Developing a Culture of Interprofessional Collaboration

As the chief nursing officer (CNO) of a large metropolitan hospital, Jesse has established a strong reputation as a “mover and shaker” in nursing leadership circles. He is greatly admired by his colleagues who are CNOs at other hospitals in the region. For the most part, Jesse is proud of his many accomplishments and very satisfied in his current role at the hospital, but lately he has been feeling restless and is concerned that the entire organization could do a better job of creative thinking to address needed changes to ensure excellence in patient care, excellence in the work environment, and excellence in individual professionalism. For this and more essays

Jesse shares his concerns with his colleagues on the hospital executive team, and they all reassure him that he should simply be satisfied with the hospital’s reputation as a premier place to work, receive care, and practice professionally. Despite his colleagues’ opinions, Jesse feels that there is an opportunity to make the best even better. He feels that there are a number of age-old issues confronting nursing that never seem to be completely addressed or resolved. The notion of interprofessional practice and collaboration is one example. Jesse realizes that the nursing profession has talked about the importance of interprofessional practice for at least 45 years, and in 2010, interprofessional practice was cited as critical for optimal patient outcomes in the Robert Wood Johnson Foundation’s Future of Nursing report, the Institute of Healthcare Improvement’s report, and the Agency for Healthcare Research and Quality’s report. Developing a Culture of Interprofessional Collaboration:

Jesse realized that the healthcare literature is replete with articles citing the benefits of interprofessional collaboration and its importance in enhancing job satisfaction, organizational commitment, and professionalism and for minimizing job stress and interprofessional conflicts. In spite of all of the evidence and rhetoric about interprofessional collaboration, Jesse realized that the hospital had not achieved interprofessional collaboration or practice. Although the hospital had made great strides in improving the organizational culture by addressing behavioral standards and values that were to be the norm for every employee and every physician affiliated with the hospital, there were many instances when physicians practiced very independently from the nurses caring for their patients.

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Both nurses and physicians were frustrated, feeling that they were not valued or respected by the other party for their knowledge and skills in caring for patients and families. Several particular situations triggered Jesse’s concern about the subject, and he felt that there was an underlying tension that could be a platform upon which to initiate some creative dialogue and ideas for changing the culture to support and encourage interprofessional collaboration and practice. He realized, however, that it was impossible to motivate others to make a change in their relationships and interactions with others, but he considered his options for developing some internal motivation that would spur individuals to take the lead in championing such a change. Jesse wanted to ensure that there was alignment among nurses and physicians with the hospital’s behavioral standards and values, which were widely accepted by employees and physicians throughout the organization. It seemed, however, that some physicians and nurses felt that collaboration was not a part of the accepted values. Jesse wanted to change this perception so that interprofessional collaboration would be a valued behavior among all disciplines and specifically between nurses and physicians.

After much thought Jesse decided to form an interprofessional task force composed of nurses, physicians, and key individuals from other divisions such as radiology, dietary, surgery, and laboratory services. In choosing individuals to be a part of the task force, he invited individuals who were exemplar collaborators and some who were referred to as “problem” individuals. He also identified a group of individuals who could be champion leaders on each of the nursing units from the recommendations of the directors of the respective nursing services. The plan was to roll down the work of the task force to the point-of-service and to bubble up ideas from the point-of-service to the task force.

One of the directors suggested that all newly hired nurses and nurses in the nurse residency program be rotated for a day or more in each of the ancillary departments, which would give the orienting nurses the opportunity to see the internal workings of each of the departments and how they interfaced with the respective nursing units. All directors felt that this was a very worthwhile plan, although there were some front-end investment costs because the on-boarding of new nurses would take at least an extra week. They all believed that this action would create a better understanding of the intersections between nursing and ancillary support departments. Read more about Developing a Culture of Interprofessional Collaboration

The first meeting of the interprofessional task force was very introductory in nature, and most participants were a bit skeptical about the efficacy of such an initiative. The “problem” physicians and nurses were the most skeptical, and their body language spoke loudly that they did not value this new initiative, nor did they value the notion of collaboration. Some of the more skeptical physicians were of the belief that physicians were the authority for the patient plan of care and that nurses were simply to follow physician orders. A few nurses on the team were quite content simply to follow physician orders and had no need for any further interaction to discuss a patient’s condition, needs, or plan of care. On the other hand, a few very progressive physicians and nurses were excited about an initiative to improve communication and collaboration among all team members for the benefit of patients and families. Fortunately, Jesse noticed that these individuals were more vocal in the task force, and he hoped that they would create the context for an innovative strategy to improve point-of-service interprofessional collaboration and provide some peer pressure for the others to follow. Jesse realized that this entire initiative was a cultural change and that it would need time to be formulated, implemented, and solidified in the minds of individuals for collaboration to become a new value and behavior.

The interprofessional task force convened a number of meetings, and the group brought forth many ideas. Part of the process included presentations of studies in both the medical and nursing literature that demonstrated the importance of interprofessional collaboration in ensuring optimal patient outcomes. Most task force participants were very engaged in the process, inquired as to how certain actions might be initiated at the unit level, and asked how they might ensure that nurses and physicians at the unit level could take ownership of the change. Jesse and the rest of the executive team reviewed the progress of the task force and attended many meetings to assure the team that they were supportive of their work. The executive team also brought in an industrial organizational psychologist who was a noted specialist in to facilitate the team meetings and discussions. The group was quite energized with this external consultant, who brought a new perspective and fresh ideas to the table. Developing a Culture of Interprofessional Collaboration:

After several months of meetings, the task force was finally ready to roll out an innovative strategy to promote interprofessional collaboration at the unit level. Jesse and the rest of the executive team were amazed at the ownership that the team had taken and how enthusiastic they were to launch the initiative. One physician leader offered to be the physician champion, and the group planned that she would present the initiative and plan at each of the specialty physician meetings and to the medical executive committee. Similarly, a clinical nurse offered to be the spokesperson for nursing because it was hoped that the initiative would quickly be embraced by nurses at the point-of-service if it was presented by a clinical nurse, rather than a line manager or director.

Because competency of the bedside nurse is one of the most important attributes of collaboration, emphasis on knowledge and skill development of all nurses was a component of the initiative. As a part of the nursing competency skill list, communication, conflict management, crucial conversations, and the art of collaboration were added as learning modules that would be included in hospital orientation and annual competency checks. The modules were added to the on-boarding orientation program for physicians as well, and interprofessional collaboration, teamwork, and conflict management topics were added to medical staff education. The hospital elected to add collaboration to its list of values and behavioral standards, and statements related to collaboration were added to every employee’s annual performance appraisal form. Developing a Culture of Interprofessional Collaboration:

Although a number of different initiatives were used to facilitate building the culture of collaboration, there was a belief that nurses and physicians interacting together at hospital-based celebrations, social gatherings, educational venues, and on the unit would build the trust level necessary in collaborative relationships. Clinical nurses and clinical nurse specialists (CNSs) were frequently invited as participants in medical staff education programs to present the nursing perspective on topics. Also, physicians were invited to be speakers at quarterly leadership meetings and other nursing education venues.

Jesse suggested that the director of research conduct a formal study to evaluate nurse and physician perspectives on the level of collaborative behavior existing before and after the rollout of the task force initiatives. The chief of the medical staff was invited to be a co-investigator and assisted in preparing an institutional review board (IRB) proposal. Post IRB approval, the baseline level of collaborative behavior of nurses and physicians were evaluated. Initial findings were presented by the director of research and chief medical staff together at medical staff and nursing unit level meetings. A year after some task force initiatives were implemented at the unit level, nursing staff and physicians were surveyed again to determine the level of change in perceptions of collaborative behavior. In analysis, they found a small improvement in the level of nurse–physician collaboration. They completed an IRB amendment to make the study longitudinal, and planned to survey nurses and physicians every year as part of the employee opinion survey and the physicians’ satisfaction survey.

Approximately 5 years after the first interprofessional task force meeting, Jesse proudly sat in the audience as the director of research and the chief of the medical staff presented 5-year collaboration outcomes. In longitudinal analysis, they learned that perceptions of nurses and physician collaborative behaviors improved over time became highly valued. Nurses and physician engagement during rounding at patient bedsides was cited as one of the most appreciated factors. Developing a Culture of Interprofessional Collaboration:

While reflecting on the past 5 years in progress toward this cultural change, Jesse realized that he had simply set the stage for the change to occur, chose individuals who were passionate about the topic (both positively and negatively), identified champions who would lead the change process, and was available to provide support as necessary.

Questions

1. How would you consider Jesse’s vision for a cultural change to normalize interprofessional collaboration as an expected behavioral standard and personal value as an innovation?
2. How did Jesse and the rest of the executive team create the context for an innovative solution to this age-old problem in health care?
3. In what ways did Jesse and his directors create the context and expectation of new employees and new physicians for collaborative behaviors?
4. How did Jesse and the executive team create alignment with this organizational goal and the overarching behavioral standards in the value statements?
5. What were some of the initiatives that motivated the interprofessional task force to become engaged in the process and to become owners of the solution?
6. How would you have handled the dissenting physicians and nurses who did not recognize the importance of collaborative behavior and who held on to past values of hierarchy, authority, and submissive, task-based nursing?
7. Although all of the initiatives were not described in this case study, if you were Jesse, what might you have done or suggested to set the context for such an important cultural change?
8. Describe what you might do as an innovation leader to ensure point-of-service engagement and ownership in creating a culture of collaboration? How would you ensure the support of other executives who might not be familiar with nor value the benefits of collaborative relationships among healthcare team members?