services related to health
promotion and illness prevention. Today‘s health care consumers have greater
knowledge about their health than in previous years and they are increasingly
influencing health care delivery. Previously people expected a physician to make
decisions about their care: today however consumers expect to be involved in making
any decision. Consumers have also aware of how life style affects health. They are
willingly participating in health promotion activities. They are beginning to view
health care professionals as recourse to guide these activities.
Self Help Initiative: Responsibility for the self is a major belief-underlying, holistic
health that recognize the inter dependent of body, mind, and spirit. Increasing people
are adopting the view that the self empowered with the ability to create are
maintaining health or disease. Today many individuals eek answer for acute and
chronic health problems through non traditional approaches to health care.
Alternative medicine and support groups are among two of the most popular self-help
choice. The most commonly used therapies of relaxation techniques, chiropractic
treatment, massage, imagery, spiritual, healing, weight los programs and herbal
medicine. Alcoholic Anonymous (AA), which formed in 1935, serves as a model for
many of these groups. The national self-help clearing house in the United State
provides information on current support groups and guidelines about how to start a
self-help group.
Changing Demographic and Epidemiology: It is predicted that by the year 2020,
there will be more than 50 million adults over the age of 65 years living in the united
state .the growing number of older adults, combined with The fact that the average
older adult has three or more chronic conditions, will greatly influence the health care
system and the insurers in the future. Closely related to the major epidemiology
influence posted by chronic illness. One of these is HIV/AIDS, a problem that

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 growing each year. The centers for disease control and prevention report that a total
of 886,575American have been diagnosed with AIDS through 2002 and the estimated
number of deaths is 501, 669.worldwide, it is estimated that 37 million adults and 2.5
million children are living with HIV/AIDS as of the end of 2003 According to the
National Coalition for the homeless and poverty are inextricably linked. Limited
resources result in difficult choices when trying to pay for housing, food, and child
care, health care so on .limited access to health care services significantly impacts the
health of the poor and the homeless.
Health Care Access: Several alternative health delivery systems have been
implemented to control costs. These include Health Maintenance Organization
(HMO), Preferred Provider Organization (PPOs) Physician/Hospital Organization
(PHO) and so on. Additionally, the development of prospective payment systems
significantly influenced the health care system. Concerns remain however about ways
to further reduce health care cost and at the same time achieve the desired goal of
improving the quality of health care delivery. Employers, legislative letters, insurers,
and health care providers continue to collaborate in efforts to resolve these concerns.
Ethical issues such as rationing of health care, access to health care, the use of health
care technology and extra ordinary interventions, and organ transplantation can be
resolved only through collaboration.
Technological Advances: Technology has had a major influence on health care cost
and services with advances in medicine and technology, an individual‘s life span can
in many case extended. However the same technology may result in fragmentation of
care and acceleration of health care costs. New medical devices, technology
advances, and new medicines frequently are introduced with, limited considerations
to the associated cost or the efficacy of their use.
Increasing gap between nursing education and nursing service: Graduate nurses
often lack practical skills despite their significant knowledge of nursing process and
theory. Clearly, a partnership between nursing educators and hospital nursing
personnel is essential to meet this challenge.

Types of relationship among Health professionals: There are three type of

relationship between health professionals:
Complementary relationship: One person is dominant and the other is submissive.
Control is not divided equally between the two participants. Relationships are
stable and predictable also inhibit creativity and independent thinking.

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Symmetrical relationship: Control is more evenly distributed between the two
participants , Free to express their opinions , Power struggles occurs when
participants compete to acquire or give up control.

Parallel relationship: Control moves back and forth between the two
participants ,Participants take turns holding and giving control, depending
on the circumstances, rather than competing for control , Effective and
flexible communication

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COLLABORATIVE MODELS: Models and frameworks had different structures,
backgrounds, and conditions, but the outcomes were similar. Organizational structure, culture
and social factors are important aspects of clinical collaboration. So it is necessary to improve
the quality and effectiveness of clinical collaboration these factors to be considered. Nursing
models or frameworks create a conceptual vision and a guide for nursing practice. So far,
different interdisciplinary collaborations have been presented according to the clinical contexts.
Despite there are the different models of collaboration a limited number of models are available
for scholars who wish to study inter professional collaboration . Development of models is often
done with qualitative approach.

Traditional Practice Model: In this model, authority tends to flow in a downward

direction with little exchange of ideas. . Patient care is fragmented ,minimal
communication between team members and the patient , minimal evaluation of the care .
Comprehensiveness and quality of care is questionable.

NURSING – INSTITUTION COLLABORATION MODEL: This model depicts

relationship of nurse within the institution with other health workers.
COLLABORATION AT CLINICAL PRACTICE LEVEL: The staff Nurse
collaborate with other staff Nurses to
Develop the plan of care
Provide the care in an integrated and
comprehensive manner
Evaluate the outcome of care
COLLABORATION WITH NURSE EDUCATOR: The clinical nurse specialist
collaborate with Nurse educator to develop a curriculum that is more appropriate to
health care needs and to day-to-day clinical practice situation
COLLABORATION WITH NURSE RESEARCHER:Communication between nurse
researcher and Nurses in clinical practice , that Nursing care problems and issues can be
approached and solved systematically

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 PUBLIC HEALTH NURSE MODEL: In this model there is communication
among all members
1. Patient needs are assessed
2. Specific plan of care is developed
3. Approach is integrated and care is provided in an efficient and effective manner
4. Periodic evaluation and redirection of care based on consumer needs
5. Nurse and Physician have mutual respect.

Nurse community collaboration: Nurse collaborates with other agencies or institution

in the community . Care is provided in a comprehensive manner .Quality is maintained ,
Professionals derive satisfaction as their individual skills and expertise are appropriately
used.
• Nurse collaborates with other agencies or institution in the
community
• Care is provided in a comprehensive manner
• Quality is maintained

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• Professionals derive satisfaction as their individual skills
and expertise are appropriately used
NURSE PHYSICIAN COLLABORATIVE PRACTICE MODEL :It began in
1970s
Within a decentralized organizational structure, Nurses and Physicians functions
collaboratively in making clinical decisions. Collaboration resulted in increased quality
of care, patient and care provider satisfaction and decreased length of stay
TEAM NURSING- it is important for team leaders
to regularly participate in Physician rounds
PRIMARY NURSING- physician should communicate either with each primary Nurse
who is assuming care for the client on that day
HOME CARE- The staff should be able to work together on decisions regarding client
care . Physician are invited to attend practice committees when clinical problems are
addressed and to present timely in service programs on new medical procedures or
research findings.

CLINICAL SCHOOL OF NURSING MODEL :It encompasses the highest

level of academic and clinical nursing research and education. This was the
concept of visionary nurses from both La Trobe and The Alfred Clinical School
of Nursing University. The development of the Clinical School offers benefits to
both hospital and university. Opportunities for exchange of ideas with clinical
nurses with increased opportunities for clinical nursing research.
PRACTICE RESEARCH MODEL: It is an innovative collaborative
partnership agreement between Fremantle Hospital and Health Service and Curtin

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 University of Technology in Perth, Western Australia. The partnership engages
academics in the clinical setting in two formalized collaborative appointments.
This partnership not only enhances communication between educational and
health services, but fosters the development of nursing research and
knowledge.This model encouraged a close working relationship between
registered nurses and academics, and has also facilitated strong links at the health
service with the Nursing Research and Evaluation Unit, medical staff and other
allied health professionals.
In the PRM, the role of the Nurse Research Consultant (NRC) was articulated as that of
mentor and consultant on issues related to research, methodology publications and
dissemination. Although the PRM was specifically designed to enhance nursing research
activity and the implementation of evidence-based community health nursing practice,
the Model also encouraged the involvement of the multidisciplinary team to work to
achieve the aims of the partnership agreement.
COLLABORATIVE CLINICAL EDUCATION EPWORTH DEAKIN
(CCEED) MODEL (2003) : In an effort to improve the quality of new graduate
transition, Epworth Hospital and Deakin University ran a collaborative project
(2003) funded by the National Safety and Quality Council to improve the support
base for new graduates while managing the quality of patient care delivery. The
Collaborative Clinical Education Epworth Deakin (CCEED) model developed to
facilitate clinical learning, promote clinical scholarship and build nurse workforce
capability.

Dedicated education unit (DEU) clinical teaching model (1999): In this model
a partnership of nurse executives, staff nurses and faculty transformed patient
care units into environment of support for nursing students and staff nurses while
continuing the critical work of providing quality care to acutely ill adults.
Key features of DEU are:
Uses existing resources
Supports the professional development of nurses
Allows for the clinical education of increased number of students.
Exclusive uses of the clinical unit by school of nursing.
Use of staff nurses who want to teach as clinical instructor.
Preparation of clinical instructor for their teaching role through collaborative staff
and faculty development activities.
Faculty role to work directly with staff as a coach, teaching/ learning resources to
develop clinical reasoning skills, to identify clinical expectations of students , and
evaluate student achievement.

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 COLLABORATIVE LEARNING UNIT MODEL : Staff ,student and
faculty work together to create a positive learning environment and
provide high quality patient care .It Increases Nursing students
opportunities and exposure to clinical situations .It provides to bridge the
gap between academic and clinical expectations .It provide increased
professional development and socialization . It increase instructor
availability and staff on the clinical unit.

COLLABORATIVE TEAM APPROACH

• It improves communication
• Enable practitioners to address complex clinical cases from different perspectives
• Improve productivity by avoiding duplication
• Includes multiple discipline such as Physician, nurses, social workers, administrators,
ethicists, clergy
• Eg: diabetes patient
CASE WESTERN RESERVE UNIVERSITY MODEL
1. Based on the concept of academic leadership for Nursing
2. Pilot project in 1960
3. It was designed to change the organization of Nursing service to a decentralized pattern
similar to the organizational structure in the School of Nursing, with a head of Nursing
for each institution rather than an overall head

SPECIFIC OBJECTIVES:

Improve the quality of patient care

Enhance the learning climate for Nursing students and staff
Promote a spirit of inquiry and the development of research in Nursing
Promote inter professional collaboration
mprove the utilization of Nurse’s time and talents

JOINT APPOINTMENTS: 1. Shared appointment-chairperson=director of each clinical

specialty, faculty=nurse clinician appointee

2. Faculty associate appointment-dean=administrative associate in hospital

3. Clinical appointment

Gender culture self assessment

Sr no COLUMN ONE COLUMN TWO
1. I prefer to compete to win I prefer to find win-win solutions
2. I like work where I know the I like to work in situations where power
hierarchy so I know what is expected is equally shared

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 of me
3. I can disagree or even argue with my
friends and allow it to affect the
relationship
4. when I lead a meeting, I
prefer to sit in front of the group or at
the head of the table
5. In arriving at a decision, I study the
options, select one and more ahead
with it
6. In the workplace, competent people
don’t worry about being nice
7. I spend little time in getting to know
my co-workers personally
8. I define a ‘team player’ as someone
who follows orders, supports the
leader unquestioningly, and does
what is needed no matter how he or
she feels
I expect my friends to side with me in
disagreements and tend to take it
personally if they don’t
when I lead a meeting, I prefer to sit
with the group in a circle
In arriving at a decision, I usually ask
several other people for their opinions
In the workplace it is possible to be both
competent and nice
It is worthwhile to spend time getting to
know my co-worker as a personal level
I define a ‘ team player’ as someone
who shares ideas, listens even when they
disagree, and works collaboratively

scoring
• COLUMN ONE- predominantly male gender style. When you work with women, you
can anticipate some difficulties because of differences in behavior & conversational
patterns
• COLUMN TWO- predominantly female gender style. When you work with men, you
can anticipate some difficulties because of differences in behavior & conversational
patterns
• BOTH- combination of male & female gender style. You should be able to work
successfully with both men and women.

Benefits of the Collaborative Model:

Schermer, Geisler, and Vang's1 cooperative venture with nursing faculty and computer
science professionals resulted in similar benefits to the collaborative model. Schermer
found that the combined efforts resulted in closer interdisciplinary relationships and
sharing of nursing research information within the university.
 1 Collaboration with faculty from nursing, other disciplines, and community
agencies in the CDIS project opened new and exciting learning and research
opportunities, especially as they address current issues. Linkages developed by
faculty engaged in community service can evolve into meaningful, real-life
projects for students, faculty, and society. Nursing students were challenged to
apply their community health knowledge as they learned the process of
developing a disaster information system.

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  Nursing students experienced an application of informatics in their discipline.
Computer science students worked with innovative mobile computing, web-
services and the Internet as they learned about disaster nursing response. The
students and faculty learned about the disciplines of nursing and computer
science. They discovered that their vocabularies and critical thinking patterns
were very diverse and this proved to be a challenge in communicating their ideas.
 They learned how to understand each other and respect the expertise that each
brought to the project. These skills will enhance the students‘ ability to work with
interdisciplinary teams.
 Motivated by the obvious need for the system, the students and faculty dedicated
themselves to producing a significant and impressive informatics application.
Through interdisciplinary collaboration nursing and computer science students
learned to apply informatics to solve a community need. Both groups frequently
commented about their personal satisfaction of working on a project that would
actually be implemented in the community and increased their interest and
dedication to the project.
 The students learned how to work together to accomplish a mutual goal from very
different perspectives. Nursing and computer science faculty found a new energy
that came from expanding their horizons beyond their comfort zone. This synergy
has evolved into an empowered team that together has received departmental,
divisional, university, local and national recognition.
 The Red Cross and ultimately their communities benefit from an information
system that can be used for local and national disasters. With the expertise and
funding sources available from academia, faculty and students capitalized on an
educational and research opportunity to collaborate with a service organization to
produce a much needed community resource. All parties benefit by producing
products and services that neither would have produced individually.
Collaboration and Independent Practice:
Inter – professional collaboration and independent practice: why these issues are
important during the twentieth century, the nursing profession has undergone
immense change.
Nursing has progressed from an occupation to a fully licensed profession, with
members that provide a broad range of services independently and in a variety of
professional relationships with other providers.
This evolution has changed how nurses are educated, clinically prepared, and how
they perceive their role.
Starting With turn – of –the –century debates concerning the appropriateness of
professional nursing practice, registered nurses began assessing not only their
licensure status but their roles related to other professionals.

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 In the early years of nursing profession, it was generally believed that the nurses
served and cared for their patients by assisting physicians. However the
perception of nursing often varied dramatically from its practice.
During wars and times of crises, nurses worked with beside physicians conducting
surgical procedures, diagnosing care, and prescribing treatments and drugs.
The role of the public health nurse, as it developed earlier in this century, was
often independent with nurses working with families of patients with tuberculosis
or other highly contagious diseases and providing a broad range of interventions,
both health and socially focused.
Intrinsic to nursing is the collaborative process: nurses and physicians working
together and independently assessing, diagnosing, and caring for consumers by
preparing patients histories, conducting physical and psychosocial assessments,
and reviewing and discussing their cases with other health professionals to
determine the hanging health status of each client.
Nurses and physicians have understood the importance of this overlap in scopes,
practice, and patient care , yet there is little literature and virtually no legislation
that clearly provides a balanced accounting of the benefits of this working
relationship.
.
CONCLUSION : All the models pursue collaboration as a means of developing trust,
recognizing the equal value of stakeholders and bringing mutual benefit to both partners
in order to promote high quality research, continued professional education and quality
health care. Application of these models can reduce the perceived gap between education
and service in nursing there by can help in the development of competent and efficient
nurses for the betterment of nursing profession.
REFERENCES:
 Kozier B, Erb G, Barman A, Synder AJ. Fundamentals of nursing; concepts, process and
practice, Edn 7th, 2001.
 Potter a, Perry G .Basic Nursing-Theory and Practice, Edn 3rd Mosby Company.
 Kaur Navdeep , Rawat HC , Advanced nursing Practice,Jaypee publishers 1st edition
 www.slideshare.com
 www.wikipedia.com
 www.google.com
 www.scribd.com

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