Physician-Nurse Collaboration

Problem Identification

Physician-nurse collaboration is an important part of patient care. Physicians are responsible for diagnosing and recommending treatments for their patients, but generally, it is the nurse who provides the prescribed treatment and care. This system places the nurse at the patient's bedside, usually over a twelve-hour period.

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It is common practice at the hospital for the physician to see the patient and leave the unit without even talking to the nurse. Physicians visit patients very briefly, usually in under five minutes. It is also common for the patient (or family members) to have questions for the physician that they often forget to ask when the physician arrives, or perhaps they were asleep when the physician came by. Later, they ask the nurse to call the physician back to their room. Some patients even state that they did not realize the person who came by was the physician. With various services coming in and out of the rooms, with all physical and occupational therapists, respiratory therapists, nutritionists, etc., it is understandable, that patients may not realize who the physician actually is. It is the nurse that the patient can usually identify as their constant caregiver.

It is also common for physicians to place orders, even STAT orders after they have left the unit. With computerized patient records, the physicians can be anywhere they can get computer access and place orders. Also, discharge orders are often placed without any conversation with the nurse.

Not only do these behaviors make the nurse feel their opinions are of no value, but often the patient has had a change in condition or other needs that require attention from the physician. If it is not an emergency, the patients try not to call the physicians but rather wait to address the issue during their rounds.

Some patients are not able to communicate either due to their diagnosis or perhaps a language barrier. The nurse has more time with the patient and is able to make a more thorough assessment of the patient's needs, but the physician sees them for only a few minutes. The nurse is able to be the voice for the patient. This is especially important if family members are absent; perhaps they live out of the area still but have input to relay to the physician through the nurse.

Improve Physician-Nurse Collaboration

On a purely business outlook, the lack of collaboration between the physician and the nurse can be compared to poor communication within the company. Failure to effectively communicate in the business world often leads to conflict, which can harm a business. A lack of communication creates uncertainty leading to stress and conflict. Companies often rely on teams to complete projects or for the routine function of the business. If team members do not communicate with each other, roles and responsibilities may become convoluted. Tasks might overlap or be overlooked causing confusion and conflict and/or leading to failure to achieve their goals (Joseph, 2015).

Physician-nurse collaboration has the capacity of affecting the physician and the nurse as well as the patients they care for. It's in their hands to create safe environment for the patients, thereby improving patient outcomes, including safety and patient satisfaction scores. The Joint Commission's National Patient Safety Goals are either directly or indirectly impacted by effective communication, and patient safety relies upon it (TJC, 2015).

Certain characteristics of physician-nurse collaboration directly correlates with the quality of patient care. Research carried out at fourteen hospitals, which had achieved "Magnet" designation from the American Nurses Credentialing Center (ANCC), also indicated that collaborative relationships between physicians and nurses were not only possible but 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 collaboration), and the quality of patient care outcomes.

According to Amy Wilson-Stronks, Project Director in the Division of Standards and Survey Methods at The Joint Commission, and Principal Investigator of the Hospitals, Language and Culture study, it is stated that ineffective communication among healthcare providers has resulted in misdiagnosis and inappropriate treatment or medication errors. Communication is important in all phases of the patients care from assessment, treatment, and diagnosis for them to be able to understand and follow discharge instructions even when they leave the hospital.

The Joint Commission's research, on sentinel event data, actually demonstrates the importance of physician-nurse communication for patient safety. As for the sentinel events that have been reported to The Joint Commission, the most common underlying root cause relates to the lack of communication. Up to 70% of adverse effects are attributed to the lack of communication and collaboration. Again, demonstrating the importance of communication to patients is a safety measure (TJC, 2015).

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In primary care, multidisciplinary teamwork is essential to develop, promote, and maintain the health of the population while improving service. It is widely accepted that interprofessional collaboration is necessary today (Xyrichis & Lowton, 2010).

The Affordable Care Act uses the Hospital Consumer Assessment of Healthcare Providers Systems' (HCAHPS) survey to report patients' experiences. It has been in use since 2006, and it measures patients' perspectives of hospital care to publicly report how well the hospital performed, i.e. a hospital "report card". The survey takes a random sample of recently discharged adult patients to give feedback on topics such as how well nurses and doctors communicated. HCAHPS was created by the Centers for Medicare & Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ) with the belief that patients (the consumer) are the best sources of information on these topics (Medicare.gov, 2015).

Patient perspectives can directly affect a hospital's bottom line. The patient-reported data is published for the consumer to be used in determining value and serves also as an indicator for Medicare and other insurance companies to be used in determining hospital reimbursements. Patient-reported data is expected to play an increasing role in ensuring early and efficient detection of healthcare system dysfunctions. Nurses are on the front line when it comes to patient interaction.

Therefore it is important that they are kept up to date on the patient's healthcare plans and goals. It does not look favorable for either the physician or the nurse if the patient is receiving conflicting information; this is easily avoided with collaboration. Quality of care, perception of healthcare dysfunction, evaluation of their interventions, and the patient's perspective from the concept of responsiveness relates to patient-reported experience measures that focus on service users' (patients') legitimate expectations (Tremblay et.al., 2015).

Despite the challenges to overcome non-collaborative habits, true collaboration is vital not only for the benefit of patients, but also for the satisfaction of healthcare providers. Collaboration between physicians and nurses is rewarding when responsibility for patients' well-being is shared. Professionalism is reinforced when all members share successes. In addition, collaboration improves job satisfaction for both the physician and the nurse and helps to prevent job "burn out" and "compassion fatigue." It helps physicians and nurses to remain empathetic, motivated, and emotionally present.

Causes of the Problem

Physicians carry a large caseload of patients. This, along with the administrative practices associated with caring for those patients, leaves the physician with very little time. With the physicians' busy schedule, they may feel as having no time to collaborate with the nurse. Physicians may have tried to collaborate, but nurses may have been unavailable when they were asked to participate, causing the physicians to interpret this that nurses are not receptive to collaboration.

It is also possible that the hospital administration has not demonstrated the importance of a collaborative relationship. From the cultural framework of organizational behavior, the key to effective physician-nurse communication is the value of the organizational culture relative to the worth of these professionals for overall success of the organization. The daily behavior of nursing leadership represents the organization's valuing of individual nurses. Nursing leaders who are invisible, dismiss other nurses' suggestions and concerns, or do not invest in development, at the same time conveying the belief that nursing's contribution is not meaningful.

This belief is projected to the organization as a whole and reflected in physician-nurse communication. Nursing leaders who do not interact with medical staff as with equal partners cannot expect individual nurses to demonstrate that kind of behavior. Organizations that view physicians as customers and believe the customer is always right to create a culture of indifference and dissatisfaction. Such a belief creates a dysfunctional culture where professional relationships are distorted by superimposed power dynamics.

In 2008, the Council on Graduate Medical Education and the National Advisory Council on Nurse Education and Practice issued a joint statement recommending that nurses and physicians should be educated together for developing shared culture. They state that current distinct and separate professional cultures serve as barriers to effective communication.

It may be that some physicians feel the nurse does not have enough education to make a valuable contribution to the medical plan of care. Whenever possible, nurses should frame their communication with physicians in terms of the medical cultural context. This means the message must be brief, well-organized, factually based, and action-oriented. The message should include a direct request relative to recommended action. Nurses and physicians are partners in patients' care. Physicians treat disease based on what they can hear, see, and count; while nurses view disease as life experience. The immediacy of patient care situations, as well as time constraints, do not allow physicians and nurses to have lengthy conversations.

Also, a physician's age, culture, and education as well as that of the nurse can cause the lack of physician-nurse collaboration. In 1967, Leonard Stein coined the term ‘doctor-nurse game’ to refer to the implicit or explicit relationships of power between doctors and nurses, and the social game played between two disciplines was carefully orchestrated to maintain that balance. Traditionally, the relationship between them had a simple hierarchy: doctors were superior to nurses; doctors were to cure, nurses were to care (Stein et al., 2009).

However, after the 1970's feminism revolution, the nursing profession changed. The nursing profession moved to universities, and nursing began to be redefined. Roles changed, men became nurses and women became doctors. Nurses stood up to doctors, offered advice, and were regarded with much more respect than they had previously been (Williamson, 2009). But many doctors still reject these changes. In the 1990's, Stein revisited his theory to find the "doctor-nurse game" was still present, although more silently demonstrated. This mindset can create a disruptive environment.

If these underlying beliefs are present, the physician-nurse communication can be conflictive to the point of dysfunction. This conflict arises from competition for status and power and different values and beliefs. Some physicians may still harbor the notion that they must be "captains of the ship" (Stein,et al, 1990). Such individuals view a recommendation or a direct request for alteration in "their" plan of care as a challenge to their status and power.

The struggles over hierarchy, power and superiority, lack of resources, and lack of collaborative opportunities have all been the reasons attributed to the reluctance or lack of physician-nurse collaboration.

Identification of the Stakeholders

Interest, power, and influence of stakeholders. The following are key stakeholders in the practice of physician-nurse collaboration:

  • Patients and their families
  • Physicians
  • Nurses

Hospital Administration:

  • Chief Nursing Officer
  • Clinical Manager
  • Unit Director
  • Chief Medical Officer
  • Risk Manager
  • Dieticians
  • Speech Therapists
  • Respiratory Therapists
  • Physical and Occupational Therapists
  • Social Workers
  • Case Managers
  • Insurance Companies and Networks
  • Hospital Stockholders

At Desert Regional Medical Center (DRMC), all the above-mentioned stakeholders have interests in physician-nurse collaboration and would benefit from the practice of it.

The patients and their families are the primary stakeholders with the greatest interest in physician-nurse collaboration. Improved communication between the physician and the nurse means that care will be delivered more quickly and more safely since the plan of care will be shared by two primarily responsible for the delivery of care individuals. The previously mentioned HCAHPS empowers patients by allowing their opinion to have an influence over the payment for the service they receive.

The presence of the physicians collaborating with their nurses will be perceived by the patients as a receipt of excellent service from care providers. It will, in fact, enable better service when communication is delivered at bedside, allowing new orders and care to be provided more quickly. This will also alleviate patients' and their families' fear and anxiety. The patients and their families have the power and influence to provide an input that can have an effect on reimbursement payments for their care.

As a result of the collaborative practice, patient satisfaction scores should increase. The physicians will benefit from physician-nurse collaboration by receiving fewer interruptions from nurses and other providers during their daily rounds. By communicating with the nurse, the plan will be known, orders will be discussed and clarified, and the nurse can provide other healthcare team members with updates when needed. The day will run more smoothly when the information has been shared, the patient will feel more satisfied. The latter fact will encourage them to report higher satisfaction scores connected to financial reimbursements. With knowledge of the plan, the nurse can ensure that treatments, tests, and even discharges are completed in a more timely manner. With improved communication, errors, omissions, and missed orders will be less likely to occur, which will lower the liability and risks of lawsuits.

The nurses will benefit by spending less time calling the physician for orders or their clarifications and asking for patients' questions. Improved communication will empower the nurse, so the information can be passed on to other providers, which will also assist the physician. Again, customer satisfaction scores will probably increase if the patient is treated more quickly as discussed. This, in turn, will assist in preventing repeated patient calls to the nurse. If the patients know what is planned and what is expected next, their anxiety will be relieved, and they will be calling their nurses less often as their questions will have been answered in advance. Hence, this will allow the nurse to coordinate care and get their work done with fewer interruptions.

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The Chief Nursing Officer (CNO)

The Chief Nursing Officer (CNO) has the power to accept or deny plans to improve the lack of physician-nurse coordination. However, the CNO should have an interest in the physician-nurse collaboration because it will promote greater teamwork. The CNO has the power to influence by assuming the role of defining and implementing the change, educating nurses, clinical supervisors, and unit directors of new policy and expectations.

The charge nurses, clinical supervisors, and unit directors will have an influence on the staff nurses (as directed from the CNO) in order to educate them in terms of the implementation process to improve physician-nurse collaboration. They will have the power to direct staff nurses at the procedures and require attendance to educational in-services for ensuring the CNO's policy is fulfilled as described. The unit director will review and observe their staff nurses during periods of physician-nurse collaboration to ensure compliance and understanding of the policy. Implementation of any change in organization relies heavily on the collaboration of administrative employees for effective initiating of the new change.

With the support of the CNO, the clinical supervisors and charge nurses will create a nursing environment that promotes physician-nurse collaboration. The clinical supervisors and charge nurses will ensure there is a smooth workflow among other stakeholders involved by being supportive of staff nurses by being available and even demonstrating the process as needed. They will also ensure all the standards set for new changes are upheld. In turn, the CNO will be available for clarification when needed.

The Chief Medical Officer (CMO)

The Chief Medical Officer (CMO) will have the power to deny or approve of the participation of the physicians in plan. The CMO will have similar influence as the CNO but will instead oversee the changes needed to ensure the physicians are educated about new expectations. Collaboration with other administrative staff including the CNO will ensure the physicians' needs are met to develop effective methods of allowing smooth flow for successful physician-nurse collaboration. The CMO has the power to ensure all the standards set for new changes are upheld and can be available to the physicians for clarifications when needed.

The Risk Manager has interest in physician-nurse collaboration project due to its potential to lower hospital liabilities. The risk manager can assess potential changes in order to ensure safety measures are included within the collaborative practices. The risk manager can monitor the safety reports (esrm's) to evaluate for fall-outs and has the influence to make modifications where needed. At specified time-frames, possibly semi-annually, the risk manager can develop evaluation methods to determine if the new policy has made improvements to decrease risks, improve safety, and reduce potential lawsuits.

During collaboration, the named administrative staff will collect and evaluate financial data for determining whether new physician-nurse collaboration has made an impact on financial savings or gains.

Medical support staff: dieticians, speech therapists, respiratory therapists, physical and occupational therapists, social workers, and case managers can influence the implementation of improved physician-nurse collaboration practices. The nurses' knowledge of the plan will benefit them because they are working on the unit using it. The nurse can serve as a resource of the unit; and after having collaborated with the physician, the nurse should be able to provide the answers to most questions. The nurse is working side-by-side with the physicians, which allows quick access for most answers regarding the patient's plan of care. An intent to discharge or transfer patients can be iterated long before the order is placed in the computer.

Insurance companies/networks hold financial rewards for effective physician-nurse collaboration practices. They have the power to withhold reimbursements if they determine the service was not provided as agreed. In addition, patient satisfaction scores are reviewed and taken into consideration for payment reimbursement. Effective physician-nurse collaboration has been proven to increase patient safety as well as satisfaction scores, both being important aspects for insurance companies. Improved communication between the physician and the nurse provides nurses with the information necessary to follow-up orders and ensure treatments are completed in a timely manner, thereby shortening hospital stays.

Desert Regional Medical Center is a profitable hospital that has stockholders interested in having financial gains for their investments. If the hospital is not providing enough returns, the administrative staff will be questioned to determine where the losses are occurring. The services of physicians and the nurses are the main commodity being sold. If patients are not happy with the services, they will shop elsewhere. This will cause a loss of revenue. Physician-nurse communication (collaboration) improves and streamlines the process in patient care and, as a result, improves safety and patient satisfaction. These measures increase profits by moving satisfied patients through the process with a safe discharge, which, in turn, makes the satisfied customer (patient) give hospital a good HCAHPS (report card).

These report cards are reviewed by potential customers (patients) and are used in determining where they would like to receive their medical services, thereby increasing profits. Stockholders have the power and influence to remove ineffective people or processes that may impede financial gains or profits. Stockholders are interested in the financial success of their investments.

Again, the patient will benefit from physician-nurse collaboration by receiving excellent care, which allows the best outcome possible. With care coordinated and the elements of care completed in a timely manner, patients will have shorter admission times, full-reimbursements will be received, and risks of errors and omissions will decrease. This translates into quicker discharges. Beds will become available sooner, which will enable more admissions. More admissions equal more opportunity for financial gain for the hospital, improving the hospitals "bottom-line". This will please hospital stockholders and encourage even more investors allowing for hospital growth. Hospital growth can mean more job opportunities for all healthcare personnel.

Purpose of Project

Improving physician-nurse collaboration is prudent because of the impact on increased patient safety and outcomes including better care decreased length of stay, decreased morbidity and mortality, and decreased costs(Kramer & Schmalenberg, 2013; Rosenstein & O’Daniel, 2013). Also, primary reasons why nurses leave the profession is dissatisfaction with their practice environment (Joint Commission on Accreditation of Healthcare Organizations, 2015), and one of the main stressors is the lack of physician-nurse communication (collaboration) and conflicts over patient care. It is important to evaluate the physicians' and nurses' perceptions of their interaction patterns, especially since nurses spend significantly more time with the patients than the physicians. By evaluating the physician-nurse environment, it can be determined where deficiencies exist.

To implement the plan successfully, it will require an analysis of the working environment and the nurses’ and physicians’ perceptions of a collaborative relationship. Education will be required to teach and improve interpersonal relationships in terms of conflict resolution strategies. Also, the continuing and long-term promotion of teamwork is needed.

Reasons related to the lack of collaboration are multidimensional and complex with various barriers to overcome. It is not only a physician, nurse, or organizational deficiency, but its roots are deeply embedded within our society. It is multidimensional because it involves status, power, and cultural aspects.

As previously stated, nursing professionals have only recently ventured to the university to receive formal education. Also, within our time, we have seen more women become physicians and more men become nurses. We currently have nurses and physicians who practiced in the bygone era when the men were traditionally physicians, women were nurses as well as the latter practicing with little training or formal education.

It is a unique time because there are physicians and nurses working side by side. They can have a very different set of values and beliefs. Currently, there are physicians who practiced during the principal time of the "doctor-nurse game," physicians who seek the input of their nurses, and nurses who would never question an order made by a physician.

Even nowadays, physicians who have immigrated from places where the hierarchical paradigm remains make decisions, and the nurses stand by without question. There are many individuals filling both physician and nursing positions who have only read in books about the women's rights struggles and worked next to someone who was actually a part of those struggles. Attitudes and conditions have evolved in a very short time.

With the "melting pot" of beliefs and opinions, conflict is not only present but also natural and is a part of interactions with others (Zerwekh & Claborn, 2006). Therefore, the goal of teaching how to resolve conflict is in order. Cooperation, assertiveness, and open communication are healthy conflict resolution strategies and necessary for positive collaboration to occur (King & Lee, 1999). Leadership support and education are the keys to improving relationships between individuals with different world views (Monin & Bathurst, 2008).

Ultimately, the promotion of physician-nurse collaboration will reduce risks, save costs, and create less stressful and more harmonious work environment leading to staff retention and satisfaction. Collaborative practice will enhance patient safety and outcomes, which will likely improve patient satisfaction scores. These improvements will increase hospital profits by decreasing hospital losses and expenditures. It is essential that leadership not only commits to support, but demonstrates collaborative practices themselves in order to ensure the collaboration is valued as an organizational goal.

Proposed Solution

The purpose of this project is to teach, encourage, and promote collaboration between physicians and nurses in an acute care (hospital) setting. Evidence confirms that collaboration has been associated with decreased mortality, increased job satisfaction, reduced turnover, and decreased costs in healthcare institutions (Kramer & Schmalenberg, 2003). The project will be centered on interdisciplinary rounding.

Administrators should ensure that hospital systems are in place for supporting and fostering good nurse-physician relationships. Cooperation and collaboration start with the messages sent by leaders and by witnessing the process in action from the top down. The Chief Nursing Officer (CNO) and Chief Medical Officer (CMO) should work together to educate the staff about the plan of increasing collaborative behaviors. By attending meetings together and having both names on paper directives, they demonstrate that it is a joint effort between medical and nursing staff.

It sends a message to physicians and the nurses that unity is embraced. Once support is garnered, they can move forward. Changes have to be approved not only by upper management, the Chief Nursing Officer and the Chief Medical Officer, but also at the unit levels, the clinical managers, and unit directors. There is the documentation gathered from evidence-based practice which supports multidisciplinary rounding used in influencing the implementation of this project.

Once approval is secured, surveys can be used to collect information, ideas, and suggestions from both medical and nursing staff for suggestions of improvements for physician-nurse collaboration and their perspectives at this time. Both disciplines must have an active voice in the process of developing collaborative environment. Their ideas and suggestions must be taken into account and used where possible in an effort to encouraging participation.

The champions can be identified, and their efforts recognized not only to reward them for providing safer patient environment, but to show them as examples of what the objectives are for collaboration and to serve as role models to peers.

A large portion of this project is informational education. Educating the physician and the nurse is expected and important in terms of having collaborative relationship. Also, an understanding of what is expected from both the physician and the nurse is needed by promoting the knowledge of their scope of practices. The scope of practice for nursing has dramatically changed over the past few years, and some physicians may not realize that these changes have occurred.

In addition to patient care, charting and other facility obligations, the nurse is held accountable for decisions made by the physician. This makes the doctor's decisions be of interest to the nurse, particularly when they involve the administration of medications. The nurse must understand why medication is given and whether the dose and route are appropriate before administering it. Without collaboration with the physician, the nurse is left for guesses. While with some medications this may not matter, many medications were made for a particular condition but are often used for another. Also, recommended dosages may be different, which may cause additional confusion for the nurse.

While everyone knows the doctor makes the diagnosis, places orders, and writes notes about the patients care, the nurse may be unaware of other responsibilities the physician is obliged to. All members of the team should have at least an idea of what the responsibilities of other team members are. Shadowing would be ideal but maybe not practical at this level. The University of Kentucky has recognized the importance of physician-nurse teamwork; and in an effort to promote teamwork, it includes shadowing nurses in residency programs. Ideally, residency and nursing programs should be included in the overall schedule.

Numerous research projects discover that physicians believed they were collaborating with nurses, yet nurses alleged otherwise. This implies that regarding collaboration, educating physicians and nurses together would be beneficial in an effort of attaining an agreement from medicine and nursing that join different perspectives and understandings of collaborative behaviors (Nair et al., 2011).

A good example of the need for evaluating the perception of collaboration is demonstrated in the author's recent conversation with a coworker. This coworker, with many years of nursing experience, stated she was apprehensive when doctors ask for her personal opinion. She stated she felt uncomfortable because they are the doctors, so why are they asking her? It was promptly explained that they are not asking for a solution or diagnosis, they are asking if she has any ideas what may be going on, and their asking was a sign of respect for her opinion. They were acknowledging her involvement with the patient and wanted to know if she had seen or heard something that could help them to care for this patient in a better way. She stated that she did not think that way, but she will try and participate next time. This is a perfect example of why it is important to gather information from the physicians and nurses in terms of what their idea of collaboration entails.

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When sharing information is not practiced consistently or timely, patients may be at an increased risk for medical errors. Sharing patient information collaboratively between physicians and nurses is an expectation of both professions in order for them to provide appropriate patient care while ensuring patient safety. According to Zwarenstein et al., an increasing empirical literature supporting interprofessional collaboration suggests that failures of collaboration between professionals have a profound negative effect on health care and health outcomes, undermining the validity of clinical decisions and interrupting or creating errors in the implementation of these decisions (2010, p. 47).

The most common form of communication found in the hospital in question is one-sided. It is in the form of orders placed in the computer or reviews of the progress notes, which places the patient potentially at risk for harm according to the collaborative research. Therefore, further examination of the obstacles or inefficiencies of sharing patient information (collaboratively) is a prudent measure. Current practice demonstrates that physicians and nurses may be working independently rather than in a team.

In addition to teamwork being necessary to contain costs and sustain quality of care, Hojat et al. (2014), Kramer and Schmalenberg (2009) report that hospitals with excellent physician-nurse collaboration had the lowest mortality ratios, suggesting physician-nurse collaboration is necessary to prevent harm for patients.

The project of improving physician-nurse collaboration will focus on interdisciplinary rounding because it is familiar to both the physician and the nurse. Burns (2011) states that dedicating time for physician-nurse rounds improves relationships between caregivers and positively affects communication and the patient’s perception of care.

A request for physicians to round with nurses should be initiated, and some services are already practicing this intervention. However, to obtain overall compliance, a directive from administration (after training) would be helpful. Current "champions" among physicians and nurses may be identified to demonstrate this technique. The Clinical Manager and the Unit Director will participate by visual management and provide feedback on their observations. Patients will also be interviewed on their perspective and adjustments to techniques made accordingly.

Prior to implementation of the project, a good foundation for the purpose and importance of the rounding can be provided through education and training; educational opportunities would be provided both through mandatory online education modules and interactive "scenario" enactments. Also, guest speakers, open forums, group discussions, collaborative workshops, and training programs will focus on improving teamwork and working relationships (for example, sensitivity training, assertiveness training, conflict management, collaboration skills, stress management, time management, and phone etiquette with an emphasis upon courtesy, respect, promptness, and preparation) (Kramer & Schmalenberg, 2003; Nair et al., 2011).

Evidence Summary to Support the Change

To facilitate the system of collaboration among the professionals, the principles including client-centered care services, epidemiology, and evidence based-informed discretions must be in place. Client-centered care emphasizes collaboration among the clients, nurses, and professionals working together at both individual and organizational levels of healthcare, while evidence based-informed decision-making processes resources relayed within the jurisdiction of the nursing profession (Weiss & Davis, 1985). Consequently, epidemiology is a basic principle that facilitates the practice of collaboration in the nursing profession as it takes into account the assessment of demographics and health status of the clients in a view of assessing the impact of the services offered.

In this regard, most of advocacies of collaborative practice in nursing including the US have frameworks for promoting collaboration and teamwork among health professionals for more flexible integration of services. These steps include publishing of successive documents such as the Health Service of All Talents (2000), which puts emphasis on a more personalized integrated form of care providing. This paper examines the mechanisms that shape collaborative practice in nursing, its framework and the perspectives, and the best way forward in terms of its integration.

In the global world, most of the forms of social legislation about health care place an emphasis on the rights of admission to health care in other states as a form of expanding the niche of care providing and building a cohesion that fosters collaboration among member states. For instance, in the UK, common themes give declarations for a mandate that makes it clear that patients are aware of their own personal contributions for an optimal health functioning system. This implies that such legislation emphasizes a proactive form of care as opposed to practitioner-defined form of care. This enables collaboration as it ensures that the patient is a full participant in the provision of care.

The other legislation of collaborative practice in nursing is the American “Nurse Practitioners Modernization Act”, which gives guidelines to all nurse practitioners to sign a practice agreement with a collaborating physician. Such legislation emphasizes that all practicing nurses should work in collaboration with a qualified physician. This legislation is vital in instilling apprenticeship as a form of skill acquisition with a view of attaining an efficient health system (Weiss & Davis, 1985).

On the other hand, several policies and protocols have been put in place among most of the countries to ensure that a collaborative form of healthcare system is achieved. Such policies include evidence based on nursing, which puts into emphasis the ways of making sure that the patient is proactive against their own health. However, protocols such as information technology ensure an efficient communication system between the patient and the practitioner. Such forms of protocols include technological applications, which use an electronic system of provision of health care, also faster and can access a wide platform of care. With such systems in place, collaboration practice has been achieved since the former increase the probability of efficiently putting together the resources within the health practice for better outcomes in healthcare industry.

In as much as there has been a platform for integration of collaborative practice in healthcare, the social healthcare legislation policies and protocols have not reached to the optimal levels of achievement in most of the countries. This is derived from the fact that the uptake of these roles is faced with challenges including poor implementation programs, lack of proper financing models, and cultural barriers, especially in poor state members (Neale, 1999).

The WHO has frameworks for action on interprofessional education and collaborative practice. The first framework evident within the jurisdiction of WHO is participation in the initiatives which are transforming education systems in nursing and midwifery and developing midwifery as an integral part of international health plans. This framework has seen WHO to be a worldwide participant in collaborative practice as it involves all member states in providing education and hiring staff from both developing and developed countries. By this consideration, midwifery is an issue which affects every corner of the nation in scaling up the transformative education in this field. The WHO, therefore, defines collaborative inclusion since every member in society has an access to this form of teaching and consequent participation.

The WHO is forging ahead towards strengthening national and subnational legislation and regulations that govern the systems of education. For instance, it is the force behind the legislation of international expatriation of nurses, who get to teach foreign communities on foreign policies in dealing with some common pandemics. The organ is also the source of legislation for common international education curricula which deals with education of every member of the society as a form of proclivity towards dealing with challenging situations in health care. Such a form of participation has increased the number of members in the health education reform system, which is also a form of collaborative practice in health care (Neale, 1999).

In meeting the requirements of collaborative practice in nursing, the WHO applies various models like planning for integrated health and education policies stipulated within its organizational values. By consideration, the organization has the mandate of ensuring that health and education systems work together in the coordination of workforce strategies. Furthermore, integration of the health workforce planned with policymaking is the major boost for interprofessional education and collaborative practice, which lies under the WHO's model of integration of programs.

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Furthermore, there are mechanisms which shape the development of interprofessional education, which include shared objectives and program content. The objectives are shared within the interprofessional education program, where health workers in varied professions interact with practicing nurses from other professional backgrounds (Weiss & Davis, 1985). This form of interaction elucidates contribution towards achieving collaborative practice as it gives first-hand information to the untutored people in the society through sharing skills with the experienced staff.

On the other hand, the program of designing the content of interprofessional education is directly contributory to collaborative practice since it ensures that the right skills are imparted for the right choice of situation. The content defines the end product of the interprofessional student, whereby the necessary curriculum is prescribed while the outdated curriculum is discarded from the education system.

Proposed Implementation Plan

Plan of Action

Contextualized health and social systems are evidently the answer to the constraints of collaborative practice. This goes from the fact that these systems operate on an integrated platform developed from a software program. Such a platform is essential as a contributory factor to collaborative nursing as it gives the right decisions free from errors elucidated in the manual systems (Evans, 1994). For instance, the GIS can be used to study and give the spatial phenomenon accurately if applied for research on socioeconomic characteristics.

Such characteristics are also attributes that define the human health, thus helping to prescribe a form of approach towards efficient health among communities. This implies that while achieving collaborative practice in nursing, there should be a more integrated system of funding towards the development of contextualized health and social systems applied practically instead of the theorized phenomenon. In this regard, contextualized health and social systems are evidently more concise and accurate as opposed to manual systems; they should, therefore, be the recommended tools for relaying information about the status of collaborative practices in nursing across the globe. However, they should be designed to cater to the needs of poor states globally to capture the system’s profitability.

Ethics of leadership is the application of the moral standards of the nursing profession among higher human resource management (Neale, 1999). Moreover, nurse leaders are mandated to sustain complex environments characterized with conflict solutions and eventual moral distresses among the practitioners. Leadership ethics is a complex notion which has obligations including value-based, rule-based, and situational form of leadership. These forms are characteristically the basis of ethics of leadership without which the leader has no moral role in making decisions on behalf of the subjects. These forms of leadership define the right forms of approach in revitalizing the role of it as a contributory factor in nursing collaborative practice.

Ethics of leadership is a factor which affects collaborative practice in nursing in a direct proportion, where both the leadership within the community and that within the nursing practice are factors of consideration. This implies that the nature of leadership would contribute positively to collaborative practice, while unethical leadership contributes negatively to it. In consideration, in most of the poor states, which are still purged of cultural norms, and uptake of cultural leadership as a form of ethical leadership has contributed negatively towards an understanding of the roles of collaborative practice. For instance, there are cultural decisions that give a direction to the ban and use of some forms of technologies like telemedicine. This form of leadership is termed as unethical since it is a hindrance to the products of efficiency in health care through collaborative practice (Neale, 1999).

As a form of ethics of leadership of application, situational ethics is also a contributory factor affecting the nursing practice and collaborative practice as a whole. This form of ethics takes into account the nature of the situation where the correct side of the situation should be given preference to the wrong one. In leadership, application of this form of ethics does not only help to achieve efficiency, but also reduces the vulnerability of the society to rampant situations.

For instance, when planning for a self-care education to the society, some communities prove to be hostile, which results from unethical leadership within the society. Such a scheme would need an ethical form of approach where the leadership within the nursing fraternity should result in an ethical decision of dialogue as a form of approach to resolve the hostility. This revokes the chances of negativity to self-care programs, most of which are products of collaborative practices in nursing.

Timeline

For an effective and efficient change management structure that fosters collaboration in nursing, the need for the articulation of a stringent timeline is wanted. The process veers through education in nursing, where there should be an initiation of a request for physicians to round with nurses. To obtain the procedure for an overall directive that articulates nursing training, there would be a forum for education programs consistent with working mergers. The education program takes into account courses for improvement of collaboration between the nurses and the health physicians. The table below shows all the activities for improvement of collaboration between the nurses and the health physicians and the required timelines.

Needed Resources and Personnel

The basic resources needed for fostering change management systems in the nursing industry include technological applications, which will involve the use of the computer machine for research into physician-nurse collaboration (Evans, 1994). The computer machine will be useful in research and evaluation of outcomes, where there would evidently be a setup of a common website. On the other hand, the personnel needed for implementation of change management systems in the nursing practice will include the medical support staff: dieticians, speech therapists, respiratory therapists, physical and occupational therapists, social workers, and case managers who will initiate the change management system through collaboration.

The nurses will also aid in change management systems as they will form the basic platform for training, while patients will aid in the evaluation of the outcomes by giving their views on the workability of the concept of collaboration. The nurse will also work side by side with the patients which allow quick access for most answers regarding the patient's plan of care. The intent to discharge or transfer patients can be iterated long before the order is placed on the computer.

Further, other resources will include the insurance companies and their networks, which will be essential in determining the financial needs and rewards for an effective program of collaboration. The insurance companies are bequeathed with the power to advance reimbursements upon determination of the workability of the program. In addition, patient satisfaction scores are reviewed and taken into consideration for payment reimbursement. Effective physician-nurse collaboration has been proven to increase patient safety as well as satisfaction scores being both important aspects to insurance companies. The improved communication between the physician and the nurse provides nurses with the information necessary for the follow-up orders and ensure treatments to be completed in a timely manner, thereby shortening hospital stays.

Proposed Change Theories

Effective leadership is the major contributory factor towards the success of any organization. In collaborative practice, a number of theories are applicable, which have been the key factor towards attaining the fruits of this noble course in nursing. Some of these theories of application include the behavioral theory, the great man theory, and participative leadership theory. The great man theory seeks for defining the leader as being differently perpetuated in his or her position in relation to the average person. Such attributes defining the difference include the intelligence, perseverance, and the ambition therein.

For the community to be fully-fledged with the power of contributive practice, both the societal leaders and the leadership within the nursing practice should possess these attributes. In the US, nurse leaders are charged with the duty of upholding professional ethics emphasized through the display of high standards of intelligence, perseverance, and ambition (Evans, 1994).

Next, the communities within which these nurses serve have leaders who have the same requirements being the greatest contributory factor towards high standards of contributive practice. This implies that for the achievement of the perspective of collaborative practice, the form of leadership should display almost all the attributes of the leadership theory of the great men.

Other theory which affects the fruits of collaborative practice is the participative leadership theory, which gives the requirement that all leaders in the nursing profession work in conjunction with the subjects who are the practitioners on one hand and the patients on the other. This form of leadership theory contributes to collaborative practice as it allows for a communal participation, which defines collaboration in the nursing field. Most of the situations where participative leadership as a theory of leadership applies is when researching on the evidence-based program within a remote community. In this case, all leaders are expected to show the highest criteria of participation through getting involved in a number of issues affecting the patients such as practical prescriptions, which elucidates collaborative practice in nursing (Weiss & Davis, 1985).

Barriers to Implementation

Some barriers to implementation include the financial constraints since the change management system will articulate a technological system of application. It is evident that the evaluation of the workability of the proposal for collaboration will also need research into current systems of collaboration, which in turn involves the articulation of technological applications. The other barrier to implementation would be the working culture, which is an attribute that is essential in consideration while considering the prevalence and integration of collaborative practice in nursing (Weiss & Davis, 1985).

The working culture determines human resources as a platform for achieving efficiency in healthcare. The working culture determines the legislations that allow for collaboration, wherein the nursing practice, some organizations allow for collaboration, while some do not fully articulate the system for collaboration. This implies that most of the countries allow foreign professional and practicing nurses to serve in the capacity of the foreign land as a way of enhancing foreign professionalism. This working culture does not give restrictions to nationals but gives room for interaction between nations, which promotes collaborative practice.

The working culture in advanced countries allow for use of technological advances with a consequent research into new forms of approach with a view of increasing patient care. In contrary to this, the working culture within developing countries does not allow a full application of the technological advancement (Akhavain et al., 1999). This controversy is a limiting factor towards the achievement of the program of collaborative practice since it is a rift among participants, who would be the collaborators in the nursing practice. In real essence, the rift is generated from differences in cultural norms, beliefs, and historical articulations among communities. For instance, there has been a great debate on the use of contraceptives with some nations supporting the ideology while some coming out in opposition. This is a form of sired barrier towards attaining the nobility of collaborative practice.

Learning Objectives and Outcomes

Team working is the process of putting together human resources to achieve a common goal. In research, teamwork has better results if the team has a prior experience in working together, which implies that teamwork is not necessarily a platform of success. However, working together in teams is sufficient in the definition of collaborative practice, where people of different backgrounds come together to work on a common goal. Teamwork enhances effectiveness in collaborative practice since it puts together the technical skills of the members coupled with expertise therein (Akhavain et al., 1999).

This form of working together enhances a platform for sharing of skills and the technical expertise, thus increasing chances of apprenticeships as a form of learning from the experts. Practicing nurses have the mandate of working in teams created among the nurses together with the patients.

For instance, Client-centered teams emphasize on collaboration among the clients, nurses, and professionals working together at both an individual and organizational level of healthcare, while evidence based-informed decision-making processes help in collaboration through sound application of the practice guidelines, protocols, and resources relayed within the jurisdiction of the nursing profession. Consequently, epidemiology is a basic principle that facilitates the practice of collaboration in the nursing profession as it puts into account the assessment of demographics and the health status of the clients in a view of assessing the impact of the services offered (Glasby, 2009).

Conclusion

Global leaders should advocate for application of teamwork, which should start from legislation that allow for interprofessional practice to enhance career building in the nursing practice as a way of creating efficiency in collaborative practice. This can happen if all agencies which are attached to the medical department come together to work in unison as a form of defining teamwork. For the efficiency of these teams, the expatriate staff should be put together with the indigenous team as a form of intermingling with the expertise therein, thus allowing for the acquisition of foreign skills.

On the other hand, there should be teams from the community teaming up with that from the practitioner’s field to help the practitioners work with the community for an effective definition of collaborative practice. This can also be achieved by setting up teams from the trained nurse with the experienced staff as a way of fostering apprenticeship since the junior staff will learn from the practical skills of the experienced a lot.

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