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III. Collaboration in Health Care.

Some level of collaboration between health care providers is necessary in any health care setting. In hospitals, careful coordination of services between nurses, nursing assistants, physicians, and a variety of health care professionals (e.g., physical therapists) must occur around the clock. In outpatient settings health care providers may operate at varying levels of collaboration depending upon the types of services offered. No single discipline or specialty can meet all of a patient's needs. A hospitalized patient, for example, may need a physician to provide a diagnosis and treatment plan, a nurse to administer medications, a nursing assistant to help with bathing and toiletting, a phlebotomist to take blood samples, a dietitian to monitor food intake, a physical therapist to aid in muscle strengthening and flexibility, and a social worker to coordinate home care following release. Without communication among all of these professionals, comprehensive and efficient treatment of the patient is not possible.

According to Baggs and Schmitt (1988), collaboration involves coordination of individual actions, cooperation in planning and working together, and sharing of goals, planning, problem-solving, decision-making, and responsibility. Collaboration can happen between two people who represent the same or different disciplines, or among small groups of people representing one or a range of disciplines. In general, health care providers tend to strongly identify with their own discipline and its language, values, and practices (Furnham, Pendleton, & Manicom, 1981; Kreps, 1988) and to relate best to members of their own discipline (Siegel, 1994). Collaboration may be very difficult to negotiate effectively because of differences in disciplinary socialization. Cross-disciplinary communication can be complex for a myriad of reasons, but it also can be professionally rewarding and beneficial to patients' (and patients' companions') experiences. Although different professions have some unique issues in collaboration,
 Nurses, pharmacists, and social workers face
 comparable issues in collaborating with physicians,
 including a lack of acceptance by physicians
 of the full breadth of other professionals'
 roles, continuing status and gender differences,
 contradictory expectations regarding the autonomy
 of nonphysicians, and a commonly
 expressed need for physicians' recognition of
 their competence ... (Abramson & Mizrahi,
 1996, p. 271)

Research on health care collaboration is very physician-centric, with most studies investigating how physicians work with members of other disciplines; it rarely specifies how nonphysicians from different disciplines communicate with members of other disciplines, or even physicians from different specialties (Atkinson, 1995). Still, a good deal of research has been conducted with the goal of improving communication between physicians and nurses, nurse practitioners, social workers, pharmacists, and, to a lesser extent, other physicians. In order to uncover some of the challenges associated with collaboration, I will begin with a brief review of findings on physicians and members of various disciplines.

A. Nurse-Physician Collaboration

Nurses and physicians generally do not share perceptions of their own and the others' roles in providing health care (Iles & Auluck, 1990; Katzman, 1989). Stein's (1967) classic rendering of the "doctor-nurse game" depicted dominating doctors to whom nurses made diagnostic and treatment recommendations in a submissive manner, such that the recommendation appeared to have been initiated by the physician. This pervasive pattern served to reinforce the existing hierarchy that framed nurses as "handmaidens" to physicians (Prescott & Bowen, 1985). The fact that nursing is overwhelmingly female (Haug, 1988) and medicine was almost exclusively a male province until the last 25 years reinforced this dynamic. The addition of more female physicians has not brought about rapid change in the nurse-physician relationship. For example, one study reported that 55% of nurses surveyed found working with female physicians to be no better or worse than working with male physicians (Nursing 91, 1991). This may be due to the fact that female physicians are trained largely by men, according to masculine communication norms (Northrup, 1994; Wear, 1997).

Over time, nursing roles have expanded, formalized, and come to be regarded as more autonomous in their areas of expertise. Many nurses assert their equality and work to improve collaborative communication with other professionals, particularly with physicians (Stein, 1990). Physicians often perceive attempts at collaborative practice by nurses as an invasion of their rightful sphere of practice (Baggs & Schmitt, 1988; Michelson, 1988). Lacking clear boundaries, nurses and physicians must continually negotiate their roles (Allen, 1997; Prescott & Bowen, 1985). While roles are evolving, continuing power and economic status differences encourage nurses to accommodate and submit to physicians (Katzman, 1989; Prescott & Bowen, 1985).

Open and frequent communication is essential to improving nurse-physician relationships (Katzman, 1989; Pike, 1991; Prescott & Bowen, 1985). Quality of relationships between nurses and physicians appears to be critical in lowering mortality rates in hospital intensive care units (Knaus, Draper, Wagner, & Zimmerman, 1986) and overall improvement of patient care (Fagin, 1992). Collaboration between doctors and nurses is especially important in caring for elderly patients (Fagin, 1992).

B. Nurse Practitioner-Physician Collaboration

The position of nurse practitioner is a relatively new one, and the negotiation of control between nurse practitioners and physicians is still very much unresolved. Physicians tend to see nurse practitioners as physicians' helpers or extenders who should operate beneath the authority of physicians (Campbell-Heider & Pollock, 1987). This encourages continuation of the doctor-nurse game which reinforces physician dominance, even though nurses at all levels hold significant informal power and influence over diagnosis and treatment decisions (Allen, 1997; Campbell-Heider & Pollock, 1987). Recent studies demonstrate that some nurse practitioners and physicians have collaborated successfully (and cost-effectively) in providing longterm care to patients (Burl, Bonner, Rao, & Khan, 1998; Ryan, 1999) and that such collaborations may improve efficiency of patient care in primary care practices (Arcangelo, Fitzgerald, Carroll, & Plumb, 1996).

C. Social Worker-Physician Collaboration

Abramson and Mizrahi (1986) define collaboration between social workers and physicians as involving "joint activity based on equality, mutual respect and shared understanding of roles" (p. 1). Mizrahi and Abramson (1994) characterize physicians' and social workers' attitudes towards collaboration as existing along a continuum from traditional hierarchical interactions through transformational partnerships. At one end of the continuum, traditional physicians maintain dominance in interactions, have little interest in psychosocial factors, and reluctantly accept social workers' function of obtaining specific services. Traditional social workers accept physician control and limit their interventions to those defined by physicians. Transitional physicians maintain an authoritative stance but appreciate social workers' handling of psychosocial issues and assistance in making discharge and placement decisions, while transitional social workers see themselves as consultants who offer resources and opinions to assist physicians in decision making. Finally, transformational physicians and social workers perceive themselves as interdependent colleagues and willingly share responsibility and decision making with each other. Since individual physicians and social workers may view their collaboration from any point on their continuum, interactions may be strained because of differing expectations for behavior (Mizrahi & Abramson, 1994).

Tension between social workers and physicians remains a common problem, and collaboration often is not successful (Abramson & Mizrahi, 1986, 1996; Hess, 1985; Schlesinger & Wolock, 1983). Abramson & Mizrahi (1996) found that physicians and social workers had different beliefs about critical components of collaboration, with physicians emphasizing competence of social workers and social workers emphasizing quality of interaction with physicians. Social workers are trained in a biopsychosocial model of care, whereas physicians are generally taught the biomedical model (Gilbar, 1996). Physicians have power and high status and therefore often do not feel the need for and are not motivated to work towards collaboration with social workers, who are motivated to increase their role in patient care and have a voice in decision making (Abramson & Mizrahi, 1986, 1996). Social workers can promote better relationships with physicians by emphasizing their ability to provide important services for physicians caring for patients (Abramson & Mizrahi, 1986). Social workers are particularly suited to cases in which there are psychosocial and cultural factors that affect delivery of medical care, emotionally difficult interactions such as delivering poor prognoses, and serving as an educator and liaison for patients' family members (Ben-Sira & Szyf, 1992). Physicians increasingly depend upon social workers as insurance companies and managed care associations require physicians to release patients from hospitals quickly; social workers arrange interim care such as rehabilitation hospitals or nursing home placement, or facilitate in-home care (Mizrahi & Abramson, 1994).

D. Pharmacist-Physician Collaboration

The nature of the pharmacist-physician relationship makes some tension inevitable: "Actions that the pharmacists must routinely perform if they are to practice pharmaceutic care (e.g., correcting, advising, reminding, recommending, reporting) are intrinsically threatening to physicians' professional identities" (Lambert, 1996, p. 1190). Aware of this dynamic, pharmacists and pharmacy students tend to use politeness and face-saving strategies to present recommendations to physicians (e.g., asking leading questions rather than directly suggesting an alternative drug) (Lambert, 1995, 1996). Therapeutic interventions by pharmacists offering safer, more medically and/or more cost effective drug alternatives to physicians are generally well-accepted and are more common in teaching hospitals than community hospitals (Greco, Mann, & Graham, 1990). Pharmacists seek to expand their roles within health care organizations, and physicians generally view such expansion as an encroachment on their territory (Lambert, 1995, 1996; Ritchey & Raney, 1981). Some researchers have found benefits to increased pharmacist involvement in geriatric patient care. For example, pharmacist review of prescriptions for elderly patients improved quality of patient care in regards to appropriate medication use by catching possible interactions, allergies, contraindications, and over-medication (Cooper, 1985; Monane, Matthias, Nagle, & Kelly, 1998).

E. Physician-Physician Collaboration

Communication between physicians is poorly researched; the overwhelming focus of research on physicians has been on their communication with patients (Atkinson, 1995). Interestingly, what research there is on communication between physicians often has focused on the negotiation of medical mistakes, collegial control, and other negatively perceived aspects of medical care (e.g., Bosk, 1979; Friedson, 1976; Millman, 1976; Pettinari, 1988). One area that has received significant attention is the culture of medicine and the socialization of medical students, interns, and residents into that culture by physicians (e.g., Atkinson, 1992; Hunter, 1991). Atkinson (1995) argues that "biomedical knowledge is socially produced and culturally specific ... [and] dependent upon certain fundamental features of medical culture, which is itself produced and reproduced through processes of socialization" (p. 46). His study of hematologists' consultations with physicians of other specialties explicates the process of producing medical knowledge through communication among physicians. For Atkinson, physicians' talk is not the means to the accomplishment of medical work; the talk is the work.

Laura L. Ellingson, Ph.D.

Department of Commincation

Santa Clara University

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Title Annotation:Communication, Collaboration, and Teamwork among Health Care Professionals
Author:Ellingson, Laura L.
Publication:Communication Research Trends
Geographic Code:1USA
Date:Sep 22, 2002
Previous Article:II. Theoretical approaches.
Next Article:IV. Health care teams.

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