13 Interprofessional Collaboration

Healthcare has faced a vast number of challenges in delivery of quality care over the past 50 years. The population is older, more diverse, medically complex with a higher prevalence of chronic disease requiring multiple specialty providers, a greater reliance on technology and innovation, and uncoordinated delivery systems. Healthcare has also shifted towards delivering care to individuals with vast healthcare disparities (Institute of Medicine [IOM], 2003a). Collaborative practice can improve the delivery of care through a concerted effort from all members of the healthcare team and leaders through the organization.

In response to these challenges, collaborative practice environments are indispensable to improving safety and patient care indicators. Collaborative practice has been found to reduce the rate of complications and errors, reduce length of stay, and lower mortality rates. Collaboration also leads to reduce conflict among staff and reduced turnover. Additionally, collaborative practice strengthens health systems, improves family health, improves infectious disease, assists with humanitarian efforts, and improved response to epidemics and noncommunicable disease (World Health Organization [WHO], 2010).

Collaboration has become an essential component to implementing health promotion and disease prevention/management (Humphreys et al., 2012; Odum & Whaley-Connell, 2012). Due to the high rates of medical errors over the past several decades, interprofessional collaboration has emerged as a pragmatic intervention step that can reduce errors and improve care (Interprofessional Education Collaborative [IPEC], 2016)

Nurses and others healthcare professionals need to work together in order to address challenges that impede progress on improving safety and quality care. The IOM (2015) states, “No single profession, working alone, can meet the complex needs of patients and communities. Nurses should continue to develop skills and competencies in leadership and innovation and collaborate with other professionals in health care delivery and health system redesign” (p. 3).

Common Concept Definitions

• Elements of Collaboration

“Participants from different cultures, high level of interaction, mutual authority, sharing of resources” (Green & Johnson, 2015, p. 5)

• Interprofessional collaborative practice (IPCP)

“When multiple health workers from different professional backgrounds work together with patients, families, and communities to deliver the highest quality of care” (Green & Johnson, 2015; WHO, 2010).

• Interdisciplinary collaboration (IDC)

A team of healthcare practitioners who make a joint, consensus decision about patient care facilitated by regular, face-to-face meetings (Ivey, Brown, Teske, & Silverman, 1988).

Note: The difference between IPCP and IDC is the former can be applied to multiple categories of “patients” (individual patient and/or family, groups, and communities) whereas the latter is applied exclusively to the patient and/or family.

• Interprofessional teamwork

“The levels of cooperation, coordination and collaboration characterizing the relationships between professions in delivering patient-centered care” (IPEC, 2016, p. 8).

• Interprofessional team-based care
  “Care delivered by intentionally created, usually relatively small work groups in health care who are recognized by others as well as by themselves as having a collective identity and shared responsibility for a patient or group of patients (e.g., rapid response team, palliative care team, primary care team, and operating room team)” (IPEC, 2016, p. 8).
• Interprofessional competencies in health care
  “Integrated enactment of knowledge, skills, values, and attitudes that define working together across the professions, with other health care workers, and with patients, along with families and communities, as appropriate to improve health outcomes in specific care contexts” (IPEC, 2016, p. 8).

The Institute of Medicine (IOM, 2011) released a landmark report called, The Future of Nursing: Leading Change, Advancing Health. The report addressed the critical role of nurses in the delivery of healthcare and made three core recommendations: transforming nursing education, practice, and leadership. The report states nurses must become leaders at every level of the healthcare system in order to participate in ongoing healthcare reform. Leadership is key to becoming a full partner on the healthcare team, and to advocate for policy changes that assist with improving delivery of healthcare.

Additionally, the report found nurses are the best source of information about the patient, family, and communities though are largely excluded from decision-making. Nurses are left with carrying out orders that may or may not be safe, quality patient-centered care. In order to be part of the decision-making process, the report suggests nurses lead through engaging all members of the healthcare team through interprofessional collaboration and mutual respect. The report offers two recommendations in the area of interprofessional collaboration:

Recommendation 2

Expand Opportunities for Nurses to Lead and Diffuse Collaborative Improvement Efforts

Recommendation 7

Prepare and Enable Nurses to Lead Change to Advance Health (IOM, 2011)

The IOM (2015) has followed up on these recommendations and has concluded nursing has made progress with providing quality, patient-centered, accessible, and affordable care, though continued efforts to meet the following recommendations are ongoing:

• Removing barriers to practice and care
• Transforming education
• Collaborating and leading
• Promoting diversity
• Improving data (IOM, 2015)

Benefits of Collaborative Practice

Today’s complex healthcare environment has made it difficult for patients to access care, especially those with chronic disease who need access to a variety of specialty services. Patients need assistance with following prescribed orders and follow up appointments with multiple providers. Interprofessional collaboration has improved access to care, safety, chronic disease outcomes, and use of specialty care (Lemieux-Charles & McGuire, 2006; WHO, 2010).

Interprofessional collaboration offers nurses the opportunity to lead and influence change at multiple levels of care (national, regional, local patient settings). Nurses can have a voice in political activism through professional organizations or through academic/practice partnerships (Moss, Seifert, & O’Sullivan, 2016). Collaboration offers nurses the opportunity to serve on boards of directors, government committees, or advisory boards. Through collaboration efforts, nurses can fulfill their role in a variety of ways, with the overarching goal of redesigning the healthcare delivery system.

Through interprofessional collaboration, healthcare organizations can improve safety and quality through committee membership. Nurses can participate in committees that are unit- or organization-wide. Committees are formed based on improving safety and quality by using outcome data, such as preventing hospital-acquired infections, falls, and increased patient satisfaction. Additionally, committees may focus on the health and well-being of staff, to reduce nurse turnover and burnout. Participating in committees benefits everyone, from the patient to the entire organization.

By joining committees, nurses have the opportunity to speak up and share their knowledge and expertise with the interprofessional team, management, and other stakeholders inside and outside of the organization. Interprofessional communication gives nurses a voice, allows them to become intimately involved in the decision-making process and creating solutions. Since nurses implement many of the solutions, nurses must share their insight to ensure the solution has a patient-centered approach. Interprofessional communication is the main way nurses can advocate for and uphold patient rights.

No committees at your workplace? Create one! Locate a problem area in your workplace or unit, research solutions, and present a plan to your manager. Chairing a committee is a good way to network with other professionals and it’s an important part of your professional development as a professional nurse.

Littlechild and Smith (2013) cite a wide range of healthcare benefits from interprofessional collaboration, including improved efficiency, higher levels of team responsiveness, creative skill sets, and the implementation of innovative holistic services. Several additional benefits of interprofessional collaboration as follows:

• Opportunity to learn new ways of thinking
• Network with professionals from different organizations
• Gain new knowledge, wisdom from others
• Access to additional resources previously unavailable
• Potential to develop new skill sets
• Increased productivity due to shared responsibility
• Access to funding, sharing of costs (research)
• Pooling of knowledge for solving large, complex problems (as cited in Green & Johnson, 2015)

Collaboration has enabled large-scale international organizations like the WHO to achieve more than previously thought possible because of the strength and support of individual members working collectively for a common goal (Green & Johnson, 2015). Collaborations with large groups of professionals and international organizations (such as the WHO) occur throughout all areas of healthcare education, research, and practice. All three domains are connected; research informs education, which informs clinical practice and education. The table below shares some exemplars of successful interprofessional collaboration in healthcare.

The following TEDx Talks video discusses the role of collaborative practice in healthcare:

video of collaborative practice in healthcare

(TEDx Talks, 2018)

Joy Doll, the speaker in the video above, discusses six lessons (below) she learned through developing a collaborative practice initiative for a healthcare organization. Joy found these lessons were vital to successful, productive teamwork:

1. Grit: willingness to take on challenges
2. Don’t listen to “NO”
3. “Ego-up”, engage in meaningful activities that lead towards the goal
4. Psychological safety: speak up with confidence, without consequences
5. Define your culture:
   • everyone teaches, everyone learns
   • assume positive intent of others
6. know yourself through self-assessment, reflection (i.e. strengths/weaknesses)

Joy reflects on the LEGO movie where leadership and collaboration are weaved into the storyline. To watch the LEGO movie, go to this website.

Cost of Reduced Collaboration

The lack of interprofessional collaboration prevents nurses from working to the full extent of their training and education. In order to improve practice, and assist with improving the delivery of healthcare, all nurses must be vested in improving and reducing the barriers of interprofessional collaboration (Moss et al., 2016).

Foundational Documents of Professional Practice

Interprofessional or interdisciplinary collaboration is an indispensable part of nursing practice. The American Nurses Association (as cited in ANA, 2021) defines collaboration as “working cooperatively with others, especially in joint intellectual efforts, in a way that includes collegial action and respectful dialogue” (p. 110).

Scope and Standards of Practice

As discussed in Week 1, the Scope and Standards of Practice, developed by the ANA (2021), serves as a template for professional nursing practice for all registered nurses. Standard 11, Collaboration, states, “The registered nurse collaborates with the healthcare consumer and other key stakeholders” (ANA, 2021, p. 95). The following is a snapshot of some of the competencies of the Collaboration standard:

• Values the expertise and contribution of other professionals and key stakeholders.
• Partners with the healthcare consumer and key stakeholders to advocate for and effect change, leading to positive outcomes and quality care.
• Uses effective group dynamics and strategies to enhance performance of the interprofessional team.
• Promotes engagement through consensus building and conflict management
• Partners with all stakeholders to create, implement, and evaluate plans (ANA, 2021, p. 96).

Nursing’s Scope of Practice is dynamic and is responsive to the changing needs of individuals and society as a whole. The nursing profession relies on all healthcare professionals to be actively involved in healthcare planning and decision-making, thus collaboration is at the core of all short- and long-term goals (ANA, 2015b). Healthcare professionals are expected to collaborate in the following ways:

• Sharing knowledge, techniques, and ideas about how to deliver and evaluate quality and outcomes in healthcare
• Sharing some functions/duties with others, and having a common focus on the overarching goal
• Recognizing the expertise of others within and outside the profession, referring patients to other providers as appropriate (ANA, 2015b)

The Code of Ethics

As discussed in Week 1, the Code of Ethics is an expression of the values, duties, and commitments of registered nurses. Provision 8 states, “The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities” (ANA, 2015a, p. 129). Provision 8 includes two interpretative statements:

8.2: Collaboration for Health Human Rights, and Health Diplomacy

• Nurses are committed to advancing health, welfare, and safety to all people, to individuals and globally. Some examples include world hunger, poverty or environmental pollution, and violation of human rights. Access and availability to quality healthcare services requires interdisciplinary planning and collaboration with partners, whether locally, state-wide, nationally, or globally (ANA, 2015a, p. 203).

8.3: Obligation to Advance Health and Human Rights and Reduce Disparities

• Through collaboration with community organizations, nurses can work individually or collectively, to assist with educating the public on current or future health threats. Nurses have a responsibility to work collaboratively with community agencies to assist the public with facilitating informed choice and identify situations that may contribute to illness, injury or disease. Lastly, the nurse needs to support initiatives that address barriers to healthcare, including the needs of the culturally diverse populations (ANA, 2015a, p. 204)

Provision 2 states, “The nurse’s primary commitment is to the patient, whether an individual, family, group, community or population” (ANA, 2015a, p. 25). Interpretive statement 2.3, titled Collaboration, explains shared goal making is a concerted effort of individuals and groups. The complexity of the healthcare system requires nurses to work closely with the interdisciplinary team for safe, quality delivery of care.

Provision of safe, quality care at the community, national, and international levels can be accomplished through creation of community partnerships, political activism and substantial collaboration with all stakeholders. It is the nurse’s ethical responsibility to consider collaboration in all aspects of nursing practice. Safe, quality care cannot be performed by one person, but together, with others, goals can be achieved. It is through communication and collaboration that nurses are able to provide the best possible care to their patients.

Nursing’s Social Policy Statement

As discussed in Week 1, nursing’s social policy statement describes the value of the nursing profession within society, defines the concept of nursing, reviews the standards of practice, and regulation of nursing practice. The nursing practice is inherently connected to society, thus requiring a social contract between society and the profession (ANA, 2015b).

Collaborative efforts with other healthcare professionals are rooted in establishing effective trusting relationships, leading to partnerships where individuals begin to value each other’s differences, similarities, experience, and knowledge.

The Essentials

Transforming practice to collaborative care environments required transformation of nursing education, as stated in the IOM (2011) report. The Essentials provide a framework for competencies within undergraduate nursing education (American Association of Colleges of Nursing [AACN], 2008).

Communication and collaboration among healthcare professionals are critical to delivering high quality and safe patient care (AACN, 2008, p.3). Collaboration is based on the complementary interaction of the team member’s roles. Understanding roles and perspectives are vital to collaboration.

Interprofessional Collaborative Practice Organizations

Interprofessional Education Collaborative

The IPEC (2016) was created in 2009 to develop core competencies for interprofessional collaborative practice. The original IPEC report was developed 2011, since revised in 2016, was developed through the initiative of six healthcare disciplines with the intent of defining core interprofessional competencies for their professions. The professions included dentistry, nursing, medicine, osteopathic medicine, pharmacy, and public health. After the release of the first IEC report, support from additional health professions and educational organizations ensued. The four core competencies for interprofessional collaborative practice are as follows:

Competency 1: Values/Ethics for Interprofessional Practice

• Work with individuals of other professions to maintain a climate of mutual respect and shared values.

Competency 2: Roles/Responsibilities

• Use the knowledge of one’s own role and those of other professions to appropriately assess and address the health care needs of patients and to promote and advance the health of populations.

Competency 3: Interprofessional Communication

• Communicate with patients, families, communities, and professionals in health and other fields in a responsive and responsible manner that supports a team approach to the promotion and maintenance of health and the prevention and treatment of disease.

Competency 4: Teams and Teamwork

• Apply relationship-building values and the principles of team dynamics to perform effectively in different team roles to plan, deliver, and evaluate patient/population- centered care and population health programs and policies that are safe, timely, efficient, effective, and equitable (IPEC, 2016, p. 10)

While standardized forms of communications improve communication, integrating the constructs of teamwork, collaboration, and the awareness of each team member’s roles is crucial to the success of interprofessional communication (IPEC, 2016).

Interprofessional Professionalism Collaborative

The Interprofessional Professionalism Collaborative (IPC, n.d.) was created to develop tools used by healthcare education organizations to assist with developing interprofessional professionalism behaviors within academic curriculum. In addition, researchers us the tools developed by the IPC to advance interprofessional professionalism, a required element of interprofessional collaborative practice. The definition of interprofessional professionalism is as follows:

Consistent demonstration of core values evidenced by professionals working together, aspiring to and wisely applying principles of, altruism and caring, excellence, ethics, respect, communication, accountability to achieve optimal health and wellness in individuals and communities (Frost et al., 2019; Stern, 2006, p. 15).

The IPC (n.d.) has identified six core interprofessional behaviors:

1. Communication
   • Impart or interchange of thoughts, opinions or information by speech, writing, or signs; “the means through which professional behavior is enacted.” (Stern 2006)
2. Respect
   • “Demonstrate regard for another person with esteem, deference and dignity . . . personal commitment to honor other peoples’ choices and rights regarding themselves . . . includes a sensitivity and responsiveness to a person’s culture, gender, age and disabilities . . . the essence of humanism . . .  signals the recognition of the worth of the individual human being and his or her belief and value system.” (Stern, 2006)
3. Altruism and Caring
   • Overt behavior that reflects concern, empathy, and consideration for the needs, values, welfare, and well-being of others and assumes the responsibility of placing the needs of the patients or client ahead of the professional interest (IPC, n.d., para. 4).
4. Excellence
   • Adherence to, exceeds, or adapts best practices to provide the highest quality care (IPC, n.d., para. 5).
5. Ethics
   • Consideration of a social, religious, or civil code of behavior in the moral fitness of a decision of course of action, especially those of a particular group, profession, or individual, as these apply to every day delivery of care (IPC, n.d., para.6).
6. Accountability
   • Accept the responsibility for the diverse roles, obligations, and actions, including self-regulations and other behaviors that positively influence patient and client outcomes, the profession, and the health needs of society (IPC, n.d., para. 7).

Nurses are engaged and motivated to provide the best possible care for their patients. Nurses use their knowledge and expertise to design patient-centered goals. In order to realize these goals, nurses must be leaders throughout the healthcare system, and engage others to participate and be vested in full collaboration with the patient’s best interest in mind. Sherman (2015) states the following behaviors helps nurses influence others to foster interprofessional collaboration:

• Establish your voice: effective communication and listening skills, address concerns, be perceived as trustworthy
• Expand networks: develop relationships with others to form a joint vision
• Shared accountability: leads to a sense of community, joint decision-making
• Empower others: encourage others to speak up and act

WHO: Interprofessional Education & Collaborative Practice

WHO (2010) has created strategies to improve interprofessional education and collaborative practice to improve health outcomes globally. To make this initiative achievable, WHO has outlined a series of action items policymakers can use to improve their local healthcare systems.

WHO (2010) explains that the overall well-being of a country is centered on maternal and child health. Each day, 1500 women die from complications during pregnancy or childbirth worldwide. Healthcare workers who work together to identify the key strengths of each team member and use those strengths to improve the care of complex health issues, can improve these alarmingly high death rates. Maternal and child health is just one of many complex health problems within society that can be improved through collaborative work environments.

Acute care hospitals conduct morning meetings or interprofessional rounds to discuss care practices, plans, discharge. Nurses are uniquely positioned at the center of the interprofessional team to monitor information exchange between nursing, medicine, dietary, social work, unlicensed staff, and others. Team collaboration will be most effective when trained team members are fully vested in the organization and are experienced in working as a cohesive team

Developing core competencies is an expectation of all nurses. Seeking out professional development opportunities is an obligation as stated in the Code of Ethics. Provision 5, interpretative statement 5.2 states, the nurse has the responsibility for professional growth and maintenance of competence (ANA, 2010a, p. 159).

Barriers and Promoters to Collaboration

Collaboration among healthcare professionals requires leadership and planning, common goals, and a “teamwork” atmosphere. The literature discussed below reviews an assortment of promoters (actions that enhance collaboration and teamwork) and barriers that impact the success of collaboration. The main take aways include a commitment to work together for a common goal, use of effective communication and collaboration skills, and the initiative to identify and resolve team conflicts.

Choi and Pak (2007) conducted a literature review to determine the promotors, barriers, and approaches to enhance interdisciplinary teamwork. The researchers discovered eight major concepts of teamwork and formulated them within the acronym “TEAMWORK.”

See Table 2 for the promoters, barriers, and approaches for each concept are aligned to the acronym, including the “14 C’s” for teamwork approaches.

Similar to some of the above points, WHO (2010) has identified the following mechanisms that impact collaborative practice, including:

• Management support: need to identify and support change champions
• Initiative to change the culture of an organization, and oneself
• Individual’s attitude towards collaboration

Hierarchical Team Structure

Lancaster, Kolakowsky‐Hayner, Kovacich, and Greer‐Williams (2015) found a lack of collaboration among physicians, nurses, and unlicensed personnel (UAP) due to hierarchical team structures. While some physicians acknowledged nurses’ knowledge and expertise, the study revealed hierarchical, subservient relationships. Nurses and UAPs did not have meaningful discussions about patient needs or care, and physicians viewed themselves as the main decision-maker.

The hierarchical structure of healthcare teams must be addressed in order to improve collaboration and communication among the team members. If unresolved, hierarchy will lead to tension, misunderstandings, and conflicts, burdening the healthcare system with consistent poor outcomes and fragmentation of care.

See more information about hierarchy in the previous chapter on Communication

Nursing leadership has a responsibility to create environments where collaboration can transpire on a daily basis, with full, open participation from all members of the interprofessional team. Awareness of the barriers to collaboration, such as unequal power among disciplines (hierarchy), language conflicts, or lack of a “good fit” among team members gives rise to educational opportunities for the organization and/or nursing units. Nurses at all levels of care in the organization are responsible for addressing their personal educational gaps, and encourage the team to seek out competency training.

Awareness of team members’ roles assists with having accurate expectations of each other. Since nurses spend the greatest amount of time with patients, they are uniquely positioned to share an abundant amount of important information about the patient, thus, an assertive, effective communication style is warranted during collaborative meetings. Eliminating the hierarchy barriers is key to ensuring nurses have the confidence to speak up without fear of being reprimanded by physicians. advocating for patient needs, ensuring safe, quality care is provided requires an environment where information is shared freely and everyone’s voice is heard.

Tools and Frameworks to Improve Interprofessional Collaboration

Morgan, Pullon, and McKinlay (2015) conducted a review of the literature examining the elements of interprofessional collaboration in primary care settings. The overarching element to achieving and sustaining effective interprofessional collaboration was the opportunity to share frequent, informal communication among team members. Continuous sharing of information led to an interprofessional collaborative practice, where knowledge is shared and created among the team members, leading to development of shared goals and joint decision-making. Two key facilitators to interprofessional collaboration are the availability of a joint meeting time to communicate and having adequate physical space.

See the previous chapter on Communication for information on TeamSTEPPS^®, an evidence-based tool designed to improve patient safety and quality though improved communication and collaboration.

In Week 4, Leadership in Nursing, discussion about the Healthy Work Environment Model (HWEM), created by the American Association of Critical Care Nurses (AACN, 2016), incorporates True Collaboration as one of the six core standards. The True Collaboration standard states nurses must be relentless in pursuing collaboration.

See Week 4 for more information about AACNs Healthy Work Environment Model

Successful collaboration is highly valued and a necessity in today’s healthcare environment. Experts suggest the daunting process of building a culture of collaboration within an organization is well worth the effort and an indispensable part of success (Adler, Heckscher, & Prusak, 2011).

Attribution

Transitions to Professional Nursing Practice. Authored by: Jamie Murphy. Provided by: SUNY Delhi. Located at: https://courses.lumenlearning.com/suny-delhi-professionalnursing. License: CC BY: Attribution