Scope of practice conflict in nursing

Chapter 13

Improving Teamwork: Collaboration, Coordination, and Conflict Resolution

Collaboration

The American Nurses Association (ANA) defines collaboration as “recognition of the expertise of others within and outside the profession, and referral to those other providers when appropriate. Collaboration involves some shared functions and a common focus on the same overall ­mission” (2010b, p. 40). This is a critical competency required to practice in any healthcare ­setting today or to participate in any aspect of healthcare delivery—critical for effective patient-centered, quality care. The increased emphasis on using interprofessional teams to meet the patient’s needs across the continuum of care requires collaboration. Team members and different healthcare providers must be able to work together; recognize strengths and limitations; respect individual responsibilities and expertise; and maintain open, effective communication.

Nurses who have long worked on teams should be familiar with teamwork. Despite this, there continues to be a separation between physicians and nurses, who often work in silos. Nurses and physicians need to work together to ensure that the patient receives the care that is required when it is required. Collaboration involves cooperative effort among all healthcare providers offering care for a patient. This will result in more effective decision making with healthcare professionals working together to accomplish identified outcomes. This is not easy to do. There are professional issues, territory issues, conflicting goals, inadequate communication, and multiple differences; however, despite all of this, effective and efficient care requires collaboration. The system is just too complex to function well without collaboration. The nurse is often the person who must lead the effort to ensure collaboration occurs.

Key Definitions Related to Collaboration

Collaboration is a cooperative effort that focuses on a win-win strategy. To collaborate effectively, each individual needs to recognize the perspective of others who are involved and eventually reach a consensus of a common goal(s). The ANA notes that collaboration involves recognition of expertise and some shared functions (2010a, 2010b). The ANA’s Nursing: Scope and Standards of Practice (2010b) and the Nursing Administration Scope and Standards of Practice (2009) also identify the need for collaboration, emphasizing that all nurses are expected to collaborate. The American Organization of Nurse Executives (AONE) also includes the need for collaboration in its descriptions of leadership competencies, as described in Appendix A.

Key concepts related to collaboration are partnership, interdependence, and collective ownership and responsibility. Considering these concepts helps in understanding the impact of collaboration. Collaboration is also a process. It is not stagnant but rather changes, which requires staff to make adjustments to collaborate with others as situations change. The American Association of Critical-Care Nurses’ nurse competencies in its Synergy Model™ states: “working with others (e.g., patients, families, healthcare providers) in a way that promotes/encourages each person’s contributions toward achieving optimal/realistic patient/family goals; involves intra- and interdisciplinary work with colleagues and the community” (American Association of ­Critical-Care Nurses, 2014). Most people can remember experiences when working with others where the work just seemed to flow with less stress and good communication. This probably means that the people working together were collaborating.

Collaboration should be a positive experience, but this is not always the case. If it is not positive, it will not be effective. If a group of nurses were surveyed, it would be surprising to get a consensus that collaboration was always a positive experience. Often attempts at collaboration mean struggle, conflict, and sometimes ineffective results. Some research has been conducted to assess the effectiveness of collaboration. The Institute of Medicine (IOM) recognizes the importance of collaboration in its rules to guide healthcare provider behavior in the 21st-century healthcare system (2001). The 10th rule, cooperation among clinicians, emphasizes, “cooperation in patient care is more important than professional prerogatives and roles” (p.93). To meet this rule, staff need to collaborate and use effective teamwork, which is weak in the healthcare delivery system.

The Future of Nursing: Leading Change, Advancing Health (Institute of Medicine, 2011) includes collaboration in its content. For example, by noting that nursing leadership competencies need to be applied in “a collaborative environment” (p.8) and “future, primary care and prevention are central drivers of the healthcare system where interprofessional collaboration and coordination are the norm” (p.2). In its recommendations for priorities in research that focus on teamwork, the report lists “identification of the main barriers to collaboration between nurses and other healthcare staff in a range of settings” (p.275).

Barriers to Effective Collaboration

As noted by the IOM, working in isolation with concern for only your own profession is not effective; however, nursing also has much work to do to improve the image of nursing and nursing leadership. Salmon (2007) comments that “improvements in care quality and safety will simply not happen with nurses working by themselves. To take it a step beyond what may seem obvious, it can’t happen just by adding physicians to the equation. It’s going to take the partnered engagement of other clinicians, health administrators, and, ultimately, the public” (p.117). Given these issues, how does the nursing profession arrive at the right balance, one that focuses on nursing and its professional role and needs, while simultaneously developing nurses who can work collaboratively with others to meet positive patient outcomes? Collaboration requires an interactive process. If staff are not willing to interact or have any other barrier to interaction, collaboration cannot take place. Lack of understanding about the roles and responsibilities of others and lack of respect for what others have to contribute interferes with effective collaboration. How much do nurses know about what physicians or social workers or physical therapists or others do and vice versa? If there is distrust, collaboration is hindered because distrust affects willingness to share information, which is an integral component in the collaborative relationship. Collaboration has an impact on whether or not a team is effective or ineffective as team members need to work with each other to develop effective teams and also need to work with others external to the team. Conflict may arise as teams and individual staff work together. Conflict and conflict resolution are discussed in more detail later in this chapter. Although each nurse must develop individual expertise, this expertise must come together with others’ expertise. Few nurses really can work effectively in isolation. Nursing is a profession that requires contact with others—patients, other nursing staff, other healthcare professionals, families, community members, and so on.

Competencies and Strategies to Achieve Effective Collaboration

The increased emphasis on interprofessional teams to meet the patient’s needs across the continuum of care requires effective use of collaboration. The very nature of a team implies that there is more than one idea or approach and not all can usually be accomplished. Decisions need to be made, and this is where collaboration comes into play. It is important to remember that collaboration is also a critical factor in the nurse-patient relationship. Nurses need to actively pursue patient collaboration to ensure that patients are involved in their own care—patient-centered care. The nursing profession has long emphasized patient participation in planning care and in patient education. Collaboration is also important in the development of effective management. To be effective in collaboration, staff require a number of skills:

Communication skills are critical. Verbal skills are the focus; however, in some instances written communication is also important when information and process are described in written format.

Staff members also need to be aware of their own feelings, as was discussed in some of the leadership theories such as emotional intelligence.

Staff need to be able to make decisions to solve problems effectively.

As is discussed in this chapter, coordination is also important when collaborating with others.

Conflicts will arise, which may interfere with collaboration. Staff need to develop negotiation skills to be used in resolving difficult conflicts.

Assessment skills are needed to collect and analyze information as collaborative relationships develop. Box 13-1 highlights these skills.

Collaborative care is central to the success of efficient, outcome-driven care. With the complex healthcare system, specialization of many healthcare professionals, variety of healthcare settings, complex reimbursement systems, technology, and new drugs, collaboration is the only way that patients will receive quality, cost-effective care. Today the healthcare system is an interdependent system with multiple settings and a variety of healthcare professionals, who are dependent on one another. Delivery of care in this complex system requires sharing of information, analysis, critical thinking, clinical judgment, reasoning, clear communication, and ability to use team problem solving. These activities are integral to successful care as the nurse works with many different healthcare providers, within many different healthcare settings, and with the patient and family to ensure quality, cost-effective care for the patient.

Collaborative planning recognizes that collaboration has a positive effect on achieving patient outcomes (Institute of Medicine, 2001). Collaborative planning requires that all parties agree on the mission and goals of the partnership so they have common expectations. All members

Box 13-1 Collaboration: Skills Needed

Effective communication

Awareness of personal feelings

Problem solving

Negotiation

Assessment

Recognition of expertise: Self and others

of the collaborative effort need to commit to open and honest communication, which is essential to sharing. This can be difficult in some HCOs, components of an organization such as specific units or departments, and for some individuals. Those who fear competition and are concerned about power will struggle with the need to share.

Regular evaluation needs to be built into collaborative planning. This evaluation should not only focus on the content of the planning but also on the process—how the collaborative relationship is working. This is something that is often neglected. Power, which is discussed later in this chapter, is related to collaboration. Usually some of the partners in a relationship have more power than others. When partners work through the collaborative planning process, some issues, such as weak communication, level of commitment, expertise, and an understanding that working together is better than working against one another, may interfere with the process. Recognizing these potential issues should be a priority to prevent barriers to success. What can be done to prevent them? Clear communication about purpose, particularly identifying issues from the past that may affect the collaborative planning, can help to clear up misconceptions. Team members need to accept the importance of effort and commit to it. All efforts should be made to keep team members committed. Evaluation data about the collaborative effort can help to improve team functioning.

Application of Collaboration

What is gained from collaboration? The complex healthcare delivery system requires many competencies, and no one healthcare profession has all of the necessary competencies to provide all the care that is required. Effective interprofessional teams and collaboration are critical. The IOM report on nursing (2004) identifies practices that have an impact on the delivery system, and these practices require collaboration to be effective. The practices are to create and maintain trust throughout the organization, deploy staff in adequate numbers, create a culture of openness so errors are reported, involve staff in decision making pertaining to work design and work flow, and actively manage the change process.

How do healthcare professionals develop the skills necessary for effective collaboration? There is a great need to incorporate more interprofessional educational experiences in all healthcare professional education, including nursing (Interprofessional Education Collaborative, 2011; World Health Organization, 2010). Students from the various healthcare professions need to have some experiences learning together in the same classroom and participating in clinical experiences together. Learning separately makes it very difficult to expect that at the time of graduation new healthcare professionals will easily collaborate when they have had limited collaborative experience with other healthcare professional students or healthcare professionals. They do not understand or respect the knowledge and learning experiences of other students or their roles and typical communication methods and processes. They may not even value or respect what other healthcare professionals offer to the team and to the patient. This causes serious problems as new healthcare professionals begin to work and are then confronted with working with one another. In addition, nurses need to have a positive understanding of their own roles and responsibilities—what they have to offer is valuable—so they can approach collaboration while understanding that they have important knowledge and competencies to add to the collaboration. This, however, must be accomplished not from the perspective of “I am better than you” but rather “How can we bring our respective skills and knowledge together to provide comprehensive, consistent care?” (Chapter 20 discusses staff education in more detail.)

Interprofessional relationships and activities can result in positive, collaborative outcomes; however, it is not easy to establish these relationships and maintain them over time. It takes time to develop an effective interprofessional environment. Other recommendations are to set realistic goals with commitment from all involved professionals, negotiate the means to meet the goals, avoid battles that serve only as barriers such as turf battles, and measure success based on established goals.

Coordination

The IOM identifies care coordination as one of the critical priority areas of care that need be monitored and improved. The purpose of care coordination is “to establish and support a continuous healing relationship, enabled by an integrated clinical environment and characterized by a proactive delivery of evidence-based care and follow-up” (Institute of Medicine, 2003b, p. 49). Patient-centered care is discussed in Chapter 9; however, patient-centered care is an important theme throughout this text. There needs to be greater attention on how care is coordinated across people, functions, activities, and sites to provide effective and efficient care that leads to the patient’s specific desired outcomes. Coordination requires that the nurse understands patient needs and the resources that are available to meet these needs. An awareness of the association of costs and services is part of coordinating patient care. The healthcare delivery system has become more complex, which has made communication and coordination more complex, all of which leads to increased risk of errors. There is greater need for interprofessional teams. Team members may not always view the patient, problems, or priorities in the same way, yet it is critical that the team find a way to work collaboratively to provide coordinated patient care. Team members need to have a better understanding of individual responsibilities and stress to appreciate each other and develop more realistic working relationships. As noted by the IOM healthcare core competency, all healthcare professionals need to know how to work in interprofessional teams (Institute of Medicine, 2003a). Recognizing this will make coordination less frustrating.

Key Definitions Related to Coordination

Coordination is the process of working to see that “the pieces and activities fit together and flow as they should” (Finkelman & Kenner, 2016, p. 328). Effective coordination requires working across services that are complementary—across clinicians or settings—to ensure quality care across patient conditions, services, and settings over time (Institute of Medicine, 2001). Examples might be physicians, nurses, social workers, pharmacists, informatics specialists, and administrators working together to improve documentation through an electronic medical record or staff from a hospital and an ambulatory care center working together to coordinate better care for patients. Coordination is related to collaboration, and in fact, it is very difficult to do one without the other. When considering patient care, however, there is a critical difference between the two. Collaboration with a patient requires a direct interaction with the patient. Coordination of care usually takes place before or after patient care is provided, or it is interwoven in the care process. In the latter situation, a nurse may ensure that all the plans for the patient’s discharge are complete or that the various treatment and exam procedures are scheduled appropriately for the patient’s needs. Coordination does not mean that the patient is not involved because patient input is critical to achieve patient-centered care, but the nurse may do the coordination such as calling for supplies or making sure a treatment is scheduled when not in the presence of the patient or while providing direct care. Both coordination and collaboration are also found daily in staff-to-staff interactions. Collaboration focuses on solving a problem with two or more people working toward this goal. Coordination is done to ensure that something happens such as the provision of services. The ANA Nursing Administration Scope and Standards of Practice (2009) includes a standard on coordination recognizing the need for nurses in administration/management to be competent in coordination, which is needed for planning and implementation of plans, implementation of the management functions, teamwork with other nurses and interprofessional teams, and is part of effective communication with staff and patients/families/significant others. The ANA supports the need for care coordination as an important component of improving the quality of care and providing for efficient and effective use of resources. Care coordination needs to be a critical competency that all registered nurses demonstrate (American Nurses Association, 2012).

Barriers to Effective Coordination

As HCOs and services become more complex and use more interprofessional teams, team members may not always have the same view of the patient, problems, or priorities. It is, however, critical that the team find a way to work collaboratively to provide coordinated patient care and prevent errors, disorganized care, and care that does not reach effective outcomes. Team members need to have a better understanding of individual responsibilities and their own stress to appreciate each other and develop more realistic working relationships. Coordination is also more effective when involved staff have a better understanding of their respective roles and work stresses. Recognizing this will make coordination less frustrating. If resources are not available

Applying Evidence-Based Practice Evidence for Effective Leadership and Practice

Citation

American Academy of Nursing. (2012, March 5). The imperative for patient, family, and population centered interprofessional approaches to care coordination and transitional care. Policy Brief 3.5.1.2. Retrieved from http://www.aannet.org/assets/docs/PolicyResources/aan_care%20coordination_3.7.12_email.pdf

Overview

The American Academy of Nursing (AAN) praises the Centers for Medicare & Medicaid Services (CMS) for its support of evidence-based care coordination and transitional care, which has been applied to Medicare and Medicaid services. The AAN recommends that the CMS consider the framework it will use to implement care coordination and the evidence to support that framework.

Application

This paper from AAN suggests various models and measurement methods to assist CMS in the implementation of greater use of care coordination, which requires an interprofessional team approach.

Questions:

What are the guiding principles recommended by the AAN?

Why is this change important?

What models are described? How is measurement included?

Analyze the recommendations made by the AAN.

when and in the manner required, this will act as a barrier to coordination. Staff who are not willing to listen and include others will find that coordination may not be as successful as planned. Other barriers are a lack of interprofessional understanding, lack of resources, and inadequate communication. Ineffective problem solving is also a critical barrier. Coordination needs to include the patient and, when appropriate and agreeable with the patient, the family. If patient engagement is not present, it is a major obstacle to care.

Competencies and Strategies to Achieve Effective Coordination

For staff to provide effective coordination, they need to make decisions to solve problems, plan, use the abilities of other staff, identify resources required, communicate, and be willing to collaborate. Delegation often is required, so delegation skills are important. (See Chapter 15 for more discussion on delegation.) The nurse also needs to develop evaluation skills to determine if outcomes are met as well as when to change course or make adjustments. The skills required for coordination are the same ones required for collaboration, with the primary goal of working together to reach agreed-upon goals. Box 13-2 highlights the skills needed for effective coordination.

Application of Coordination

Coordination is integral to daily operations, short- and long-range planning, and the daily care process. All of these activities require coordination of clinical and administrative resources. The following strategies are helpful in improving coordination (Finkelman & Kenner, 2016):

All staff need to understand the importance of coordination.

All staff should have a clear understanding of purpose and goals.

All staff should have knowledge of policies and procedures with an understanding of what has to be done, by whom, and how it will help to facilitate coordination.

Improved organizational performance will depend on coordination at all levels in the organization.

Communication needs to be clear and timely. (See Chapter 14.)

Orientation and staff development programs should emphasize the importance of coordination and how to use it.

Box 13-2 Coordination: Skills Needed

Problem solve

Plan

Use abilities of others

Identify needed resources

Communicate

Collaborate

Delegate

Evaluate

Coordination requires effective communication and collaboration.

Staff/team members need to appreciate the expertise of other team members.

Delegation should be used as needed. (See Chapter 15.)

Health care uses many tools that focus on coordination of care to ensure patient-centered care. Some of these are case management, clinical pathways, practice guidelines, and disease management. To be successful and meet expected outcomes, these tools or methods also require collaboration with the patient, patient’s family and significant other, and other healthcare staff, and they are very useful when coordination is required. With insurers emphasizing more effective and efficient care, coordination plays a major role in reaching this goal. Coordination requires that the nurse understand patient needs and the resources that are available to meet these needs. An awareness of the association of costs and services is part of coordinating patient care. In addition, coordination is a very important part of management within the healthcare delivery system. This system has become more complex, which has made communication and coordination more complex. Coordination is required to get resources, schedule staff, plan work activities, implement quality improvement, and perform all types of management functions. With the growth of informatics in documentation and decision-making tools, additional methods are now available and new ones will be developed. (See Chapter 19.) Figure 13-1 describes one view of competencies needed to get results

Negotiation and Conflict Resolution

There may be conflict between professions, but there is also conflict within the nursing profession and with coworkers. In these situations, staff members may attack one another by asserting their position or by criticizing ideas. In some cases, they attack one another personally. Collaboration is used frequently to reach an agreement during a conflict. This is often true with nurse-physician collaboration, though ideally collaboration should be part of all of their interactions. Nurse-physician relationships are complex. There is overlapping focus in that both are concerned about the patient, though each may come from different points of view, which is not always understood or appreciated. There is also some confusion about roles, which can lead to problems. In some cases there is a certain amount of competition, which really is a sad statement; the goal should be focused on what is best for the patient and not what is best for individual staff or individual professions.

Conflict can never be eliminated in organizations; however, conflict can be managed. Typically conflict arises when people feel strongly about something. Conflicts may take place between individual staff, within a unit, or within a department. They may be interunit and interdepartmental, affect the entire HCO, or even occur between multiple organizations, between or within teams or units, or between an HCO and the community. When people disagree, this may lead to conflict—having views that are different and do not seem to be easy to resolve (MindTools®, 2014a).

Key Definitions Related to Conflict

There are three types of conflict: individual, interpersonal, and intergroup/organizational (MindTools®, 2014a).

Individual conflict. The most common type of individual conflict in the workplace is role conflict, which occurs when there is incompatibility between one or more role expectations. When staff do not understand the roles of other staff, this can be very stressful for the individual and affects work. Staff may be critical of each other for not doing some work activity when in reality it is not part of the role and responsibilities of that staff member, or staff members may feel that another staff member is doing some activity that really is not his or her responsibility.

Interpersonal conflict. This conflict occurs between people. Sometimes this is due to differences and/or personalities; competition; or concern about territory, control, or loss.

Intergroup/organizational conflict. Conflict also occurs between teams (e.g., units, services, teams, healthcare professional groups, agencies, community and a healthcare provider organization, and so on). Sometimes this is due to competition, lack of understanding of purpose for another team, and lack of leadership within a team or across teams within an HCO.

Gets Results

A leader’s ultimate purpose is to accomplish organizational results. A leader gets results by providing guidance and managing resources, as well as performing the other leader competencies. This competency is focused on consistent and ethical task accomplishment through supervising, managing, monitoring, and controlling of the work.

Prioritizes, organizes, and coordinates taskings for teams or other organizational structures/groups

Uses planning to ensure each course of action achieves the desired outcome.

Organizes groups and teams to accomplish work.

Plans to ensure that all tasks can be executed in the time available and that tasks depending on other tasks are executed in the correct sequence.

Limits overspecification and micromanagement.

Identifies and accounts for individual and group capabilities and commitment to task

Considers duty positions, capabilities, and developmental needs when assigning tasks.

Conducts initial assessments when beginning a new task or assuming a new position.

Designates, clarifies, and deconflicts roles

Establishes and employs procedures for monitoring, coordinating, and regulating subordinates’ actions and activities.

Mediates peer conflicts and disagreements.

Identifies, contends for, allocates, and manages resources

Allocates adequate time for task completion.

Keeps track of people and equipment.

Allocates time to prepare and conduct rehearsals.

Continually seeks improvement in operating efficiency, resource conservation, and fiscal responsibility.

Attracts, recognizes, and retains talent.

Removes work barriers

Protects organization from unnecessary taskings and distractions.

Recognizes and resolves scheduling conflicts.