The Times, They Are a Changin'

According to Lindeke and Seickert,1 collaboration in health care is a complex process that requires intentional knowledge sharing and joint responsibility for patient care. Collaborative nurse–physician relationships are synergistic—a relationship in which the sum is greater than its parts, based on mutual respect for each person's unique perspectives and contributions to the health care team.

Why do collaborative nurse–physician relationships matter? Patient outcomes and workplace satisfaction are influenced by the nature of this relationship, proven by research into this topic. Collaborative relationships have been associated with reduced mortality, decreased length of stay, reduced costs, higher nurse autonomy, and nurse job satisfaction. From a patient safety perspective, the Joint Commission on Accreditation of Healthcare Organizations has identified communication failure as the leading cause of medication errors and diagnostic delays or omissions.2 A safety culture is based on the equality of all participants having the ability to intervene in a potentially harmful situation. Hierarchy, or power based on one's position, is not acceptable in a culture that strives to eliminate error. Customer satisfaction is also influenced by collaborative practice. Patients are more likely to be satisfied when the plan of care is developed by the physician, the nurse, and the patient, and when a clear understanding of expectations can be set and met.

If collaborative relationships are so beneficial to the health care environment, why are they so difficult to create and sustain? The answers are numerous. Gender and economic disparity between nurses and physicians and educational differences impact the relationship. Professional enculturation of nurses and physicians over generations has perpetuated the belief in a social structure dominated by the medical profession.

But the times, they are a changin'.

Nurses want to find fulfillment in their calling, seeking and expecting it in the environment in which they practice. The relationship between nurses and physicians is a significant influence in that practice environment, and nursing needs to take ownership of changing the quality of that relationship. According to Peter Block,3 the primacy of that relationship at the care delivery level is crucial. Nurses need the ability to set boundaries, to say “no.” This “no” gives nurses the opportunity to define the nature of work and how it is done. It is not the end of a conversation, but the beginning of an open dialogue about the quality of care and the people providing it. Secondly, he states that the relationship between nurses and physicians should be a partnership, not a patriarchy. It cannot be legislated, regulated, or mandated, but rather will occur as a result of a shift in the conversation between nurses and doctors. Both sides need to be able to express their wants and needs. They may not always be satisfied, but the ability to state a point of view creates a partnership.

Changes are occurring on the physician side of the relationship as well. The Accreditation Council for Graduate Medical Education Competency Outcomes Project has identified six elements beyond medical education alone that make a competent physician.4 Two of the competencies that emphasize the collaborative relationship are Interpersonal and Communication Skills, defined as effective information exchange and teaming with patients, their families, and other health professionals, and Systems-Based Practice, an awareness of and responsiveness to the health care system and the ability to effectively use system resources to provide optimal care. Essentially, physicians are being educated that they are no longer “individualists” in practice but members of a team, and that practicing in a team environment is vitally important to their success as a physician.

How then do we achieve this collaboration in practice? It begins with the conversation Block describes and is sustained by structures that foster communication and partnership. These structures include interdisciplinary meetings, care-decision pathways that represent both medical and nursing interventions, conflict resolution channels for situations that exceed the skills of the parties involved to reconcile, and a commitment to teamwork expressed by both nursing and physician leadership. The times are indeed changing and the future is ours to create. Let's make it happen.