AACN News—December 2004—Opinions

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Vol. 21, No. 12, DECEMBER 2004

President's Note: Life Your Contribution
Is Your Collaboration ‘True’?

By Kathy McCauley, RN, PhD, BC, FAAN
AACN President

Life is like the carpool lane. The only way to get to your destination quickly is to take some people with you.
—Peter Ward

Collaboration: Communication based on mutual trust and respect. Willing cooperation. That is how the dictionary defines it.

In a national AACN survey, nearly 90% of members and constituents reported that collaboration with physicians and administrators is essential to creating a healthy work environment. Mutual respect between nurses and physicians for each other’s knowledge and competence, coupled with a mutual concern that quality patient care will be provided, are key organizational elements of work environments that attract and retain nurses.1,2 In fact, nurse-physician collaboration has been found to be one of the three strongest predictors of psychological empowerment of nurses.3

Why then would we further qualify collaboration with an adjective like “true”? Is there such a thing as false collaboration?

Lip Service
Most health professionals genuinely intend to collaborate willingly, based on mutual trust and respect. Their good intentions prompt organizations to establish joint practice committees and a host of interdisciplinary task forces. Sometimes these groups even include consumers—patients, former patients, their families. Yet, more often than we might admit, collaboration receives lip service. This happens especially at the unit and organizational levels, where collaboration is essential in achieving the best outcomes for patients and their families. Outcomes that result from living our contributions.

Lip service to collaboration often happens when high census, short staffing and other inadequate resources demand our attention. We become distracted from the benefits that collaboration offers in our quest for new solutions to these very distractions.

Different Views
Why does true collaboration seem to elude us? Often, it is because of differing worldviews. Although health professionals interact from the beginning of our educations, we’re often strangers to each other. We work alongside each other, bringing our unique knowledge and skills to the service of patients and their families. But we do this in parallel play, unaware of how our colleagues in other professions view the world we share.

The same thing happens among nurses. Clinical nurses and nurse managers are often at odds. Each group sees the other as an obstacle in making a contribution. New nurses view experienced ones as impossible to please know-it-alls. Experienced nurses view new ones as well intentioned, but inconvenient when time is of the essence.

Patient Situations
Then one day, a patient situation causes us to intersect. Or even collide. Whether between professions or within a profession, we come face to face with the reality that we don’t practice true collaboration. It’s usually a high-stake situation. Maybe a situation like family visiting practices. Or, inviting family presence during complex procedures and CPR.

Recently, physician Donald Berwick and colleague Meera Kotagal called for sweeping change in family visiting practices across the nation’s hospitals.4 Writing from Boston’s highly influential Institute for Healthcare Improvement, they argued that families have the right to be with a critically ill loved one and that, in fact, patients benefit from this presence.

In a national audio conference that followed, Berwick and AACN member Vicki Spuhler, a nurse manager at LDS Hospital in Salt Lake City, Utah, hosted a lively discussion of the topic with nearly 150 participating hospitals. Spuhler talked about the true collaboration that led to her hospital’s successful visiting program. She described what it took for the interdisciplinary team to become comfortable and, above all, how the program has minimized the disruptions in care that unmet family needs will cause.

A few weeks later, the Wall Street Journal picked up the topic with a story titled “Hospitals let families witness procedures.”5 The subhead carried the real message: “Staying with patients in the ER or ICU can have benefits, but some doctors object.”

In truth, some nurses also object. These are uncomfortable times for health professionals who object to family presence. As I travel around the country, some nurses tell me that staffing is too tight to support having “two patients”—the actual patient and the family. Families will be traumatized by what they see, some say. We’ll need to censor our behavior so families don’t get the wrong impression, others explain, otherwise it may interfere with our clinical judgment.

To achieve effective family presence, we need a clearly defined process in which we are supported in tailoring practices to individual situations. That requires collaboration at many levels—individual, unit, organizational—and must include patients and families. Perhaps our inability to implement appropriate family visiting programs isn’t about time and other environmental pressures. After all, nurses have been studying and advocating this for more than a decade. And now physician colleagues have started to do the same. Maybe we’re facing a glaring example of our failure to achieve true collaboration.

Full Partners
True collaboration is how we become full partners. And, to be full partners we must be willing to know what others do. True collaboration means dialogue where everyone learns and comes together to a greater truth, all to the benefit of patients and their families. We need everyone’s best thinking—not just that of the loudest voices or those with the loftiest titles.

Giving equal power and respect to everyone’s voice, integrating individual differences and competing interests, true collaboration does not tolerate behaviors that intimidate and stifle divergent opinions. In return, true collaboration holds each person accountable for presenting an honest and thorough perspective, supported by evidence that helps to consider alternatives.

And, it means that we agree on what happens when someone refuses to collaborate. In short, it affirms that collaboration isn’t optional. Patients benefit from true collaboration and are harmed by its absence. Physician Bill Knaus discovered this more than 20 years ago in the first APACHE studies.

Your Experience?
That we need to talk about “true” collaboration confirms that it doesn’t happen in most healthcare situations. That we hear louder whispers about success stories confirms that many are on the journey. What about you? Have you experienced true collaboration? How did you get there? What were the results? Write to me at kathy.mccauley@aacn.org so your colleagues and I can celebrate your living contribution of collaboration.

1. American Hospital Association Commission on Workforce for Hospitals and Health Systems. In Our Hands: How Hospital Leaders Can Build a Thriving Workforce. Chicago, Ill: American Hospital Association Commission on Workforce for Hospitals and Health Systems; 2002.
2. American Organization of Nursing Executives. Healthy Work Environments: Striving for Excellence. Vol 2. Chicago, Ill: McManis & Monsalve Associates; 2003.
3. Larrabee JH, Janney MA, Ostrow CL, Withrow ML, Hobbs GR Jr, Burant C. Predicting registered nurse job satisfaction and intent to leave. J Nurs Admin. 2003;33:271-283.
4. Berwick DM, Kotagal M. Restricted visiting in ICUs: time for a change. JAMA. 2004;292:736-737.
5. Hospitals let families witness procedures. The Wall Street Journal. October 12, 2004;D1, D7.
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