Collaborative practice within the intensive care unit: a deconstruction

Collaborative practice within the i n t e n s i v e c a r e unit: a

deconstruction

Julie S. Taylor The concept of collaborative practice has attracted much attention in the last few years - - how well do doctors and nurses work together as a team in providing the best possible care for their patients? Consequently there are numerous articles on the subject, most of which seem to suggest that collaborative practice is essential, particularly within the intensive care unit (ICU). It has been linked to both job satisfaction and to patient outcomes (mortality or readmission to the ICU). Indeed, it seems to have evolved as a benchmark for good ICU practice. This paper focuses on some of the most influential writings on this phenomenon, the first stage of a postgraduate study on collaborative practice in intensive care. A deconstructive reading of such literature raises some interesting questions. T h e r e are inadequacies in the existing claims, which perhaps suggest that a re-examination of both the feasibility and desirability of collaborative practice is needed.

(Taylor 1995) was designed to reconstruct this phenomenon, using Denzin's (1989) methodology of interpretive interactionism. Integral in this is a &constructive reading and critical. analysis of h o w the phenomenon has been presented, studied and analysed in the literature, leading to a presentation of any biases and preconceptions that may be found there. This paper is an account of that analytical reading (or &construction), which provided the comerstone of the subsequent enquiry.

DEFINING COLLABORATIVE PRACTICE The concept of collaborative practice between doctors and nurses is widely written about, although it is difficult to find an agreed statement of meaning. Despite the lack of clarity about the term, or any empirical basis for it, collaborative practice is promoted as a way to improve patient outcomes (Dunbar & BryanBrown 1988). Broadly, it could mean that it is a process of individuals or institutions working together to achieve a c o m m o n goal (Hiderly 1991, Jones 1994), or to plan and implement care (Lewis 1985). Others have attempted to define collaborative practice more precisely: Collaboration is the most positive way to resolve c o n f l i c t . . , requiring the finding of solutions where both parties' concerns are openly shared and recognised in a way consistent with identified, broad, comprehensive c o m m o n goals (Wonsetter 1987, p.30). Collaboration implies sharing of information and also implies that each participant in the health care system respects the other's skill and expertise. Collaboration also requires that nurses and physicians reconsider their definition o f clinical decisionmaking to recognise the contributions of others to patient care (Roberts 1987, p.81). Collaboration...

INTRODUCTION

julie s. Taylor MSc, RGN, Pathway leader (Critical care), North Yorkshire College of Health Studies, York District Hospital, Wigginton Road, York YO2 INN, UK

(Requestsfor offprints to JST) Manuscript accepted 20 February 1996

This paper developed from a longstanding interest in doctor-nurse relationships. Intensive care units (ICUs) provide a unique environment in which to examine these, as doctors and nurses work more closely together in ICUs than they do in some other areas. The literature surrounding collaborative practice is both myriad and persuasive, and indeed, claims that collaborative practice improves patient outcomes in ICUs must be taken seriously. Research undertaken for a postgraduate study

Intensiveand Critical Care Nursing(1996) 12,64-70 © 1996PearsonProfessJonalLtd

is a cooperative venture based on shared power and authority. It is non-hierarchical in nature, and it assumes power based on a knowledge or expertise rather than power based on role or function (Kraus 1980, p.12). Collaboration is joint-communicating and decision-making with the expressed goal of satisfying the patient's wellness and illness needs whilst respecting the unique qualities and abilities of each professional (Coluccio & Maguire 1983, p.59). And so the literature goes on, with the concept o f collaborative practice a little woolly,

Collaborative practice within the intensive care unit: a deconstruction

extremely difficult to measure and possibly unrealistic. I concur with King et al (1993), that collaborative practice is more an attitude than anything else. Despite that, it has been a widely debated concept for the last decade or so in the American literature. It has not just been debated, but apparently practised as well. 'Despite its elusiveness, its essence continues to be sought after as a means of improving working relationships and patient outcomes' (Henneman et al 1995, p.103). In 1982, following some of their Demonstration Projects, the American Association of Critical Care Nurses (AACN) claimed that collaboration in care decisions was a crucial variable in improving patient outcomes. However, their model provided no theoretical framework, nor did it suggest guidelines for implementation of the model (King et al 1993). The National Committee for Joint Practice (NCJP) identified the following elements as essential for collaborative practice environments: • primary nursing • integrated patient records • clinical decision-making by nurses to be encouraged • a joint practice committee • joint patient care reviews (NCJP 1981). At a critical care conference sponsored by the National Institute of Health (1983), the value of collaborative practice was recognised. Since then, copious articles have appeared in the nursing literature, all describing (and praising) A A C N Demonstration Projects on collaborative practice. Some writers have emerged more influentially than others and it is their work which is the focus of attention here first.

COLLABORATIVE PRACTICE SCALES W h e n deconstructing the literature, it became clear that many writers had based their definition of collaboration on a model conceptualised by Thomas (1976) and Kilmann & Thomas (1977). Weiss & Davis (1985)broadened this model, rewriting it to cover interpersonal relationships generally, as a two-dimensional model. This is apparently fairly fundamental work in defining collaboration, as at least half of

1"+

[] Competition

Desire to satisfy own concern

$-

[~ Collaboration [] Sharing

[] Avoidance

[] Accommodation -

~-- Desire tosatisfy ~> + other's concern

Fig. I Conflict solving model. Reproduced with the kind permission of Rand McNally (Thomas 1976, p. 900).

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the literature makes reference to the Weiss & Davis model. It could thus be argued that this is possibly the most influential work on collaboration. As such, it is worth further examination. The original Thomas model (1976) examined conflict-solving behaviours, concluding that collaboration combines a high level of cooperativeness (concern for another's interests) with a high level of assertiveness (concern for own interests). This is shown more clearly in Figure 1. Weiss & Davis used this model to develop two Collaborative Practice Scales (CPS), one for nurses, one for doctors. Collaborative practice was defined 'as interactions between nurse and physician that enable the skills and knowledge of both professionals to synergistically influence the patient care being provided' (p.299). They adapted the model so that it could be used for interpersonal problem-solving behaviour (Fig. 2). In both models, collaboration is regarded as a high level of concern for self (assertiveness), combined with a high level o f concern for others (cooperativeness). Interestingly, both Thomas and Weiss & Davis use the term 'assertiveness' in a context that implies selfinterest, in a manner that for many may be confused with aggression (Holland & Ward 1990). From this, Weiss & Davis developed their collaborative practice scales, which were Likerttype statements to measure features of collaboration within the doctor-nurse relationship. For example 'I tell MDs when, in my judgement, their orders seem inappropriate' or 'I consider nurses' opinions when developing a treatment plan' (Weiss & Davis 1985, p.300). Weiss had previously developed the items for inclusion on the scales by using structured dialogues with nurses, physicians and consumers (Weiss 1983). In Weiss & Davis's study (1985) higher scores imply greater use of collaborative practice by doctor or nurse. R a n d o m selection of 200 doctors and 200 nurses to receive the CPS yielded a poor response (nurses 47.5%; doctors 21.5%), so another 200 doctors were approached. A similar response from the second batch gave the researchers a total physician sample of 94. Statistical analyses using Eigenvalues and alpha coefficients are endlessly paraded, with the conclusion that the CPS are valid and reliable. Overall, the authors' conclusions are vague in this difficult paper, but they do discuss the limitations in some depth. This paper is particularly interesting when considering the research literature on collaborative practice. It is cited in numerous other studies on the phenomenon and is hailed as a rewriting of Thomas's 1976 model into a twodimensional model; b u t in this analysis of the literature it was difficult to discern any appreciable differences between Thomas's original concept (Fig. 1) and the 'improved' Weiss &

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Intensive and Critical Care Nursing

Assertion

[] Competition

[] Collaboration

Assertiveness

[] Sharing

$

Unassertion

[] Avoidance

[] Accommodation

Uncooperation

Cooperation Cooperativeness -~ Fig. 2 Collaboration model, Reproducedwith the kind permissionof NursingResearch (Weiss & Davis 1985, p. 299). ~-

Davis version (Fig. 2). Weiss & Davis applied this to nurses and doctors (CPS), although they made full acknowledgement to "Thomas's work. However, more recent studies have claimed this to be new and influential work (for example Johnson 1992, Jones 1994a,b). From the Weiss & Davis model, collaboration appears to imply inclusion of only doctor/nurse concerns. Assertiveness and cooperation levels define the relationship, from which everything else can then be explained (communication, autonomy, role definition, competence and other such factors). Somewhere the patient seems to have been lost, thus this two-dimensional model does not satisfactorily embrace all the views proffered in the literature. Another fundamental problem pertains to the well-documented limitations of this sort of questionnaire, one that asks people to rate their behaviour. W h e n respondents are asked questions on the CPS, how valid are the responses in real terms? It is possible that perceived rather than actual actions were often described. The initial low response rate that sent the researchers trawling for more subjects is also slightly questionable. This is an extremely tortuous paper to read and most writers on the subject of collaborative practice have probably read abridged interpretations of it that do not quite reflect its original substance. For example, Jones (1994b) describes how Weiss & Davis measured assertiveness for nurses and cooperativeness for doctors, rather than both domains for each practitioner. The many articles charting the 'success' of Collaborative Practice Demonstration Units refer to the work by Weiss & Davis without actually referencing it (for example Mitchell et al 1989, Hamilton 1991, Birenbanm 1994). In this way, the CPS have become an integral feature of many other similar studies and appear to be regarded as almost the definitive word on the subject. It appears that ira behaviour appears on the CPS, it must be collaborative practice.

DECISION SCALES

ABOUT

TRANSFER

One of the most prolific writers on collaborative practice must be Judith Baggs, sometimes alone,

sometimes with others; thus her work must be considered when dealing with this phenomenon. Again American, Baggs has published extensively, although after the first few readings it becomes clear that most of her articles are citing the same study in a slightly different format (a not uncommon practice). The apparent qualit,/and reputation of her work, then, is possibly unjustifiably enhanced by the quanti W of her publications. The impetus for her studies came from the work by Knaus et al (1986), which concluded that the relationship between doctors and nurses in ICUs was a significant element in lower patient mortality rates. From an extensive literature review, Baggs & Schmitt (1988) criticised the prevalent use of the term collaborative practice, which was being used without any agreed definition. Examining the literature on teamwork and communication, they concluded that collaborative practice had four other critical attributes besides cooperation and assertiveness. These were: 1. 2. 3. 4.

shared responsibility for planning shared decision-making open communications coordination.

From this they were able to define collaborative practice as: Nurses and physicians cooperatively working together, sharing responsibility for problem-solving and decision-making, to formulate and carry out plans for patient care (Baggs & Schmitt 1988, p.145). Baggs & Schmitt argued that the NCJP provided little theoretical justification for their choice of es,entlal factors for collaborative practice, but that anecdotal evidence from both doctors and nurses working in Demonstration Project Units suggested that patient care had improved. Baggs & Schmitt's paper provides a critical review of the major work on this concept. In a series of relational statements taken from the literature, they underpin the reasons why the subject is so important. Summarised, they state that effective collaboration can lead to improved patient mortality rates, fewer patient readmissions to ICU, decreased costs, better efficiency, less nursing stress, improved quality of care, increased patient satisfaction, and greater nursing job satisfaction. It is immediately apparent that whilst patients and nurses gain from collaborative practice according to this summary, doctors are not mentioned. It seems feasible that Baggs & Schmitt have either assumed that the medical staff will focus upon better patient outcomes as reason enough to support collaboration, or that they have marginalised the medical staff. Based upon the

Collaborative practice within the intensive care unit: a deconstruction

conclusions in this review, however, Baggs & Schmitt emphasised that there was a need for an instrument to measure collaborative practice - which Baggs then went on to develop. Following the arguments cited above, Baggs et al (1992) conducted a research study that generated data supporting the association o f collaboration and I C U patient outcomes. They chose one aspect o f specific I C U decision-making, that of transfer of a patient from ICU. It is well-documented that transferring a patient, either within a hospital or to another setting (perhaps for specialist treatment or to be nearer relafives) can be linked to patient outcomes o f either death or readmission to I C U (Franklin &Jackson 1983, 1Kubins & Moscowitz 1988). Baggs et al (1992) distributed a questionnaire to 56 nurses and 31 physicians working on one Medical ICU. They had developed a new Likert-type instrument o f global questions, known as a Decision about Transfer Scale (DATS), which investigated satisfaction as well as outcome. Both nurses and physicians were given the CPS (Weiss & Davis 1985), and nurses were given the Index o f W o r k Satisfaction (IWS). Both instruments had established validity and reliability (Weiss & Davis 1985, Stamps & Piedmonte 1986). It is not clear why medical staff were not given the IWS. Although the IWS concerns nursing j o b satisfaction, Baggs et al do not specify how they then measured physician j o b satisfaction. The questionnaires were distributed during 286 consecutive patient decisions regarding transfer o f patients to a ward within the same hospital, consequently before outcomes were known. Patients were observed for 30 days after transfer, or until hospital discharge or death, whichever occurred first. The nurse and physician responsible for each patient were asked to complete the DATS. As there were more patient transfers than there were individuals in the sample, it is reasonable to assume that the sample group must have completed more than one D A T S each, although this is not made particularly explicit. Nurses and doctors scored quite similarly on satisfaction, but very differently on collaboration. Baggs et al (1992) concluded that satisfaction and collaboration were strongly linked for nurses, but only weakly to moderately for doctors. However, they could not elicit whether collaboration had the same meaning for the two groups, nor how much influence on patient outcomes collaboration had. Despite printing their definition o f collaboration on the form, there were widely differing ideas o f how much collaboration occurred. Nurses felt it meant a better outcome, but medical staff did not. Baggs et al generated the theory that the more complex a situation was, the more important collaboration became.

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Severity o f illness has long been an indicator of patient outcome, and most ICUs have both accepted and adopted a tool known as A P A C H E II (Acute Physiology and Chronic Health Evaluation). A P A C H E II allocates points for age, chronic disease, and the degree o f physiological derangement as indicated by specified tests. These points as a total score are a useful predictor o f patient outcome and are widely used (Knaus et al 1986). Although there are criticisms of this tool (Boyd & Grounds 1993, O h et al 1993), it does provide some objective data regarding outcomes. Baggs et al (1992) controlled for this by collecting A P A C H E II scores for all eligible patients during their first and last 24 hours on the ICU, but found that this had no statistically significant relationship to collaboration as measured in the study. Overall, the study appears to have been rigorously conducted, although there were no definitive conclusions. Collaboration could not really be identified as a factor in patient outcomes, as it was not a crucial variable. The writers were cautious in stating their results, emphasising the need for replication studies in other areas. It is clear from Baggs' work with others, however, that collaboration is linked to nursing j o b satisfaction and could possibly be a factor in I C U patient outcomes (Baggs & Schmitt 1988, Baggs et al 1992). Her most recent work, the development o f an instrument to measure collaboration and satisfaction about care decisions (CSACD), has further confirmed this (Baggs 1994). Indeed, many articles in the literature have utilised the C S A C D in underlining the importance o f collaboration.

THE

DOCTOR-NURSE

GAME

The impetus for the study, which included this analysis of literature, was further influenced by the proposals o f Stein et al (1990): the 'doctor-nurse game'. This is a series o f reflections comparing the current scenario with the findings o f a study they had conducted in 1967. Twenty years ago, both doctors and nurses agreed that their relationship was hierarchical. Nurses made recommendations to doctors without appearing to do so and the resultant actions were seen to have been initiated by the doctor. Likewise, a doctor could ask for advice from a nurse, but in such a way that it did not look as if they were asking. The cardinal rule was to avoid open disagreement, and if the game succeeded both parties were rewarded. Patient care was efficient and the physicians used nurses as consultants, which raised nurses' self-esteem. Through the alliance, doctors gained respect. There were penalties for failure

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Intensiveand Critical Care Nursing too, as doctors who did not recognise nurses were seen as 'clods'. Likewise, nurses who were too outspoken had 'hell to pay!' Their respective training enforced the rules of the game. Nurses learnt that making a suggestion to a doctor was paramount to an insult, because it was questioning the doctor's knowledge. At the same time, nurses were told they had to make suggestions, thus 'the way out of the bind was to use the doctor-nurse game and c o m m u nicate the recommendation without appearing to do so' (p.546). Stein et al describe many changes since then: an increase in female doctors and male nurses; fewer nurses; the erosion o f the handmaiden image; nurses as advanced practitioners; poor working conditions and others. Stein et al suggest that by 1990, nurses had stopped playing the game because the relationship had changed in five ways: 1. Nurses' goals have changed; they want more autonomy and to be seen as equal partners with the whole multidisciplinary team (not just doctors). 2. Nurses' motivation has changed, mostly because o f the civil rights' and women's movements. 3. There is a vehicle for change; nurse education is very different now. Socialisation is towards collegiality rather than hierarchical relationships. 4. Effects on nurses; they feel free to challenge and confront doctors, and can make many decisions without consulting the medical staff. 5. Effects on doctors; they feel betrayed, angry and puzzled, as they never saw the relationship as hierarchical in the first place. Doctors are confused by this. Stein et al (1990) assert that due to these changes, doctors are of the opinion that nurses no longer want to nurse, a situation they are unhappy with as they prefer nurses who cheerfully do as they are told. The writers point out that those in power often never realise the oppression this causes. Although this changed relationship may seem negative, 'physicians and nurses can both benefit if their relationship becomes more mutually interdependent. Subservient and dominant roles are both psychologically restricting. W h e n a subordinate becomes liberated, there is the potential for the dominant one to become liberated too' (Stein et al 1990, p.549). Whilst the 'doctor-nurse game' is an oftacknowledged concept in the literature, there has been little research on it. However, Pilliteri & Ackerman (1993) attempted to redress this deficit in an interesting diary study. They highlighted the fact that although in recent studies on nurse abuse patients were the most guilty o f it, doctors in fact came second. In their qualita-

tive approach, they compared the doctor-nurse interactions recorded in the journals o f t w o similar doctors, who had practised 100 years apart. They then analysed c o m m o n areas o f the doctor-nurse relationship and found some surprises. In 1888 nurses gained most of their learning from doctors. In 1990, doctors acknowledge learning from nurses. Both doctors wished that nurses would take more responsibility, but in 1990 the doctor acknowledged that nurses did take quite a lot o f responsibility. In 1888, there were some specific examples of doctor-nurse collaboration, although none were cited in the 1990 journal. Both doctors complained o f being very tired and being woken at night, which they felt the nurses did not understand or appreciate, which could lead to conflict. Neither doctor interacted with nurses socially. Both doctors felt they had more authority than nurses and both complained about nurses who were assertive. Whilst the researchers acknowledge the limitations o f such a small study it does raise some interesting points, especially in the light o f the doctor-nurse game. In the 100 years between the opinions o f these two doctors, little has really changed. Whilst nurses are now contributing to decision-making, have more responsibility and act more asserfvely, doctors do not seem to have changed their attitudes much and still find conflict for similar reasons. Although there are few British studies that lend insight to the collaboration phenomenon, Busby & Gilchrist (1992) were disappointed by their own results. They hypothesised that as studies on cooperation and teamwork are now dated, the role o f the nurse should be much more autonomous. As advocates and c o m municators, nurses should have a valid part in the ward team. Using questionnaires and interviews with a sample consisting o f 33 consultants, 14 nurses, and eight patients, they observed three ward rounds. Contrary to their research hope, it was apparent that medical staff dominated and that nurses did not assert themselves on ward rounds. M t h o u g h nurses were asked for information about patients, they were rarely asked for an opinion. Altogether, only 12% o f comments made on these ward rounds were made by nurses. W h e n interviewed, the majority of nurses expressed a desire for more cooperation, but only 18% o f the doctors supported the same view.

REDEFINING PRACTICE

COLLABORATIVE

It appears from the literature that nurses have changed, that they are more autonomous and

Collaborative practice within the intensive care unit: a deconstruction

have more role responsibility. Perhaps their attitudes have changed with this, although few doctors appear to have adapted to this emergent nurse role and are still holding o n to the 'doctor-nurse game'. Even so, it is gratifying to see doctors writing in a way that challenges this (Stein et al are all physicians), as most o f the literature o n collaborative practice emanates from nurses. It is of some concern that so m a n y have written about the p h e n o m e n o n in a way that constitutes little more than 'doctor-bashing' (Brooking 1991). As influential writers, o n the subject, Weiss & Davis (1985) only elucidate the positive effects o f collaborative practice in a general or nurse-specific way. Baggs (1994) attempts to link it to improved patient outcomes (positive for both doctors and nurses), but only clearly demonstrates the link with enhanced nursing j o b satisfaction. These three are n o t the only examples o f views concerning collaborative practice, b u t they do provide a fairly comprehensive introduction to current thought and w o r k o n the p h e n o m e n a associated with the concept of collaborative practice. O n reading this literature, two important themes surfaced. T h e o v e r w h e l m i n g majority o f research o n collaborative practice appears to have b e e n c o n d u c t e d in the USA, most o f which has b e e n in the form o f large surveys, analysed by means o f statistics. T h e few British studies have confirmed that there is little collaboration, b u t there is no discussion o f the u n d e r l y i n g principles (Busby & Gilchrist 1992, Gregson et al 1992). T h e n u m e r o u s claims regarding collaborative practice suggest that it is a crucial feature in I C U s in reducing mortality, b u t this is n o t empirically demonstrated at any point. Whilst it is clearly connected to nursing j o b satisfaction, this in itself is n o t necessarily linked to patient outcomes. Isolating collaborative practice as a variable in patient outcomes currently appears impossible and yet it is repeatedly claimed as such (Franklin & Jackson 1983, iKubins & Moskowitz 1988, Mitchell et al 1989, Baggs 1994). Although slightly different meanings are given to the p h e n o m e n o n , the overall impresson from the literature indiCates that collaborative practice is c o n c e r n e d with trust b e t w e e n doctors and nurses. A n amalgamated definition constructed from the evidence discussed in this paper could be: Collaborative practice is the recognition o f and respect for each participant's u n i q u e expertise in health care delivery. Doctors and nurses w o r k together non-hierarchically in contributing to decisions made together about the patients. T h e relationship is characterised by trust and m u t u a l c o m m u n i c a tion. This leads to increased j o b satisfaction and better patient outcomes.

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In seeking to explore collaborative practice as a p h e n o m e n o n w i t h i n an I C U , this definition from the literature needs to be c o n sidered very carefully. Is it measurable? Is it realistic? Is it desirable? D e c o n s t r u c t i o n o f the literature leads to a gut reaction o f ' n o ' o n all counts, b u t research is indicated in order to u n d e r p i n this. A l t h o u g h I C U doctors and nurses all w a n t the best for their patients, concrete truths and pointers are needed, rather t h a n mere speculation or impossible directives.

REFERENCES

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