Reaching Collaboration Through Empowerment: A Developmental Process

lo(;;\.\’ C L I N I C A L

I S S U E S

Reaching Collaboration Through Empowerment: A Developmental Process Barbara Sheer, DNSc, NPC

Nurses are well positioned to pIay an influential role in health care reform. As the concept of collaboration takes on new meanings, nurses must be prepared to function in interdisciplinary groups. They need to move from a unidisciplinary model of problem solving through a nursing approach to a multidisciplinary model, where different professions work as equal members of a team. The ultimate goal is to reach an interdisciplinary model in which team members from a variety of disciplines modify their perspective in light of other perspectives. Empowerment is viewed as an individual developmental process that occurs in stages during a period of time. Nurses will be better able to collaborate in an egalitarian manner once they have personally become empowered. It is up to nursing to seize the opportunity to become an equal partner in today’s health care.JOGNN, 25, 513-517; 1996.

Collaboration in the Health Care System Health care reform has profound implications for the manner in which nursing is perceived in the future. It is becoming apparent that society can no longer afford high technology, tertiary care for everyone. The length of hospital stays is decreasing, giving rise to a higher acuity level in the hospital and in the home. The health care pendulum is shifting toward health promotion and disease prevention as a measure of long-term cost containment. These changes reflect not only a shift from traditional medicine to primary health care but also to a system in which nurses are equal partners in the delivery of care. During the past decade, nurses have actively sought a more influential role in health care, addressing the need for collaborative, rather than unilateral, models of health care delivery (Mauksch, 1981). Nurses are well positioned to take advantage of the changes occurring in health care reform. They have a long history of primary

July/August 1YYG

care and have never strayed from a focus of health as a centering point (Mooney, 1995). However, in the past they have been limited in their ability to fully participate in primary care because of a morass of legal and historical precedents, outdated management systems, and traditional leadership values (Trofino, 1992).

With the shift from traditional medical care to primary health care nurses are in a pivotal position.

Nurses of the future will need to position themselves to practice to the fullest extent of their ever-increasing scope. Nurses must be prepared to function in a changing environment as a member of the health care team. The concept of collaboration will take on new meaning for them. This articles discusses the developmental process of empowerment that will help nurses to function as equal partners in an multidisciplinary team.

The Meaning of Collaboration Although collaboration has not been clearly defined, the description of models of collaborative practices are increasing in the literature. The definition of collaboration most often used in the nursing literature is “to work together, especially in a joint intellectual effort” (Baggs & Schmitt, 1988; Evans, 1994). When taken in the context of interdisciplinary models, critical attributes of collaboration include sharing in planning, making decisions within a collegial structure, solving problems, setting goals and assuming responsibility, and accepting accountability (Baggs CL Schmitt, 1988; Mauksch, 1981; Pike, 1991; Pike CL Alpert, 1994; Weiss, 1985). Mutual

J O G N N 513

CLINICAL I S S U E S

problem solving is not typically found within a traditional hierarchy (Weiss, 1985). Collaboration implies trust and respect for one another and for the work and perspectives that each participant contributes (Pike clr Alpert, 1994). It signifies an evolving relationship. I t implies a bond or synergistic alliance that maximizes the contributions of each participant, recognizing complementary roles (Fagin, 1992; Pike, 1991). Coeling and Wilcox (1994) stress the importance of the communication process with critical segments being content, relationship, and time. I n a collaborative relationship every member has power. Members are satisfied with their level of power (Drinka, 1994). Power within a collaborative relationship remains in a dynamic state of being defined and redefined i n situational and organizational terms (Gomberg clr Sinesi, 1994).

proach to practice. This results in fundamentally different ways of approaching individual client problems. In the multidisciplinary stage of development, individuals representing different professions work together as a team. Members of each discipline share their knowledge and skill in approaching the problems to be solved. This effort affords the opportunity for team members to learn about alternative methods of approaching problems.

To practice to the fullest extent of their scope of practice, nurses need to be equal members of a comprehensive interdisciplinary team.

Barriers to Collaboration Barriers to collaboration include education, lack of understanding of the roles and responsibilities of other professions, ineffective communication, sex role stereotyping, hierarchy of relationships, class, and economics.

The interdisciplinary stage of development is achieved when the individual team members understand and are conversant in the cognitive maps of other members. The group functions as a team when individuals modify their perspectives in light of others’ perspectives. This stage of team functioning can be accomplished more easily by educating different professionals together in an educational model that focuses on collaboration. Some medical schools are beginning to have their medical students interact with other members of the professional team as part of their curriculum. Many courses are team taught by nurses, physicians, social workers, and other health care professionals. In this model, knowledge is discovered in the collaborative interchange. The new knowledge base is greater than the sum of the knowledge of the participants. Additional insights are discovered through the group process.

Education Education is a barrier on two levels. Weiss and Davis (1983) suggest that nurses with graduate education demonstrate greater competence in collaborative practice behaviors than do nurses with a baccalaureate degree. This may simply be a function of increased professional maturity or because advanced preparation places one on an educational level that is equivalent to other professions and increases critical thinking. The gap between medicine and nursing has been narrowing, and some nursing leaders are suggesting the doctorate as an entry level degree in an effort to close the gap (Fagin, 1992). On another level, experts (Clark, 1994; Fagin, 1992; Katzman clr Roberts, 1988) advocate educating interdisciplinary health care professionals together because cooperative learning fosters positive collegial relationships. Cooperative learning can produce what Clark (1994) refers to as a reflective practitioner who is conversant in the cognitive maps, or thought processes, of other health professionals. Incorporation of the cognitive maps and value systems of other professionals assists the practitioner to understand different ways of approaching a problem. I t assists the group to move through three developmental stages: from the unidisciplinary stage through the multidisciplinary stage to the interdisciplinary stage, which is the ultimate goal. The current structure of our educational system fosters independence, individualism, and competition. Students are socialized into a profession by cultivation of the values of that profession. Knowledge is transmitted from instructor to student. This method fosters individualism and unidisciplinary group functioning but is antithetical to the collaborative process. The knowledge, skills, and values that are internalized guide the individual’s ap-

Roles and Responsibilities Another major barrier to collaboration is the lack of understanding of roles and responsibilities. Many physicians and nurses who have been in practice for more than 30 years still picture the nurse as a handmaid who carries out the physician’s orders (Bradford, 1989). Even some younger physicians perceive the nurse as providing all of the care but d o not see the need for collaborating to achieve high quality care (Bradford, 1989). Measures suggested by Evans (1994) to increase professional understanding of other disciplines include interdisciplinary education and shadowing members of other disciplines for a day to discover what they do. Traditionally, there has been little in the professional development of physicians that has helped them comprehend the practice of nursing. Readiness to collaborate requires familiarity with the nature and scope of another’s practice (Weiss, 1985). Resistance to collaboration may be related to lack of understanding and appreciation for the actual and potential contributions of various groups in health care.

514 J O C N N

Volume 25, Number G

Developmentally Based Care

Ineffective Communication Ineffective or decreased communication constitutes a great barrier to interdisciplinary collaboration (Baggs 8r Schmitt, 1988; Bradford, 1989; Evans, 1994). The best communication occurs when the participants mutually listen, understand, accept, and are reasonably satisfied with the relational context. The responsibility for good communication rests on the participants. In 1967 Stein described the “doctor-nurse game,” in which nurses communicate their recommendations to physicians without appearing to make them and physicians request nurses’ recommendations without appearing to ask for them. More recently Stein, Watts, and Howell (1990) found that the game is no longer being played by nurses. The nurses in this study wanted to become autonomous and work cooperatively as equal partners. Although some may argue that to be autonomous does not suggest cooperative work with others, autonomy is necessary to the collaborative process. A concept inherent in the definition of collaboration is to work together (Evans, 1994) or to “co-operate.” The principal difference over time in the two groups of nurses studied by Stein et al. (1990) was the manner of socialization throughout their educational process. In addition, the social environment had changed, resulting in a deterioration of public esteem for physicians. Gender Issues Gender issues have been a barrier to collaboration because traditionally most nurses have been women and most physicians have been men. Men and women are socialized differently from birth. During development, women are socialized to have a greater need for involvement, whereas men are taught to value independence, status, and hierarchy. Only recently have these differences been discussed and analyzed in the work place. Glass (1992) found men more task oriented and women more relationship oriented. Men viewed themselves as being more precise than women. Consistent with these findings, Coeling and Wilcox (1994) found that physicians emphasized content issues, whereas nurses expressed concern with relationship issues. Although physicians expected others to be friendly toward them, they preferred to remain distant from others. Hierarchy of Relationships Historically, nurse-physician relationships have been characterized by physician dominance and nurse deference. The physician’s role is much like the father who brieflyvisits home, then leaves for work. The nurse is like the mother, who remains to care for the children (patients) 24 hours a day (Katzman & Roberts, 1988). The medical paradigm is hierarchical in nature, with the physician being the captain of the ship. Nurses have worked hard throughout the years to shed the handmaid image. Prescott and Bowen (1985)found that physicians frequently challenged the authority of nurses to make certain decisions based on the belief that nurses lacked the necessary knowledge base. They verified that the compe-

July/Augurt 1996

tence of a physician is assumed by everyone, and the incompetence of a physician must be proven to be believed, whereas each nurse must prove herself or himself in each new experience. An example of this continues as advanced practice nurses challenge each state for expanded privileges, such as prescriptive writing ability. In every state nurses must prove their competence in pharmacology to medical boards and the legislatures, whereas physicians never need to prove competence in pharmacology to any governing body after initial licensure. A final vestige of the hierarchy can be found in the use of names and titles. Many nurses continue to overlook being referred to as “girls” by physicians and expect to be addressed on a first name basis. However, physicians most often are addressed by their title by nurses. Social Class Social class gaps have been real (Fagin, 1992). Nursing traditionally has drawn students from the middle and lower socioeconomic classes. Medicine has drawn students from the upper middle and upper socioeconomic classes. As more nurses receive master’s and doctoral degrees, the social status gap will become less of a barrier. Economics Physicians traditionally have been in independent practices and have been well paid for their services. They often have been the employer, whereas nurses have remained the employee. With the advent of managed care, physicians are losing some of their independence as they become the employee. In many situations, advanced practice nurses are on equal status with physicians on the team. Third party reimbursements often are made for the task or procedure performed, rather than by the professional performing the task. In this way, nurses and physicians often are competing for the same health care dollar.

Research in Collaboration Research has supported the value of collaboration. Collaborative relationships provide positive outcomes for patients, families, and providers of care (Evans, 1994; Fagin, 1992; Pike & Alpert, 1994). Standards of excellence are reached in a cost-effective manner, particularly in the care of the elderly and hospitalized acutely ill adults (Evans, 1994). There is increased job satisfaction and increased self-esteem in nurses. According to Stein et al. (1990),both nurses and physicians can benefit if the relationship becomes more mutually interdependent. Both subservient and dominant roles are psychologically restricting. When a subordinate becomes liberated, there is the potential for the dominant one to be liberated also.

Developmental Model for Empowerment To adequately move into a collaborative model, nurses must be competent and must believe in their competence. They need to overcome timidity, fear, and self-

J O C N N 515

CLINICAL I S S U E S

doubt and impart a sense of value about their work (Evans, 1994; Pike, 1991). They need to develop a vision of practice. Reaching the vision is a developmental process. A developmental model of empowerment (Kieffer, 1984) can be used to help nurses attain the personal characteristics needed to collaborate on an egalitarian level. The model progresses from powerlessness to participatory competence. Kieffer refers to four distinct and progressive eras or stages.

Throughout the development of empowerment there is a movement from victim to colleague. Empowerment allows nurses to break free of constraints and to initiate creative care. The process of empowerment is never completed. It is evolutionary and incremental, at times bold and demanding. Initially it is difficult to achieve and finally so easy to accomplish. If empowerment is nurtured, it can become part of the culture.

Era of Entry The era of entry begins with the individual nurse feeling somewhat powerless within the system. There is determination and pride mixed with a feeling of isolation and the sense that nothing the individual can d o will really make a difference. There is a deep sense of commitment and feelings of support for and attachment to the community of peers. At this point there is a mobilizing episode that signals the birth of participatory competence. The episode is perceived as an attack on the nurse’s sense of integrity and mobilizes the person to enter a stage of participation. The nurse may be unsure of how to begin but is determined to do something. Progression through this stage may take a year, during which time there is demystification of power and reorienting the self in relation to authority.

Empowerment enables nurses to engage in collaborative practice. It allows to them to take risks and develop their own creative vision. Strategies for empowerment include education, mentoring, political activism, organization, women’s health issues networking, external relationships and =-education.

strategies f o r the Development of Empowerment

To collaborate on an equal level nurses must be empowered.

Era of Commitment The era of commitment is the culmination of the developmental process of collaboration. It is similar to adulthood in that experience becomes the core of learning. The relationship between experience and reflection evokes new understandings. This process is more than acquiring new skills. It is a process of reconstructing and reorienting personal beliefs about social relationships.

Education is a prerequisite for a profession. If the goal is collaborative practice on a collegial level, graduate education is required. To foster the formation of interdisciplinary teams of reflective practitioners, the educational process needs to focus on collaborative learning approaches. The emphasis needs to be on active learning in interdisciplinary groups. The desired outcome is a broader perspective and a knowledge and appreciation of being able to function as a team member in a changing health care system. Mentoring is the next step. A mentor guides others through the developmental stages toward empowerment, acting as a role model and assisting those seeking mentoring to gain the confidence necessary for effective problem solving. The mentor projects the image the individual desires to attain. Political activism on the local, state, and national levels is another step toward empowerment. Nurses are in a unique position to share their vision and knowledge with policy makers. Legislators need to be informed of nurses’ sometimes invisible contribution to the health care of the nation. By sharing their expertise, nurses will gain additional confidence in the realization of the importance of their message. Professional organizations offer a variety of opportunities for empowerment. Joining together with others with a similar vision creates a sense of community focus and offers a mechanism for the individual to apply new insights. It provides a support system for individuals at all stages of development. It provides support for the neophyte, an opportunity for developing leadership skills for the more empowered, and the opportunity for mentoring

516 J O G N N

Volume 25.Number 6

Era of Advancement The era of advancement parallels childhood. The nurse relies on an outside mentor who acts as a role model. This stage also usually develops throughout the course of a year. Individuals become part of an organization that generates a sense of strength. The organization or peer group affords the nurse a support system with which to engage in mutual problem solving. Confidence grows as the activities continue. There is cultivation and clarification of pertinent issues. Responses to the issues are refined and synthesized. This process ultimately leads to the maturation of empowerment. Era of Incorporation At this point nurses move into the era of incorporation.

Survival skills are constructed, organizing skills are learned, and leadership skills are developed. Successfully negotiating roadblocks and obstacles to goals strengthens these skills. As individuals’ skills increase, they begin to see themselves as skilled problem solvers. This insight ushers them into a more mature state of empowerment.

Developmentally Based Care

for individuals who have reached the stage of commitment. Focusing on women’s health issues capitalizes on the strengths of nursing. It affords another mechanism for support through the developmental stages of empowerment. Upon becoming personally empowered the nurse is ready to collaborate on a egalitarian level. External relationships with other professionals provide the opportunity for collaboration on multiple levels. The nurse is ready to move from unidisciplinary group functioning, through multidisciplinary groups, to the ultimate goal of the interdisciplinary group. Today the health care paradigm is changing. The shift is toward health promotion and disease prevention. This is essentially an area where nurses excel and where collaborative efforts at providing heal.th care are possible. It is up to nurses to seize the opportunity to make a difference. All nurses can mature through the developmental stages of empowerment, but they must take the first step. Change can be frightening, but there are mentors and support systems in place. Nursing can become an empowered profession if nurses decide to move into the future. One thing is for certain, change is inevitable; it will occur with or without their input.

References Baggs, J. G., & Schmitt, M. H. (1988). Collaboration between nurses and physicians. Image:Journal of Nursing Scholarship, 20, 145-149. Bradford, R. (1989). Obstacles to collaborative practice. Nursing Management, 20,721-723. Clark, P. G., (1994). Social, professional and educational values on the interdisciplinary team: Implications for gerontological and geriatric education. Educational Gerontology, 20, 35-51. Coeling, H. V., 62 Wilcox, J. R. (1994). Steps to collaboration. Nursing Adm in istration Quarterly, 18(4), 44 -55. Drinka, T. J. (1994). Interdisciplinary geriatric teams: Approaches to conflict as indicators of potential to model teamwork. Educational Gerontology, 20, 87-103. Evans, J. A. (1994). The role of the nurse manager in creating an environment for collaborative practice. Holistic Nurse Practitioner, 8(3), 22-31.

July/August 199G

Fagin, C. M. (1992). Collaboration between nurses & physicians. Nursing &Health Care, 13,354-363. Glass, L. (1992). He says, she says: Closing the communication gap between the sexes. New York: Putnam Publishing. Gomberg, S., & Sinesi, L. (1994). A collaborative interaction model and the implementation of shared governance. Holistic Nurse Practitioner, 8(3), 12-21. Katzman, E. M., Roberts, J. I. (1988). Nurse-physician conflicts as barriers to the enactment of nursing roles. WesternJournal ofNursing Research, 10, 576-590. Kieffer, C. H. (1984). Citizen empowerment: A developmental perspective. Prevention in Human Services, 3,9-35. Mauksch, I. G. (1981). Nurse-physician collaboration a changing relationship. Journal of Nursing Administration, 11(6), 35-38. Mooney, M. M. (1995). Primary care is no place for physicians. Nursing G Health Care, 16 84-86. Pike, A. (1991). Moral outrage and moral discourse in nursephysician collaboration. Journal ofProfessiona1Nursing, 7, 357-363. Pike, A., & Alpert, H. B. (1994). Pioneering the future: The 7 north model of collaboration. Nursing Administration Quarterly, 18(4), 11-18. Prescott, P. A., & Bowen, S. A. (1985). Physician-nurse relationships. Annals oflnternal Medicine, 103, 127-133. Stein, L. I. (1967). The doctor-nurse game. Archives of General Psychiaty, 16 699. Stein, L. I., Watts, D. T., & Howell, T. (1990). The doctor-nurse game revisited. The New EnglandJournal ofMedicine, 22, 546-549. Trofino, J. (1992). On the scene: Historical overview Riverview Medical Center. Nursing Administration Quarterly, 16, 20-24. Weiss, S. J. (1985). The influence of discourse on collaboration among nurses, physicians and consumers. Research in Nursing and Health, 8,49-59. Weiss, S. J., & Davis, H. P. (1983). Validity and reliabilityof the collaborative practice scales. Nursing Research, 34, 299305.

Addressf o r correspondence: Barbara Sheer, DNSc, NPC, University of Delaware, College of Nursing, Newark, DE 19716. Barbara Sheer b a n assistant professor in the College of Nursing of the University of Delaware in Newark, DE.

J O C N N 517