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Oncology nurses' experience of collaboration: A case study
European Journal of Oncology Nursing xxx (2015) 1e7
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European Journal of Oncology Nursing journal homepage: www.elsevier.com/locate/ejon
Oncology nurses' experience of collaboration: A case study Jane Moore*, Dawn Prentice Department of Nursing, Faculty of Applied Health Sciences, Brock University, Canada
a b s t r a c t Keywords: Case study design Nurseenurse collaboration Oncology Qualitative research Leadership
Purpose: Changes in the health system have created new models of healthcare delivery such as nurse-led teams. This has resulted in the increased opportunity for enhanced collaboration among nurses. Oncology nurses have a long history of working together, yet little is known about their perceptions about collaboration in the practice setting. This paper aimed to explore and describe the experiences of collaboration among oncology nurses, and to understand the factors that influenced collaboration. Method: Qualitative, case study design was used to study fourteen oncology nurses from one cancer center in Canada. Participants were registered nurses or nurse practitioners, employed full-time or permanent part-time in an oncology nurse role, and working on an in-patient or out-patient unit. Data were collected in 2013 using individual telephone interviews and document reviews. Results: Thematic analysis revealed two themes: Art of dancing together, and the stumbling point. The first theme related to the facilitators of collaboration including having: regular face-to-face interaction, an existing and/or previous relationship, oncology nursing experience, and good interpersonal skills. The second theme related to the barriers to collaboration such as: role ambiguity, organizational leadership, and multi-generational differences. Conclusions: Collaboration is a complex process that does not occur spontaneously. To improve collaboration nursing leadership needs to support and promote opportunities for nurses to build the relationships required to effectively collaborate. It is equally important that individual nurses be willing to collaborate and possess the interpersonal skills required to build and maintain the collaborative relationship despite differences in age, generation, and clinical experience. © 2015 Elsevier Ltd. All rights reserved.
Introduction The changing landscape of healthcare and the development of new health delivery models have provided the opportunity for enhanced collaboration among nurses (Canadian Nurses Association [CNA], 2008; Duffield et al., 2009). The current environment requires nurses to be innovative, and willing to work collaboratively in order to deliver high quality and cost-effective care. Collaboration among nurses is an expected standard of nursing practice mandated by various nursing associations (American Nurses Association (ANA), 2003; CNA, 2007) and a professional responsibility and competency that applies to all nurses (ANA, 2003; Apker et al., 2006; CNA, 2007; Meretoja et al.,
* Corresponding author. Tel.: þ1 905 688 5550x4189; fax: þ1 905 688 6658. E-mail addresses: [email protected] (J. Moore), [email protected] (D. Prentice).
2002). In oncology settings collaboration is particularly important due to the inherent challenges of the work environment (Medland et al., 2004; Quattrin et al., 2006). Given that collaboration is an expectation of all nurses, and that oncology nurses spend much of their time partnering with other nurses to provide patient care, research is needed to understand how collaboration is constructed in the practice setting. Collaboration is considered the cornerstone of clinical practice and has been identified as the appropriate interaction mode within and between disciplines (Bedwell et al., 2012). The majority of literature pertaining to collaboration in the context of healthcare has related to interprofessional interactions. The evidence has focused on the general concept of collaboration (Petri, 2010), the factors that encouraged and discouraged collaboration (El-Jardali, 2003; Resnick and Bonner, 2003), the outcomes of collaboration and collaborative relationships (Estabrooks et al., 2005), and the measurement of collaboration (Hojat et al., 2001; Sasahara et al., 2003; Ushiro, 2009).
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In the last two decades, there has been considerable study on interprofessional collaboration; however, there has been limited research on collaboration among nurses. Stefaniak (1998) examined the perceptions of collaboration among nurses. She identified three occasions that influenced nurseenurse collaboration: knowledge/skills deficits, change and transitions, and communication gaps. Ritter-Teitel (2001) found that nurseenurse collaboration and problem solving was a predictor for urinary tract infections. Sasahara et al. (2003) investigated nurses' experiences caring for terminally ill cancer patients in Japan. The study showed that under the survey domain of ‘Collaboration Among Nurses’, nurses felt there were few opportunities for discussion among nurses, there was poor communication with other nurses, they were unable to share their feelings with other nurses, and they were unable to provide consistent care due to different views of the nursing staff. Estabrooks et al. (2007) examined factors that predicted the use of research by staff nurses, and found that nurseenurse collaboration was predictive of staff nurse research utilization. Lastly, Moore and Prentice (2013) examined the collaborative process between nurse practitioners and registered nurses in oncology. The study found that social interaction among the nurses was a key contributor to the development and maintenance of the collaborative relationship, and a major barrier to nurseenurse collaboration was the lack of formal nursing education relating to the enactment of collaboration in practice (Moore and Prentice, 2013). Given the limited research on nurseenurse collaboration, this study was undertaken to contribute to the building of evidence on this topic. The purpose of this qualitative case study was to explore and describe the experiences of collaboration among oncology nurses working in all types of nursing roles at one cancer center in Canada in order to understand how the nurses collaborated, and to identify factors that influenced collaboration. The study was guided by a modified version of Corser's Model of Collaborative NurseePhysician Interaction (1998), and adapted based on the findings from a study by Moore and Prentice (2013) which illustrated that several factors influenced nurse practitioner and registered nurse collaboration: personal/interpersonal, social/professional, educational and organizational. Methods The study was guided by qualitative case study design and methods defined by Yin (2009). An embedded, single case design was selected to capture the circumstances, dynamics, and complexities of an everyday situation (nurseenurse collaboration) while considering the influence of organizational, professional, personal and interpersonal factors. The single site design was chosen to enable the researchers to collect more compelling evidence and increase the robustness of the overall study (Yin, 2009). The exploratory, descriptive case study was used to provide a description of collaboration among oncology nurses within the context of the practice setting. Two research questions were posed: 1) how do nurses collaborate in practice? and 2) what factors influenced collaboration among oncology nurses? Yin (2009) says that “how” or “why” questions are often used in case study design, however, “what” questions are appropriate to use when conducting an exploratory case study as the data may assist with developing propositions for further inquiry. The case or the main unit of analysis for this study was the oncology nurses, and the embedded units were the nursing roles. Purposive, maximum variation sampling was used to document the diverse variations of oncology nurse collaboration and identify important common patterns (Miles and Huberman, 1994). Maximum variation sampling captured a range of perspectives that
related to oncology nurse collaboration: nurse roles, clinical practice units, and employment status. To obtain as much information as possible from practicing, professional nurses, cases were selected based on the following criteria: The nurses were either registered nurses (RN) or nurse practitioners (RN-EC e extended class) in the province in which the study was conducted; The nurses were employed full-time or permanent part-time in one of the following oncology nursing roles: specialized oncology nurse or advanced oncology nurse (Canadian Association of Nursing in Oncology, 2001); The nurses were working on an in-patient or out-patient adult unit for a minimum of one year (time), and; The nurses were employed by the cancer center (place).
Data collection All nurses (approximately 500) at the cancer center were approached via email communication for recruitment into the study. A total of fourteen nurses volunteered and completed the study. Data for this study were collected over ten months in 2013 through a combination of qualitative methods including openended, semi-structured telephone interviews and document reviews. Interviews Individual telephone interviews lasted 45e60 min and took place during unpaid work time. The nurses were asked to share their experiences, thoughts, and concerns about how they collaborated in the practice setting, and the influence of the personal/ interpersonal, organizational, social, professional, and collegial factors on the collaborative process (Table 1). After the 14th interview no new information emerged and data saturation was achieved. Documents Documents were reviewed to corroborate and augment evidence from the telephone interviews. The documents assisted with obtaining an understanding of the nurses' competencies, qualifications, and professional, regulatory, organizational, and educational factors that may have influenced collaboration. The documents included: a) the job descriptions of each participant at the hospital, b) the Canadian Nurses Association Framework for the Practice of Registered Nurses in Canada (2007), c) the College of
Table 1 Interview guide. 1. 2.
3. 4. 5. 6. 7. 8.
How do you collaborate with other nurses on your unit? What factors influence collaboration among nurses on your unit (organizational, professional, educational, social, personal/interpersonal, time)? What factors facilitate collaboration among nurses on your unit? What are the barriers to collaboration among nurses on your unit? Tell me about the types of collaborative interaction among nurses on your unit? Have you received any formal education about how to collaboration with other nurses? How has your formal education helped/hindered you to successfully collaboration with nurses in the practice setting? Has your employer helped/hindered you to successfully collaboration with nurses in the practice setting?
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Nurses of Ontario National Competencies (2009), and d) the Canadian Association of Nurses in Oncology (CANO) (2001) Standards of Care, Roles in Oncology Nursing and Roles Competencies. Data analysis A thematic analysis of the interview and documentary data was conducted. Thematic analysis entails identifying, analyzing, and reporting patterns within data (Braun and Clarke, 2006). The process for interview data analysis involved listening to the audiotaped interviews and making initial notes, followed by reading the entire transcription of each interview to gain a sense of the meaning of the whole followed by a second reading. Both authors individually coded each transcript and then recoded them together to reach consensus. Coding of the data was completed by hand and NVivo version 10 (QSR International, 2014) was used to organize the data from each transcript. Once coding was completed, analysis of the data began with highlighting emerging themes. The interpretation phase of analysis involved attaching the meaning and significance to the themes. The findings were presented through the major themes with interpretive comment provided throughout. The procedure for analysis of documents was similar to that of the interview data. Rigor Rigor was ensured through the use of Yin's (2009) principles of data collection, and Lincoln and Guba's (1985) criteria for establishing trustworthiness. The use of multiple data sources is an important feature of case study design and is seen as a form of triangulation. The researcher triangulated interview and documentary data to develop a more holistic and contextual portrayal, and corroborate the phenomenon under study (McDonnell et al., 2000). Credibility was achieved through use of multiple sources of evidence. Member checking was completed after emailing the participants a draft of the initial findings and requesting their comments. Dependability was strengthened by creating a study database and maintaining a chain of evidence to develop an audit trail. Confirmability was achieved by developing codes, categories and definitions of these, which could be used by other researchers. Transferability was established by providing an accurate description of the study methodology and findings (Jones and Lyons, 2014). Ethical considerations Research Ethics Board approval was obtained at the university and the hospital where the study was conducted. The potential participants were initially contacted by email at work using a recruitment script, and interested participants were emailed an information letter and the informed consent. Participants were informed that their identity and that of their workplace would not be disclosed. Confidentiality of the participants was ensured by use of coding numbers (example e RN001). Informed consent was obtained by all participants in the study. All participants completed the study. Findings Participants ranged in age from 31 to 64 years with the largest group (n ¼ 9) being between 46 and 60 years. Twelve women and two men were interviewed, and all were registered with the provincial college of nurses as either an RN (n ¼ 12) or an RN (EC) (n ¼ 2). The Canadian Association of Nursing in Oncology (CANO) (2001) suggests there are three nursing roles in oncology: a) generalist nurse, b) specialized oncology nurse, and c) advanced oncology nurse. There were no generalist nurse participants in this
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study as the role is limited to nurses working in settings where patients with cancer receive care along with other patient populations. Since the setting for this study was a cancer center, nurses were either in specialized or advanced oncology nurse roles. The specialized oncology nurse is described as one who has cancer care experience and education (CANO, 2001). The advanced oncology nurse is prepared at the Master's level, and the graduate program is focused in oncology nursing with an emphasis on a clinical disease site (CANO, 2001). Advanced oncology nurse roles include nurse practitioners (RN-EC), clinical nurse specialists (CNSs), and advanced practice nurse educators (APNEs). In this study nine participants were employed in specialized oncology nurse roles and five in advanced oncology nurse roles. Those in specialist oncology nurse roles included: two staff RNs, two patient resource/discharge coordinators, two patient care coordinators, two clinical/unit nurse managers, one research nurse/coordinator, and one senior nurse administrator. The participants in advanced oncology nurses roles were: one clinical nurse specialist, two nurse practitioners, and one advanced practice nurse educator. The level of nursing education ranged from college diploma (equivalent to an associate degree, [n ¼ 5]), baccalaureate degree (n ¼ 3), and graduate degree (n ¼ 6). Over half of the nurses had oncology nurse certification, and two had completed a nurse practitioner certification which is the basic entry to practice requirement for an RN (EC) designation in the province. The nurses' years of experience in oncology nursing ranged from 1 to 39 years. Half of the nurses worked on in-patient units, and the remainder on out-patient units. The nurses were employed in the clinical practice sites of malignant hematology (leukemia, lymphoma, myeloma, bone marrow transplant), solid tumors (head and neck, gastrointestinal, genitourninary, gynecology, prostate, lung, breast), and palliative care. Two themes emerged from the data analysis: 1) Art of dancing together, and 2) The stumbling point. The choice of a dance analogy symbolizes that successful collaboration is comprised of factors that must work together ‘in rhythm”. Without the presence of these factors, collaboration may not occur. Art of dancing together The first theme was related to factors that encouraged or facilitated collaboration among oncology registered nurses. Nurses collaborated for the primary purpose of planning, organizing and providing patient care while using different methods such as teleconferences and emails, and face-to-face conversations to communicate. The preferred method of collaboration was verbal and in-person. RN010, an advanced oncology nurse stated that she liked face-to-face interaction because: “I collaborate directly with them [nurses], so when patients come into this nurse-led clinic, they are triaged by the RN, who then decides if they need a more detailed assessment … then they will call me, and we will talk about patient plans and treatment together … this helps us with continuity of care … and to get to know each other … personally and professionally”. Similarly, RN014 said that face-to-face interaction at weekly staff meetings helped nurses collaborate by contributing to the development and maintenance of the relationship between nurses. The nurses reported that staff meetings were used to connect with nurses in order to get to know each other or as RN014 said staff meetings provided her with the opportunity to reconnect with nurses who may be on a different shift and not seen recently: “I will ask them how's your work going? How are the kids? What can I help you with … you seem really busy? That type of
Please cite this article in press as: Moore, J., Prentice, D., Oncology nurses' experience of collaboration: A case study, European Journal of Oncology Nursing (2015), http://dx.doi.org/10.1016/j.ejon.2015.02.011
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stuff … I think this is how collaboration is built … and continues”.
… communicate with them … take time to know the person as a person rather than just a nurse doing their job …” (RN014).
While collaboration was enacted in practice for the central purpose of patient care, oncology nurses reported they collaborated for professional and educational reasons as well. This was accomplished by interacting at professional meetings such as: the Canadian Association of Oncology Nurses annual conference, clinical unit practice council meetings, and when working on special clinical or organizational projects. Nurses once again viewed these opportunities to collaborate as a way of developing and maintaining relationships. RN012 said:
Lastly, having certain personal characteristics was viewed by the nurses as a facilitator of collaboration. Personal characteristics are the traits that distinguish the characteristics or qualities of an individual (Merriam-Webster Online Dictionary, 2015). These characteristics included having a sense of humour and a positive attitude, being open and honest and sharing common interests, values and goals both professionally and personally. Nurses provided some of examples of the impact of individual personal characteristics on collaboration:
“I find it easier with certain individuals who I know … to work on committee projects … it is easier to collaborate with them … because I have known them a long time”.
“They've got to have similar work ethic or practice … common standards … common values, common respect, and common humour … as these things play a really big role in nursing” (RN001).
“I see all of them [nurses at a conference] collaborating and mentoring others … it certainly fosters you to move forward and further your education … and practice” (RN003). Having a previous and/or existing relationship was a facilitator of collaboration. Successful collaboration required a relationship that is developed over time, and is maintained through regularly working together on the clinical unit. RN009 working in an advanced oncology nurse role as a nurse practitioner stated: “Working together for a long time in hematology … the ones [nurses] that I've had a good rapport with from before [when previously working as a specialist oncology nurse) … we share and exchange information and they contact me for questions … they look to me for leadership … and support … and collaboration”. Collaboration was facilitated by having oncology nursing knowledge and experience. Demonstrating knowledge and experience contributed to the development of professional credibility, trust, and mutual respect among the oncology nurses. The nurses said: “Some of the [clinical] trial nurses come from the in-patient units or out-patient settings, but within [the hospital], and those nurses tend to have better relationships with the unit nurses … having a prior relationship really does help … with collaboration” (RN006). “If I had been someone who came there [hospital] with no experience in head and neck, they probably would collaborate less because they wouldn't perceive me as having the knowledge they are looking for …” (RN010). Other facilitators of collaboration included possessing certain interpersonal skills such as having effective communication skills e good listening skills, being respectful of other individual's opinions and nursing roles, participating in a conversation, and demonstrating a willingness to cooperate and collaborate. Interpersonal skills involve an interaction between individuals that assist with building relationships: “Having good communication skills is so important … they [nurses] have to be open to suggestions, open to support and help … and actually go the extra yard for the patient … if not, there are problems collaborating with them …” (RN013). “To form genuine relationships with colleagues … the golden rule … is, I'm going to treat people the way I want to be treated
“Sometimes it depends on the personalities; you know you can work with one group and have a great day, and you can work with … one person, and it could be a horrible day … personal factors can be huge” (RN007).
The stumbling point The second theme related to barriers or factors that discouraged or impeded collaboration from occurring among the oncology nurses. Role ambiguity was described by the nurses as being a barrier to collaboration. Nurses in certain roles such as advanced practice nurse roles (APN) and nurses working in clinical trials believed there was a lack of understanding of their specific roles and this discouraged nurseenurse collaboration: “I feel quite isolated at times … being an individual in this role [APN] … they [nurses] need to understand that you're on any floor [in the hospital] … it's hard to be collaborative when there is only one of you … and they need to have an understanding of the role” (RN002). “In-patient nurses really have little idea of what clinical trials is about … they have a lack of knowledge about what clinical trials nurses do … they just see it as a make work project for them” (RN006). The nurses reported that lack of leadership support was a barrier to their collaboration. This related to organizational structures and resources, and differences in shared philosophical values and goals. RN009 said the recent changes in model of care (e.g. moving to a clinical site specific model) mandated by leadership resulted in reduced continuity of patient care and less opportunity for nurseenurse collaboration: “The environment has always been … a little bit hostile … and with a lot of changes going on … and the head of the program not good … this has caused anger and sort of unhappiness … and general burnout … not great for collaboration” Similarly, the nurses described organizational structures that impaired nurseenurse collaboration by discouraging open communication and shared decision-making regarding patient care: “A big barrier I'm finding right now is the upper [management] at the very top … they have specific objectives and agenda that they want people in the middle … and the bottom to exercise … to just do it, but the rules of the place don't allow that to happen
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… we are such a big institution … we don't work well for patients … because I can't convey things to the nurses” (RN014). “If you're in an environment where it's punitive to ask questions … then people are not going to speak up … they would sit silent … and not say anything with anybody about what should be done …” (RN007). Collaboration requires leadership to promote/support the development and maintenance of relationships among oncology nurses. The nurses reported the structure of their work was a barrier to collaboration given scheduling and staffing issues and heavy workload relating to patient care: “There is no time [for collaboration] … because of the busyness of people … doesn't help with building the relationship …” (RN002). “Our workload is extremely heavy … it's not always easy [to collaborate]” (RN005). “I don't want to use the term clique … but some people are not part of that model [willingness to collaborate] … the casual staff or relief staff or who do occasional shifts are … kind of out of that … unlike most of the nurses who do work consistent lines and with the same team member” (RN008). The nurses said leadership did not provide the resources needed for successful collaboration. RN013 said that a clinical manager wanted to create an opportunity for nurses to collaborate but was impeded by senior management: “She has been trying to organize a half day retreat for clinical trial nurses so we can collaborate and get to know each other and work together on things that we want to aim for, and getting that support from higher up and giving us support by not having patients to see that day has not been very forthcoming”. Multigenerational issues among the nurses were also a barrier to collaboration but for different reasons. Older nurses were less interested in collaborating with younger, new, or casual part-time nurses who they did not have a relationship with, and who they viewed as less professionally credible. “I do tend to gravitate towards my peers of my age group … because I find they are the ones that know things or know how to get things done, or can help you out” (RN013). “Nurses who are younger or novice or new wouldn't be able to give you as much information … so they are more difficult to collaborate with …” (RN004). Younger nurses reported that they were less interested in collaborating with some older nurses due to having a prior negative interaction, and because of communication problems: “There are a few older nurses that have been on my unit for 30 years and I think they negatively impact [other nurses] because they are quite jaded … its mostly hard on younger nurses” (RN003). “On our team there is a big age gap … I'm not the same age as them … people [older nurses] have a lot of baggage … so it's hard to get over that baggage … especially since nurses eat their young … and it's kind of true … they [older nurses] leave them [younger nurses] to kind of flounder … they not interested in collaborating with them …” (RN009).
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“Some [older] nurses are not so good at communicating with young or new nurses … you can be harassed or blazed … or singled out from the rest of the team” (RN008). Lastly, nurses reported that having a ‘difficult personality’, a negative attitude, being resistant to change, not being open and honest, and having different goals, values, and beliefs in relation to work issues were barriers to collaboration: “Some nurses have anger and unhappiness … and are never going to change … they just don't want to collaborate [with you] … and you don't want to collaborate with them …”(RN009). “Being negative created such an awful [workplace] … and it was disheartening to see behavior among certain nurses … you wouldn't tend to go to them for help or anything …” (RN001).
Discussion Our findings add to the literature on intraprofessional collaboration among nurses. Collaboration is a complex interactional process that requires key factors to be present at both the organizational and individual level. At the organizational level, nursing leadership need to support collaboration by promoting a common vision and/or philosophy of collaborative practice (Borrill et al., 2002). The nurses in this study reported that organizational leadership was viewed as a barrier to their collaboration largely due to structural, philosophical and resource issues. Some nurses mentioned the environment was ‘punitive’ or ‘hostile’, two factors that would impede collaboration. Collaboration also requires having the time and opportunity to build and maintain the relationships among nurses that contribute to the development of essential mutual trust and respect. With this in mind, nursing leadership needs to provide resources to ensure realistic staffing levels and reasonable patient workload assignments, as this not only encourages collaboration, but may also improve nursing job satisfaction and quality of care for patients (Manojlovich et al., 2011; Trinkoff et al., 2011; Valiani, 2013). Resources should also include standardized documents, policies and leading edge technology that could facilitate opportunities for communication, coordination and systems needed to enhance collaboration (Cabello, 2002; D'Amour and Oandasan, 2005; McCallin, 2005). Role ambiguity was considered a stumbling point or barrier to collaboration. Some participants had little knowledge of what certain oncology nurses did, and because they did not understand the role, they were less interested in collaborating with those nurses. The roles that were most confusing were those in research nurse and/or those in advanced practice nurse roles. While a somewhat surprising result given that all participants were oncology registered nurses employed at the same organization, there is some literature to support this finding. Ocker and PawlikPlank (2000) found in their review of the literature that the research nurse role can be poorly defined and may have role overlap with the oncology nurse clinician when providing care for patients enrolled in clinical trials. This creates the opportunity for confusion in relation to role definition and role ambiguity. The issue of role ambiguity between different types of advanced practice nurses (e.g. clinical nurse specialists, nurse practitioners) has been well documented in the literature. In the last decade cancer care has become highly specialized, thus requiring different types of RN roles. Role ambiguity may be a barrier to the integration of oncology nursing roles. Several authors suggest that leadership, and particularly nursing leaders are in the ideal position to improve role clarity by facilitating the development of documents that
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clearly describe and communicate the role to not only nurses but to all healthcare providers (Anderson-Johnson and Nelson, 2012; Farrell et al., 2011; O'Rourke and White, 2011; Patel et al., 2012). For optimal collaboration to take place, oncology nurses must understand the knowledge, skills, and roles of each other in order to maximize and respect the expertise of each nurse. Generational issues also discouraged collaboration among the oncology nurses. Older, experienced oncology nurses reported less interest in collaborating with younger nurses with little or no oncology experience, and the younger nurses reported observing and/or experiencing bullying comments and behaviors that negatively impacted their collaboration with older nurses. Moreover, because of these experiences, younger nurses were less willing to collaborate with older nurses. The fact that the oncology nurses found it challenging to collaborate with nurses from different generations is not surprising. Today multigenerational nurses are working together in many healthcare settings. Nursing leadership has a key role in creating work environments that embrace the diversity and contribution of all nurses (Outten, 2012) regardless of age. If not addressed, the impact of diversity among multigenerational caregivers can cause conflict, which may result in poor patient outcomes, job dissatisfaction and potentially turnover (Outten, 2012). To improve multigenerational collaboration nurses need to be flexible in their communication approach, and consider diversity as a positive factor in building effective teams (Barry, 2014). Moreover nurses should remember that effective collaboration is a required professional competency with is main goal on improving patient care outcomes. While favorable and supportive organizational leadership is important to nurseenurse collaboration, this alone is not enough. Our findings showed how the individual nurse can positively or negatively impact the collaborative process. For example, if a nurse chooses not to collaborate, or if his/her attitudes and communication skills are not conducive to entering into collaborative interaction then the collaboration is doomed to fail. As D 0 Amour and colleagues (1999) note “… collaboration is, by its very nature voluntary” (p. 141). Furthermore, if a nurse is employed on a unit where certain staff members are known to be ‘unapproachable’ no other nurse will seek out that individual's assistance unless truly necessary. This can be especially problematic for a new graduate or junior nurse who may need the mentoring expertise of the senior nurse. Many nurses transitioning into new roles often feel afraid or intimidated to seek assistance from experienced nurses who they view as unapproachable (Romyn et al., 2009; Wu et al., 2012). Our findings also highlighted the importance of the interpersonal relationship as a central component of collaboration. This was not surprising as it seems natural that nurses would value what is viewed as a fundamental goal of the nursing profession e developing relationships. Farrell (2001) suggests that relationships are built through the formation of a ‘collaborative circle’, which combines the elements of friendship and work. Over time, colleagues develop their own routines, language, and individual roles. We found this to be true in our study; collaboration was influenced by the existence of a prior and/or current relationship among the RNs; as well as the interpersonal skills of the individual nurses. When the RNs invested in a positive way in the relationship; collaboration was successful. Whereas, if the interaction was negative or neglected, the relationship was poor and collaboration was unsuccessful. The importance of good interpersonal relationships cannot be understated. While they take time and effort to develop and maintain; relationships are a key facilitator of collaboration. Revisiting our dance analogy, for collaboration to be effective the dancers must work in rhythm with each other, and any stumbling points along the way can impact the collaboration dance.
Limitations While the sample size was small in quantitative terms, in qualitative case study design, this was viewed as a strength rather than a limitation as it supported an in-depth description of nurse enurse collaboration. There were a few limitations pertinent to this study: it took place at one organization, and in one country, and therefore future studies would be required to determine the applicability of findings in other settings and geographic locations. Conclusions Nurseenurse collaboration is a complex, interactional and relational process among colleagues who share a common professional education, values, socialization, identity, and experience (College of Registered Nurses of Nova Scotia, 2014). Our findings suggest that collaboration occurs over time during which nurses build and maintain relationships. For collaboration to be successful many factors at both the organizational and individual level need to be in place. Most importantly nurses need to be open to collaborating with other colleagues. Given that excellence in patient care is a shared goal among all healthcare providers, facilitating opportunities for collaborative practice is essential. Further research is needed to obtain an understanding of the impact of nurseenurse collaboration on patient, nurse, and system outcomes. Conflicts of interest statement “We wish to confirm that there are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome. We confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. We further confirm that the order of authors listed in the manuscript has been approved by all of us. We confirm that we have given due consideration to the protection of intellectual property associated with this work and that there are no impediments to publication, including the timing of publication, with respect to intellectual property. In so doing we confirm that we have followed the regulations of our institutions concerning intellectual property.” References American Nurses Association, 2003. Nursing Social Policy Statement. Author, Washington, DC. Anderson-Johnson, P., Nelson, J., 2012. Testing a model of clarity of self, role, and system as predictors of job satisfaction of nurses in Jamaica. In: 23rd International Nursing Research Congress: Sigma Theta Tau International, the Honor Society of Nursing. September 12. Apker, J., Prop, K., Zabava-Ford, W., Hofmeister, M., 2006. Collaboration, credibility, compassion and coordination: professional nurse communication skill sets in health care team interactions. Journal of Professional Nursing 22, 180e189. Barry, M., 2014. Better, safer patient care through evidence-based practice and teamwork. The American Nurse 46, 12. Bedwell, W., Wildman, J., Diazgranados, D., Salazar, M., Kramer, W., Salas, E., 2012. Collaboration at work: an integrated multilevel conceptualization. Human Resource Management Review 22, 128e145. Borrill, C., West, A., Dawson, J., Shaprio, D., Rees, A., Richards, A., et al., 2002. Team Working and Effectiveness in Healthcare: Findings from the Healthcare Team Effectiveness Project. Aston Centre for Health Service Organization Research. Retrieved January 19, 2014 from. http://homepages.inf.ed.ac.uk/jeanc/DOHglossy-brochure.pdf. Braun, V., Clarke, V., 2006. Using thematic analysis in psychology. Qualitative Research in Psychology 3, 77e101. Cabello, C., 2002. A collaborative approach to integrating outpatient and inpatient transplantation services. Outcomes Management 6, 67e72. Canadian Association of Nursing in Oncology, 2001. Standards of Care, Roles in Oncology and Role Competencies. Retrieved May 28, 2014 from. http://www. cano-acio.ca/nursingroles.
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Contents lists available at ScienceDirect
European Journal of Oncology Nursing journal homepage: www.elsevier.com/locate/ejon
Oncology nurses' experience of collaboration: A case study Jane Moore*, Dawn Prentice Department of Nursing, Faculty of Applied Health Sciences, Brock University, Canada
a b s t r a c t Keywords: Case study design Nurseenurse collaboration Oncology Qualitative research Leadership
Purpose: Changes in the health system have created new models of healthcare delivery such as nurse-led teams. This has resulted in the increased opportunity for enhanced collaboration among nurses. Oncology nurses have a long history of working together, yet little is known about their perceptions about collaboration in the practice setting. This paper aimed to explore and describe the experiences of collaboration among oncology nurses, and to understand the factors that influenced collaboration. Method: Qualitative, case study design was used to study fourteen oncology nurses from one cancer center in Canada. Participants were registered nurses or nurse practitioners, employed full-time or permanent part-time in an oncology nurse role, and working on an in-patient or out-patient unit. Data were collected in 2013 using individual telephone interviews and document reviews. Results: Thematic analysis revealed two themes: Art of dancing together, and the stumbling point. The first theme related to the facilitators of collaboration including having: regular face-to-face interaction, an existing and/or previous relationship, oncology nursing experience, and good interpersonal skills. The second theme related to the barriers to collaboration such as: role ambiguity, organizational leadership, and multi-generational differences. Conclusions: Collaboration is a complex process that does not occur spontaneously. To improve collaboration nursing leadership needs to support and promote opportunities for nurses to build the relationships required to effectively collaborate. It is equally important that individual nurses be willing to collaborate and possess the interpersonal skills required to build and maintain the collaborative relationship despite differences in age, generation, and clinical experience. © 2015 Elsevier Ltd. All rights reserved.
Introduction The changing landscape of healthcare and the development of new health delivery models have provided the opportunity for enhanced collaboration among nurses (Canadian Nurses Association [CNA], 2008; Duffield et al., 2009). The current environment requires nurses to be innovative, and willing to work collaboratively in order to deliver high quality and cost-effective care. Collaboration among nurses is an expected standard of nursing practice mandated by various nursing associations (American Nurses Association (ANA), 2003; CNA, 2007) and a professional responsibility and competency that applies to all nurses (ANA, 2003; Apker et al., 2006; CNA, 2007; Meretoja et al.,
* Corresponding author. Tel.: þ1 905 688 5550x4189; fax: þ1 905 688 6658. E-mail addresses: [email protected] (J. Moore), [email protected] (D. Prentice).
2002). In oncology settings collaboration is particularly important due to the inherent challenges of the work environment (Medland et al., 2004; Quattrin et al., 2006). Given that collaboration is an expectation of all nurses, and that oncology nurses spend much of their time partnering with other nurses to provide patient care, research is needed to understand how collaboration is constructed in the practice setting. Collaboration is considered the cornerstone of clinical practice and has been identified as the appropriate interaction mode within and between disciplines (Bedwell et al., 2012). The majority of literature pertaining to collaboration in the context of healthcare has related to interprofessional interactions. The evidence has focused on the general concept of collaboration (Petri, 2010), the factors that encouraged and discouraged collaboration (El-Jardali, 2003; Resnick and Bonner, 2003), the outcomes of collaboration and collaborative relationships (Estabrooks et al., 2005), and the measurement of collaboration (Hojat et al., 2001; Sasahara et al., 2003; Ushiro, 2009).
http://dx.doi.org/10.1016/j.ejon.2015.02.011 1462-3889/© 2015 Elsevier Ltd. All rights reserved.
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In the last two decades, there has been considerable study on interprofessional collaboration; however, there has been limited research on collaboration among nurses. Stefaniak (1998) examined the perceptions of collaboration among nurses. She identified three occasions that influenced nurseenurse collaboration: knowledge/skills deficits, change and transitions, and communication gaps. Ritter-Teitel (2001) found that nurseenurse collaboration and problem solving was a predictor for urinary tract infections. Sasahara et al. (2003) investigated nurses' experiences caring for terminally ill cancer patients in Japan. The study showed that under the survey domain of ‘Collaboration Among Nurses’, nurses felt there were few opportunities for discussion among nurses, there was poor communication with other nurses, they were unable to share their feelings with other nurses, and they were unable to provide consistent care due to different views of the nursing staff. Estabrooks et al. (2007) examined factors that predicted the use of research by staff nurses, and found that nurseenurse collaboration was predictive of staff nurse research utilization. Lastly, Moore and Prentice (2013) examined the collaborative process between nurse practitioners and registered nurses in oncology. The study found that social interaction among the nurses was a key contributor to the development and maintenance of the collaborative relationship, and a major barrier to nurseenurse collaboration was the lack of formal nursing education relating to the enactment of collaboration in practice (Moore and Prentice, 2013). Given the limited research on nurseenurse collaboration, this study was undertaken to contribute to the building of evidence on this topic. The purpose of this qualitative case study was to explore and describe the experiences of collaboration among oncology nurses working in all types of nursing roles at one cancer center in Canada in order to understand how the nurses collaborated, and to identify factors that influenced collaboration. The study was guided by a modified version of Corser's Model of Collaborative NurseePhysician Interaction (1998), and adapted based on the findings from a study by Moore and Prentice (2013) which illustrated that several factors influenced nurse practitioner and registered nurse collaboration: personal/interpersonal, social/professional, educational and organizational. Methods The study was guided by qualitative case study design and methods defined by Yin (2009). An embedded, single case design was selected to capture the circumstances, dynamics, and complexities of an everyday situation (nurseenurse collaboration) while considering the influence of organizational, professional, personal and interpersonal factors. The single site design was chosen to enable the researchers to collect more compelling evidence and increase the robustness of the overall study (Yin, 2009). The exploratory, descriptive case study was used to provide a description of collaboration among oncology nurses within the context of the practice setting. Two research questions were posed: 1) how do nurses collaborate in practice? and 2) what factors influenced collaboration among oncology nurses? Yin (2009) says that “how” or “why” questions are often used in case study design, however, “what” questions are appropriate to use when conducting an exploratory case study as the data may assist with developing propositions for further inquiry. The case or the main unit of analysis for this study was the oncology nurses, and the embedded units were the nursing roles. Purposive, maximum variation sampling was used to document the diverse variations of oncology nurse collaboration and identify important common patterns (Miles and Huberman, 1994). Maximum variation sampling captured a range of perspectives that
related to oncology nurse collaboration: nurse roles, clinical practice units, and employment status. To obtain as much information as possible from practicing, professional nurses, cases were selected based on the following criteria: The nurses were either registered nurses (RN) or nurse practitioners (RN-EC e extended class) in the province in which the study was conducted; The nurses were employed full-time or permanent part-time in one of the following oncology nursing roles: specialized oncology nurse or advanced oncology nurse (Canadian Association of Nursing in Oncology, 2001); The nurses were working on an in-patient or out-patient adult unit for a minimum of one year (time), and; The nurses were employed by the cancer center (place).
Data collection All nurses (approximately 500) at the cancer center were approached via email communication for recruitment into the study. A total of fourteen nurses volunteered and completed the study. Data for this study were collected over ten months in 2013 through a combination of qualitative methods including openended, semi-structured telephone interviews and document reviews. Interviews Individual telephone interviews lasted 45e60 min and took place during unpaid work time. The nurses were asked to share their experiences, thoughts, and concerns about how they collaborated in the practice setting, and the influence of the personal/ interpersonal, organizational, social, professional, and collegial factors on the collaborative process (Table 1). After the 14th interview no new information emerged and data saturation was achieved. Documents Documents were reviewed to corroborate and augment evidence from the telephone interviews. The documents assisted with obtaining an understanding of the nurses' competencies, qualifications, and professional, regulatory, organizational, and educational factors that may have influenced collaboration. The documents included: a) the job descriptions of each participant at the hospital, b) the Canadian Nurses Association Framework for the Practice of Registered Nurses in Canada (2007), c) the College of
Table 1 Interview guide. 1. 2.
3. 4. 5. 6. 7. 8.
How do you collaborate with other nurses on your unit? What factors influence collaboration among nurses on your unit (organizational, professional, educational, social, personal/interpersonal, time)? What factors facilitate collaboration among nurses on your unit? What are the barriers to collaboration among nurses on your unit? Tell me about the types of collaborative interaction among nurses on your unit? Have you received any formal education about how to collaboration with other nurses? How has your formal education helped/hindered you to successfully collaboration with nurses in the practice setting? Has your employer helped/hindered you to successfully collaboration with nurses in the practice setting?
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Nurses of Ontario National Competencies (2009), and d) the Canadian Association of Nurses in Oncology (CANO) (2001) Standards of Care, Roles in Oncology Nursing and Roles Competencies. Data analysis A thematic analysis of the interview and documentary data was conducted. Thematic analysis entails identifying, analyzing, and reporting patterns within data (Braun and Clarke, 2006). The process for interview data analysis involved listening to the audiotaped interviews and making initial notes, followed by reading the entire transcription of each interview to gain a sense of the meaning of the whole followed by a second reading. Both authors individually coded each transcript and then recoded them together to reach consensus. Coding of the data was completed by hand and NVivo version 10 (QSR International, 2014) was used to organize the data from each transcript. Once coding was completed, analysis of the data began with highlighting emerging themes. The interpretation phase of analysis involved attaching the meaning and significance to the themes. The findings were presented through the major themes with interpretive comment provided throughout. The procedure for analysis of documents was similar to that of the interview data. Rigor Rigor was ensured through the use of Yin's (2009) principles of data collection, and Lincoln and Guba's (1985) criteria for establishing trustworthiness. The use of multiple data sources is an important feature of case study design and is seen as a form of triangulation. The researcher triangulated interview and documentary data to develop a more holistic and contextual portrayal, and corroborate the phenomenon under study (McDonnell et al., 2000). Credibility was achieved through use of multiple sources of evidence. Member checking was completed after emailing the participants a draft of the initial findings and requesting their comments. Dependability was strengthened by creating a study database and maintaining a chain of evidence to develop an audit trail. Confirmability was achieved by developing codes, categories and definitions of these, which could be used by other researchers. Transferability was established by providing an accurate description of the study methodology and findings (Jones and Lyons, 2014). Ethical considerations Research Ethics Board approval was obtained at the university and the hospital where the study was conducted. The potential participants were initially contacted by email at work using a recruitment script, and interested participants were emailed an information letter and the informed consent. Participants were informed that their identity and that of their workplace would not be disclosed. Confidentiality of the participants was ensured by use of coding numbers (example e RN001). Informed consent was obtained by all participants in the study. All participants completed the study. Findings Participants ranged in age from 31 to 64 years with the largest group (n ¼ 9) being between 46 and 60 years. Twelve women and two men were interviewed, and all were registered with the provincial college of nurses as either an RN (n ¼ 12) or an RN (EC) (n ¼ 2). The Canadian Association of Nursing in Oncology (CANO) (2001) suggests there are three nursing roles in oncology: a) generalist nurse, b) specialized oncology nurse, and c) advanced oncology nurse. There were no generalist nurse participants in this
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study as the role is limited to nurses working in settings where patients with cancer receive care along with other patient populations. Since the setting for this study was a cancer center, nurses were either in specialized or advanced oncology nurse roles. The specialized oncology nurse is described as one who has cancer care experience and education (CANO, 2001). The advanced oncology nurse is prepared at the Master's level, and the graduate program is focused in oncology nursing with an emphasis on a clinical disease site (CANO, 2001). Advanced oncology nurse roles include nurse practitioners (RN-EC), clinical nurse specialists (CNSs), and advanced practice nurse educators (APNEs). In this study nine participants were employed in specialized oncology nurse roles and five in advanced oncology nurse roles. Those in specialist oncology nurse roles included: two staff RNs, two patient resource/discharge coordinators, two patient care coordinators, two clinical/unit nurse managers, one research nurse/coordinator, and one senior nurse administrator. The participants in advanced oncology nurses roles were: one clinical nurse specialist, two nurse practitioners, and one advanced practice nurse educator. The level of nursing education ranged from college diploma (equivalent to an associate degree, [n ¼ 5]), baccalaureate degree (n ¼ 3), and graduate degree (n ¼ 6). Over half of the nurses had oncology nurse certification, and two had completed a nurse practitioner certification which is the basic entry to practice requirement for an RN (EC) designation in the province. The nurses' years of experience in oncology nursing ranged from 1 to 39 years. Half of the nurses worked on in-patient units, and the remainder on out-patient units. The nurses were employed in the clinical practice sites of malignant hematology (leukemia, lymphoma, myeloma, bone marrow transplant), solid tumors (head and neck, gastrointestinal, genitourninary, gynecology, prostate, lung, breast), and palliative care. Two themes emerged from the data analysis: 1) Art of dancing together, and 2) The stumbling point. The choice of a dance analogy symbolizes that successful collaboration is comprised of factors that must work together ‘in rhythm”. Without the presence of these factors, collaboration may not occur. Art of dancing together The first theme was related to factors that encouraged or facilitated collaboration among oncology registered nurses. Nurses collaborated for the primary purpose of planning, organizing and providing patient care while using different methods such as teleconferences and emails, and face-to-face conversations to communicate. The preferred method of collaboration was verbal and in-person. RN010, an advanced oncology nurse stated that she liked face-to-face interaction because: “I collaborate directly with them [nurses], so when patients come into this nurse-led clinic, they are triaged by the RN, who then decides if they need a more detailed assessment … then they will call me, and we will talk about patient plans and treatment together … this helps us with continuity of care … and to get to know each other … personally and professionally”. Similarly, RN014 said that face-to-face interaction at weekly staff meetings helped nurses collaborate by contributing to the development and maintenance of the relationship between nurses. The nurses reported that staff meetings were used to connect with nurses in order to get to know each other or as RN014 said staff meetings provided her with the opportunity to reconnect with nurses who may be on a different shift and not seen recently: “I will ask them how's your work going? How are the kids? What can I help you with … you seem really busy? That type of
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stuff … I think this is how collaboration is built … and continues”.
… communicate with them … take time to know the person as a person rather than just a nurse doing their job …” (RN014).
While collaboration was enacted in practice for the central purpose of patient care, oncology nurses reported they collaborated for professional and educational reasons as well. This was accomplished by interacting at professional meetings such as: the Canadian Association of Oncology Nurses annual conference, clinical unit practice council meetings, and when working on special clinical or organizational projects. Nurses once again viewed these opportunities to collaborate as a way of developing and maintaining relationships. RN012 said:
Lastly, having certain personal characteristics was viewed by the nurses as a facilitator of collaboration. Personal characteristics are the traits that distinguish the characteristics or qualities of an individual (Merriam-Webster Online Dictionary, 2015). These characteristics included having a sense of humour and a positive attitude, being open and honest and sharing common interests, values and goals both professionally and personally. Nurses provided some of examples of the impact of individual personal characteristics on collaboration:
“I find it easier with certain individuals who I know … to work on committee projects … it is easier to collaborate with them … because I have known them a long time”.
“They've got to have similar work ethic or practice … common standards … common values, common respect, and common humour … as these things play a really big role in nursing” (RN001).
“I see all of them [nurses at a conference] collaborating and mentoring others … it certainly fosters you to move forward and further your education … and practice” (RN003). Having a previous and/or existing relationship was a facilitator of collaboration. Successful collaboration required a relationship that is developed over time, and is maintained through regularly working together on the clinical unit. RN009 working in an advanced oncology nurse role as a nurse practitioner stated: “Working together for a long time in hematology … the ones [nurses] that I've had a good rapport with from before [when previously working as a specialist oncology nurse) … we share and exchange information and they contact me for questions … they look to me for leadership … and support … and collaboration”. Collaboration was facilitated by having oncology nursing knowledge and experience. Demonstrating knowledge and experience contributed to the development of professional credibility, trust, and mutual respect among the oncology nurses. The nurses said: “Some of the [clinical] trial nurses come from the in-patient units or out-patient settings, but within [the hospital], and those nurses tend to have better relationships with the unit nurses … having a prior relationship really does help … with collaboration” (RN006). “If I had been someone who came there [hospital] with no experience in head and neck, they probably would collaborate less because they wouldn't perceive me as having the knowledge they are looking for …” (RN010). Other facilitators of collaboration included possessing certain interpersonal skills such as having effective communication skills e good listening skills, being respectful of other individual's opinions and nursing roles, participating in a conversation, and demonstrating a willingness to cooperate and collaborate. Interpersonal skills involve an interaction between individuals that assist with building relationships: “Having good communication skills is so important … they [nurses] have to be open to suggestions, open to support and help … and actually go the extra yard for the patient … if not, there are problems collaborating with them …” (RN013). “To form genuine relationships with colleagues … the golden rule … is, I'm going to treat people the way I want to be treated
“Sometimes it depends on the personalities; you know you can work with one group and have a great day, and you can work with … one person, and it could be a horrible day … personal factors can be huge” (RN007).
The stumbling point The second theme related to barriers or factors that discouraged or impeded collaboration from occurring among the oncology nurses. Role ambiguity was described by the nurses as being a barrier to collaboration. Nurses in certain roles such as advanced practice nurse roles (APN) and nurses working in clinical trials believed there was a lack of understanding of their specific roles and this discouraged nurseenurse collaboration: “I feel quite isolated at times … being an individual in this role [APN] … they [nurses] need to understand that you're on any floor [in the hospital] … it's hard to be collaborative when there is only one of you … and they need to have an understanding of the role” (RN002). “In-patient nurses really have little idea of what clinical trials is about … they have a lack of knowledge about what clinical trials nurses do … they just see it as a make work project for them” (RN006). The nurses reported that lack of leadership support was a barrier to their collaboration. This related to organizational structures and resources, and differences in shared philosophical values and goals. RN009 said the recent changes in model of care (e.g. moving to a clinical site specific model) mandated by leadership resulted in reduced continuity of patient care and less opportunity for nurseenurse collaboration: “The environment has always been … a little bit hostile … and with a lot of changes going on … and the head of the program not good … this has caused anger and sort of unhappiness … and general burnout … not great for collaboration” Similarly, the nurses described organizational structures that impaired nurseenurse collaboration by discouraging open communication and shared decision-making regarding patient care: “A big barrier I'm finding right now is the upper [management] at the very top … they have specific objectives and agenda that they want people in the middle … and the bottom to exercise … to just do it, but the rules of the place don't allow that to happen
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… we are such a big institution … we don't work well for patients … because I can't convey things to the nurses” (RN014). “If you're in an environment where it's punitive to ask questions … then people are not going to speak up … they would sit silent … and not say anything with anybody about what should be done …” (RN007). Collaboration requires leadership to promote/support the development and maintenance of relationships among oncology nurses. The nurses reported the structure of their work was a barrier to collaboration given scheduling and staffing issues and heavy workload relating to patient care: “There is no time [for collaboration] … because of the busyness of people … doesn't help with building the relationship …” (RN002). “Our workload is extremely heavy … it's not always easy [to collaborate]” (RN005). “I don't want to use the term clique … but some people are not part of that model [willingness to collaborate] … the casual staff or relief staff or who do occasional shifts are … kind of out of that … unlike most of the nurses who do work consistent lines and with the same team member” (RN008). The nurses said leadership did not provide the resources needed for successful collaboration. RN013 said that a clinical manager wanted to create an opportunity for nurses to collaborate but was impeded by senior management: “She has been trying to organize a half day retreat for clinical trial nurses so we can collaborate and get to know each other and work together on things that we want to aim for, and getting that support from higher up and giving us support by not having patients to see that day has not been very forthcoming”. Multigenerational issues among the nurses were also a barrier to collaboration but for different reasons. Older nurses were less interested in collaborating with younger, new, or casual part-time nurses who they did not have a relationship with, and who they viewed as less professionally credible. “I do tend to gravitate towards my peers of my age group … because I find they are the ones that know things or know how to get things done, or can help you out” (RN013). “Nurses who are younger or novice or new wouldn't be able to give you as much information … so they are more difficult to collaborate with …” (RN004). Younger nurses reported that they were less interested in collaborating with some older nurses due to having a prior negative interaction, and because of communication problems: “There are a few older nurses that have been on my unit for 30 years and I think they negatively impact [other nurses] because they are quite jaded … its mostly hard on younger nurses” (RN003). “On our team there is a big age gap … I'm not the same age as them … people [older nurses] have a lot of baggage … so it's hard to get over that baggage … especially since nurses eat their young … and it's kind of true … they [older nurses] leave them [younger nurses] to kind of flounder … they not interested in collaborating with them …” (RN009).
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“Some [older] nurses are not so good at communicating with young or new nurses … you can be harassed or blazed … or singled out from the rest of the team” (RN008). Lastly, nurses reported that having a ‘difficult personality’, a negative attitude, being resistant to change, not being open and honest, and having different goals, values, and beliefs in relation to work issues were barriers to collaboration: “Some nurses have anger and unhappiness … and are never going to change … they just don't want to collaborate [with you] … and you don't want to collaborate with them …”(RN009). “Being negative created such an awful [workplace] … and it was disheartening to see behavior among certain nurses … you wouldn't tend to go to them for help or anything …” (RN001).
Discussion Our findings add to the literature on intraprofessional collaboration among nurses. Collaboration is a complex interactional process that requires key factors to be present at both the organizational and individual level. At the organizational level, nursing leadership need to support collaboration by promoting a common vision and/or philosophy of collaborative practice (Borrill et al., 2002). The nurses in this study reported that organizational leadership was viewed as a barrier to their collaboration largely due to structural, philosophical and resource issues. Some nurses mentioned the environment was ‘punitive’ or ‘hostile’, two factors that would impede collaboration. Collaboration also requires having the time and opportunity to build and maintain the relationships among nurses that contribute to the development of essential mutual trust and respect. With this in mind, nursing leadership needs to provide resources to ensure realistic staffing levels and reasonable patient workload assignments, as this not only encourages collaboration, but may also improve nursing job satisfaction and quality of care for patients (Manojlovich et al., 2011; Trinkoff et al., 2011; Valiani, 2013). Resources should also include standardized documents, policies and leading edge technology that could facilitate opportunities for communication, coordination and systems needed to enhance collaboration (Cabello, 2002; D'Amour and Oandasan, 2005; McCallin, 2005). Role ambiguity was considered a stumbling point or barrier to collaboration. Some participants had little knowledge of what certain oncology nurses did, and because they did not understand the role, they were less interested in collaborating with those nurses. The roles that were most confusing were those in research nurse and/or those in advanced practice nurse roles. While a somewhat surprising result given that all participants were oncology registered nurses employed at the same organization, there is some literature to support this finding. Ocker and PawlikPlank (2000) found in their review of the literature that the research nurse role can be poorly defined and may have role overlap with the oncology nurse clinician when providing care for patients enrolled in clinical trials. This creates the opportunity for confusion in relation to role definition and role ambiguity. The issue of role ambiguity between different types of advanced practice nurses (e.g. clinical nurse specialists, nurse practitioners) has been well documented in the literature. In the last decade cancer care has become highly specialized, thus requiring different types of RN roles. Role ambiguity may be a barrier to the integration of oncology nursing roles. Several authors suggest that leadership, and particularly nursing leaders are in the ideal position to improve role clarity by facilitating the development of documents that
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clearly describe and communicate the role to not only nurses but to all healthcare providers (Anderson-Johnson and Nelson, 2012; Farrell et al., 2011; O'Rourke and White, 2011; Patel et al., 2012). For optimal collaboration to take place, oncology nurses must understand the knowledge, skills, and roles of each other in order to maximize and respect the expertise of each nurse. Generational issues also discouraged collaboration among the oncology nurses. Older, experienced oncology nurses reported less interest in collaborating with younger nurses with little or no oncology experience, and the younger nurses reported observing and/or experiencing bullying comments and behaviors that negatively impacted their collaboration with older nurses. Moreover, because of these experiences, younger nurses were less willing to collaborate with older nurses. The fact that the oncology nurses found it challenging to collaborate with nurses from different generations is not surprising. Today multigenerational nurses are working together in many healthcare settings. Nursing leadership has a key role in creating work environments that embrace the diversity and contribution of all nurses (Outten, 2012) regardless of age. If not addressed, the impact of diversity among multigenerational caregivers can cause conflict, which may result in poor patient outcomes, job dissatisfaction and potentially turnover (Outten, 2012). To improve multigenerational collaboration nurses need to be flexible in their communication approach, and consider diversity as a positive factor in building effective teams (Barry, 2014). Moreover nurses should remember that effective collaboration is a required professional competency with is main goal on improving patient care outcomes. While favorable and supportive organizational leadership is important to nurseenurse collaboration, this alone is not enough. Our findings showed how the individual nurse can positively or negatively impact the collaborative process. For example, if a nurse chooses not to collaborate, or if his/her attitudes and communication skills are not conducive to entering into collaborative interaction then the collaboration is doomed to fail. As D 0 Amour and colleagues (1999) note “… collaboration is, by its very nature voluntary” (p. 141). Furthermore, if a nurse is employed on a unit where certain staff members are known to be ‘unapproachable’ no other nurse will seek out that individual's assistance unless truly necessary. This can be especially problematic for a new graduate or junior nurse who may need the mentoring expertise of the senior nurse. Many nurses transitioning into new roles often feel afraid or intimidated to seek assistance from experienced nurses who they view as unapproachable (Romyn et al., 2009; Wu et al., 2012). Our findings also highlighted the importance of the interpersonal relationship as a central component of collaboration. This was not surprising as it seems natural that nurses would value what is viewed as a fundamental goal of the nursing profession e developing relationships. Farrell (2001) suggests that relationships are built through the formation of a ‘collaborative circle’, which combines the elements of friendship and work. Over time, colleagues develop their own routines, language, and individual roles. We found this to be true in our study; collaboration was influenced by the existence of a prior and/or current relationship among the RNs; as well as the interpersonal skills of the individual nurses. When the RNs invested in a positive way in the relationship; collaboration was successful. Whereas, if the interaction was negative or neglected, the relationship was poor and collaboration was unsuccessful. The importance of good interpersonal relationships cannot be understated. While they take time and effort to develop and maintain; relationships are a key facilitator of collaboration. Revisiting our dance analogy, for collaboration to be effective the dancers must work in rhythm with each other, and any stumbling points along the way can impact the collaboration dance.
Limitations While the sample size was small in quantitative terms, in qualitative case study design, this was viewed as a strength rather than a limitation as it supported an in-depth description of nurse enurse collaboration. There were a few limitations pertinent to this study: it took place at one organization, and in one country, and therefore future studies would be required to determine the applicability of findings in other settings and geographic locations. Conclusions Nurseenurse collaboration is a complex, interactional and relational process among colleagues who share a common professional education, values, socialization, identity, and experience (College of Registered Nurses of Nova Scotia, 2014). Our findings suggest that collaboration occurs over time during which nurses build and maintain relationships. For collaboration to be successful many factors at both the organizational and individual level need to be in place. Most importantly nurses need to be open to collaborating with other colleagues. Given that excellence in patient care is a shared goal among all healthcare providers, facilitating opportunities for collaborative practice is essential. Further research is needed to obtain an understanding of the impact of nurseenurse collaboration on patient, nurse, and system outcomes. Conflicts of interest statement “We wish to confirm that there are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome. We confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. We further confirm that the order of authors listed in the manuscript has been approved by all of us. We confirm that we have given due consideration to the protection of intellectual property associated with this work and that there are no impediments to publication, including the timing of publication, with respect to intellectual property. In so doing we confirm that we have followed the regulations of our institutions concerning intellectual property.” References American Nurses Association, 2003. Nursing Social Policy Statement. Author, Washington, DC. Anderson-Johnson, P., Nelson, J., 2012. Testing a model of clarity of self, role, and system as predictors of job satisfaction of nurses in Jamaica. In: 23rd International Nursing Research Congress: Sigma Theta Tau International, the Honor Society of Nursing. September 12. Apker, J., Prop, K., Zabava-Ford, W., Hofmeister, M., 2006. Collaboration, credibility, compassion and coordination: professional nurse communication skill sets in health care team interactions. Journal of Professional Nursing 22, 180e189. Barry, M., 2014. Better, safer patient care through evidence-based practice and teamwork. The American Nurse 46, 12. Bedwell, W., Wildman, J., Diazgranados, D., Salazar, M., Kramer, W., Salas, E., 2012. Collaboration at work: an integrated multilevel conceptualization. Human Resource Management Review 22, 128e145. Borrill, C., West, A., Dawson, J., Shaprio, D., Rees, A., Richards, A., et al., 2002. Team Working and Effectiveness in Healthcare: Findings from the Healthcare Team Effectiveness Project. Aston Centre for Health Service Organization Research. Retrieved January 19, 2014 from. http://homepages.inf.ed.ac.uk/jeanc/DOHglossy-brochure.pdf. Braun, V., Clarke, V., 2006. Using thematic analysis in psychology. Qualitative Research in Psychology 3, 77e101. Cabello, C., 2002. A collaborative approach to integrating outpatient and inpatient transplantation services. Outcomes Management 6, 67e72. Canadian Association of Nursing in Oncology, 2001. Standards of Care, Roles in Oncology and Role Competencies. Retrieved May 28, 2014 from. http://www. cano-acio.ca/nursingroles.
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