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Persistent isolationist or collaborator? The


nurse's role in interprofessional collaborative
practice

Article in Journal of Nursing Management April 2010


DOI: 10.1111/j.1365-2834.2010.01072.x Source: PubMed

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Carole Orchard
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Journal of Nursing Management, 2010, 18, 248257

Persistent isolationist or collaborator? The nurses role in


interprofessional collaborative practice

CAROLE A. ORCHARD RN, BSN, MEd, EdD

Associate Professor & Coordinator of Interprofessional Health Education & Research, The University of Western
Ontario, London, Ontario, Canada

Correspondence O R C H A R D C A . (2010) Journal of Nursing Management 18, 248257


Carole A. Orchard Persistent isolationist or collaborator? The nurses role in interprofessional
G22 Siebens Drake Research collaborative practice
Institute
1400 Richmond Street Aim The present study explores current understanding about interprofessional
The University of Western Ontario collaborative client-centred practice and nursings role in this form of care delivery.
London ON, N6A 5C1 Background A profession-only focus on nursing practice has been challenged at
Canada professional, national governmental and World Health Organization levels stressing
E-mail: corchard@uwo.ca for more interprofessional patient-centred collaborative teamwork.
Evaluation Moving to patient-centred collaborative practice is fraught with
barriers. Enablers can result in building trust, power sharing and shared decision-
making. Changing current workplace environments requires institutional commit-
ments to support collaborative team development.
Key issue(s) Nurses can become collaborative members of teams through: (1)
re-socialize; (2) understanding and articulating nurses roles, knowledge and skills to
others; (3) other health providers sharing the same to nurses; (4) identifying where
shared roles, knowledge and skills exist; and (5) learning to work in collaborative
teams. Nurses must address some fundamental issues about practice that negate
collaboration and patient-centred care.
Conclusions All professionals, including nurses, must move away from a service-
oriented delivery to a patient-centred collaborative approach to care.
Implications for nursing management The values within health organizations need
to be underpinned by collaborative interprofessional patient-centred practice. To
accomplish this goal, administrators and managers must support assessment of
employees and visiting physicians as to their conformance with agency established
expectations for such practice.
Keywords: collaborative practice, interprofessional, nursing practice, patient-centred
care, teamwork

Accepted for publication: 4 January 2010

only nursing theories, but metaparadigms within


Introduction
which to locate these theories (Fawcett 1984, Locsin
Over the past several decades nursing has sought to & Purnell 2009). Nursing has also articulated codes of
establish itself as a recognized profession. To achieve ethics and standards for practice. These in turn, have
this goal a strong thrust has been made to generate not provided the means to create processes and markers
DOI: 10.1111/j.1365-2834.2010.01072.x
248 2010 The Author. Journal compilation 2010 Blackwell Publishing Ltd
Interprofessional collaborative practice

for regulating and for accrediting nursing practice and impacting on the person or interaction between the
education. people and nurses (Fawcett 1984). In each of the nurs-
In recent times a profession-only focus on our ing theories the patient (person) plays a significant role
practice has been challenged stressing the need for in their care and, would lead nurses to believe they
more patient-centred and collaborative teamwork practice patient-centred care.
across all health professions (Evans 1994, Mariano However, when most nursing theories are actualized
1998, Andrews & Kacmar 2001, George et al. 2002, in practice the focus seems to shift onto the nurse and
Gardner 2005). A challenge raised at many tables his/her expertise in providing care. Thus the patient
including the World Health Organisation (1988, 2005) takes a sub-role to the importance of the work of the
and government authorities in Canada (Romanow nurse. A recent study carried out by CHSRF (2009) to
2002, Health Canada 2004), the UK (Barrett et al. determine what role patients wish to assume within
2005), Australia (Australian Nursing Federation 2006) health care teams, found that patients were surprised
and the US (Baldwin 2007). To date there is a robust they could be members of their health care teams.
literature base on collaboration between nurses and Participants further expressed their frustrations in
physicians but this rarely moves beyond single profes- often: not being listened to by health professionals;
sional collaborations (Baggs & Schmitt 1988, 1997, having their expressed opinions being either ignored
Henneman 1995, Baggs et al. 1999, Hojat et al. 2001, or discounted; and when they went to the trouble of
Lindeke & Sieckert 2005). The question arises, how researching information about their conditions and
can nursing embrace interprofessional collaborative presented it to the health providers they were either
practice while retaining its identity as a unique pro- questioned about its source or the information was set
fession? And further, what impact will nurses experi- aside. As an outcome, one has to ask how patient-
ence, if they move to interprofessional collaborative centred is our care and how respectful are we to
practice? our patients? And further, why do patients feel so
The present study explores the current understanding frustrated about their encounters with health profes-
about interprofessional collaborative client-centred sionals?
practice and how nursing, as a practice discipline, can
move towards this form of care delivery while retaining
Nurse professional socialization
its unique professional lens.
If we explore the origins of our education as profes-
sionals, explanations emerge. Our first focus is on how
Nursing theories and patient-centred practice
nurses are socialized into the nursing profession. For a
What is interprofessional patient-centred collaborative wide number of health professionals, educated before
practice? According to Orchard it is a partnership be- the 1970s, curricula was often absent in courses that
tween a team of health professionals and a patient provided exploration of their professional development.
where the patient retains control over his/her care and is A study carried out by Reutter et al. (1997) is one of the
provided access to knowledge and skills of team mem- few that explores professional development of BScN
bers to arrive at a realistic team shared pan of care and students across a nursing education programme. The
access to the resources to achieve the plan (2010). If we authors concluded that nurses professional socializa-
reflect on the meaning of person and their wholeness tion is the result of a combination of functionalism
within our nursing metaparadigm, consistently nurse (Burrell & Morgan 1979) and interactionism (Sharrock
theorists place a strong focus on the role of patients1 in et al. 2003). The former relates to student nurses
our nursing interactions (Kikuchi & Simmons 1994). learning their professionalism through observation of
Theories either reflect a mechanism2or an organicism3 other nurses; while in the latter student nurses learn
(Fawcett 1984). Nursings role within models focuses their roles from interactions and explorations of what it
on developmental aspects of the person, on systems means to be a nurse from faculty, peers and nurses in
practice. Current nursing students are consistently
1
Patient is used to mean a client or other name who is the
provided with learning that creates opportunities to
recipient of care. inductively develop their professionalism and also to
2
Meaning the person is seen as an integrated whole within reflect on current enactment of professional nursing
his/her environment. practice in actual healthcare settings. Why is this
3
Meaning holism is assumed and cannot be reduced into important for interprofessional collaborative practice?
distinct parts views.

2010 The Author. Journal compilation 2010 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 248257 249
C. A. Orchard

Interprofessional education research reports on the these nursing practices have the potential to create
reality that most individuals are socialized into their conflicts between nurses and other health providers.
profession by society before entering their programmes. Moreover, without a clear understanding of the roles,
As individuals talk to people and see/read media knowledge and skills of other health providers nurses
depictions of various professionals, they explore the practice with on a daily basis, can lead to what is
idea of being one professional vs. another. What they termed turf wars or tribalism and enacted by arguing
hear are both truths and myths about the role of pro- to whose scope of practice care decisions belong
fessionals (Flannagan 1979, DuToit 1995). Once indi- (Hudson 2002, Ten Hoope-Bender et al. 2006, Zwar-
viduals enter their chosen professional programmes, the enstein et al. 2009). Many of these issues are the
faculty reinforces accurate information and correct foundation of work environment problems that have
myths or inaccuracies. At the same time, our present been widely studied in nursing by Laschinger et al.
educational programmes neglect correction of myths (1998, 2001); Laschinger et al. 2002, Laschinger &
and inaccuracies about other health professionals and Finegan (2005), McVicar (2003), McGrath et al.
these persist in the minds of students who then (2003), Lambert et al. (2004) and others over the past
take these altered perceptions of others into their decade.
professional practice (Clark 1997, World Health
Organisation 1988, DAmour & Oandasan 2005,
Nursing practice education
World Health Organisation 2005, Carpenter &
Dickinson 2008). Consequently students enter into practice settings with
gaps in their ability to work in interprofessional
teams. Although learning is often provided in small
Nursing education
groups with emphasis on group dynamics, conflict
A further impact on our ability to practice collabora- resolution and management within nursing pro-
tively results from nursings uni-professional educa- grammes, actual preparation for teamwork in practice
tional approach (McCallin 2001). Many years ago is rarely taught and simulated. Where it exists the
nursing took education of nurses away from physicians focus is generally on a nursing-only team. At the same
with the goal of establishing nursing as a distinct pro- time, it is common for nursing students, as well as
fession. As a result nursing students study in-depth with those from other professional programmes, to be
other nursing students often in small learning clusters, evaluated by their supervisors on the quality of their
leading to development of cohesive groups. Psycholo- teamwork, not only with other nurses but also other
gists equate the impact of the above approach to social health professionals. Hence, there is a gap between
contact (Pettigrew 1998) and identity (Ashforth & an expectation of interprofessional team practice and
Mael 1989) theories. These theories provide an under- the preparation for it, in most nursing education
standing of a uni-professional education approach on programmes.
future collaborative practice. When a group of indi- Many nurse authors raise the point that there are
viduals has such in-depth exposure to each other, they other health professionals providing patients with care,
develop what is termed in-group alliances to each but then focus only on the nursing care provided by
other. Those who reside outside of these in-groups are nurses (Kruijver et al. 2000, McCabe 2004, Shattell
considered out-group members and in turn, are not 2004). Measurement of outcomes of care are also often
afforded the same level of trust as occurs with their in- attempted to be assessed with a focus on nursing-only
group colleagues. Furthermore, our nursing pro- interventions. Findings can only be erroneous unless all
grammes, as well as in most other health professions, other providers and their impact on the care are con-
have led nursing academics to guide nurses develop- sidered as well. Not an easy task but a necessary one for
ment of a unique language, nursing-specific communi- rigour in findings. This further isolates nurses from the
cation patterns and ways of providing patient/client practice of others.
encounters as well as perceptions of the knowledge, This situation is further impacted by the failure of
skills and roles of other health providers (Headrick employer-run new staff orientation programmes pro-
et al. 1998). As a consequence other health providers viding opportunities for cross-professional develop-
may not understand the language we use; our commu- ment of teamwork as a practice expectation within
nication patterns may not fit with those of other prac- institutions or agencies (Glouberman & Mintzberg
titioners; and our needs for information about patients 2001, DAmour et al. 2008, Fewster-Thuente & Vel-
may not be relevant to other health providers. All of sor-Friedrich 2008). This does not suggest that teams

250 2010 The Author. Journal compilation 2010 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 248257
Interprofessional collaborative practice

in organizations are constantly at cross-purposes with 2003, Pearson & Pandya 2006). In reality other health
each other or that their members consistently are in professionals come with similar educational knowledge
conflict. On the contrary there are many well-func- bases and may even share skills. An approach we
tioning teams in agencies. However, formal prepara- have employed to help is posting of a set of electronic
tion for health providers to work within teams has posters about the roles, knowledge and skills of health
been neglected in most education and orientation providers on our website (http://www.ang.org.au/
programmes (Headrick et al. 1998, Burke et al. pdf/submissions/2006/SubANFmedicaleducation.pdf).
2000). Although helpful in a general context they require
adaptation to a practice setting and become context
specific. Thus, role clarification within each health
Understanding nursing and others roles,
providers is required whenever they form a group to
knowledge and skills
deliver care to patients/clients.
Findings from our ongoing interprofessional collabo- At this point, we need to take stock of what changes
rative practice research emphasize the importance of are needed to help nursing become more collaborative
health providers to clarify roles to effective collabora- with other health providers. Clearly nurses need to: (1)
tive practice. This presents yet another question for re-socialize themselves to be part of collaborative
nursing. How well can we articulate our roles to others? teams; (2) understand and be able to articulate their
In my personal experience working with health pro- own roles, knowledge and skills to others; (3) gain an
fessionals in their collaborative team development, understanding of roles, knowledge and skills of other
nurses seem to have a greater difficulty articulating their health providers; (4) gain an understanding of where
roles to others, than, for example, occupational thera- there are shared roles, knowledge and skills across their
pists, and when they provide statements these are pre- own and other health providers; and (5) learn how to
dominantly focused on physical tasks and rarely about work in collaborative teams.
the theories and knowledge nurses bring to practice in
formulating patient interventions. Where does this
Collaborative practice
problem arise from? If we reflect on our current nursing
education curricula, there is a strong emphasis on To date most practice is multi-disciplinary with each
exposing nursing students in their first year to nursing practitioner independently assessing and planning for
theories. In no way, am I suggesting nursing theories, the care of patients and meeting with colleagues to dis-
not be taught. However, at the same time there appears cuss their individual plans for primarily information and
to be limited attention in helping nursing students reaction purposes. Collaborative practice shifts to hav-
understand the various roles that nurses perform, and ing all practitioners come together with a patient, and
when done rarely provides opportunities for students to develop a shared plan of care. Is this a total change to
practice articulating these roles. Nursing literature is existing team-based practice or simply an enhancement?
also weak on research related to nursing roles, while This is difficult to respond to without analysing how
there is a robust research base on the roles of advanced practice is currently delivered within groups of health
practice nurses and nurse practitioners (Davies & providers. An assessment of the level of collaboration
Hughes 1995, Pearson & Peels 2002, Daly & Carnwell within teams is required. Sullivan (1998) defined
2003, Hind et al. 2003, Bryant-Lukosius et al. 2004, collaboration as a dynamic, transforming process of
Myfanwy 2005). Yet nurse authors such as Evans creating a power-sharing partnership for pervasive
(1994) stress the limited abilities of nurses to know the application in health care practice (p. 65) and is
scopes of their own and other professions creating comprised of four major attributes: process, partner-
impediments to collaborative practice. ship, practice and outcomes (1998, p. 118). Henneman
In the meantime, orientation programmes need to (1995) identified collaborative attributes as: part-
provide opportunities for health providers to talk about nership, cooperation, participation, shared planning
their own roles, knowledge and skills to each other. The and decision making, power sharing and coordination
importance of this seemingly simple task, which by the (contributing expertise and sharing responsibility).
way if you try it, you will learn how difficult a task this Orchard et al. (2005) incorporated the above into the
is to provide, is a means to correct myths and help all formulation of their definition for interprofessional
team members learn how others with similar skills sets, collaborative practice as involve[ing] a partnership
can assist in providing care. This is referred to in the between a team of health professionals and a client in a
interprofessional literature as role sharing (Barrett et al. participatory, collaborative and coordinated approach

2010 The Author. Journal compilation 2010 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 248257 251
C. A. Orchard

to share decision-making around health and social Nurses tend to perceive themselves at the lower end
issues (p. 1). Moving to such practice, is fraught with of a power hierarchy within the health system. How-
barriers (organizational structuralism, power imbal- ever, from my interprofessional work with other health
ances and socialization into roles) which can be over- professionals, nursing is seen as quite a powerful jux-
come through application of enablers (role clarification taposition to other professionals, and this includes
and role valuing) resulting in building of trust, power physicians. How can we change these perceptual
sharing and shared decision-making in collaborative dynamics?
practice. Orchards Conceptual Framework for Creating
the Culture for Interprofessional Collaborative Practice
Nurses in interprofessional teams
(IPCP) assists in providing a means to achieve these
outcomes (2005). Learning to work within interprofessional teams
requires nurses to reflect on the use of unique nursing
language that is either not well understood by others or
How transformative is this shift for teams?
has a different meaning to another health professional
Many teams emulate components of the above by: (1) (Irvine et al. 2002, Lumague et al. 2006, Zwarenstein
allowing members to plan together, (2) seeking others et al. 2009). Principles for interprofessional communi-
input into decisions, (3) asking other members their cation need to be articulated by the team to make it an
views about patient treatments, (4) delegating some expectation that any member will seek clarification
aspects of work to colleagues, and (5) setting consistent when words are not understood reflecting unique jar-
care goals for patients. Hence, there exists a strong gon used only by nurses. These principles need to fur-
foundation for collaborative practice within existing ther outline how teams will organize themselves for and
teams. The true benefit in collaborative practice resides during meetings. To date this is often a happening with
in the empowerment of all members to enhance their irregular levels of planning and chairing, leading to
abilities to work more effectively together. In collabo- frustrating experiences for all. Specific decisions are
rative teams all members feel: (1) respected for their needed about planning, management, documentation
knowledge and skills; (2) valued by all team members; and resolution of team meetings. All areas that have
(3) comfortable entering into discussions about plans been neglected as norms of operating in many practice
for a patients care; (4) open to ask to take responsibility areas to date. Those teams that are effective have
for aspects of patients care within their own levels of developed their own means to function. Having such
regulated competences; and (5) trusted by each other. principles as norms of team functioning within agencies
Empowerment has been an ongoing practice struggle can create a supportive collaborative practice environ-
for nurses (Lewis 2000, Kramer & Schmalenberg 2003, ment.
Gravel et al. 2006). Knowing whether a team is col- Nurses and other health professionals also need to
laborative or not, is a difficult task for members. relinquish profession-specific ownership over patient
Assessing when a team is collaborative with its mem- assessment or history taking. Patients report their frus-
bers is both a personal and perceptual determination. tration in providing the same information to more than
Orchard and Weinberger (2005) originally developed one health professional. Our current patterns relate to a
the Assessment of Interprofessional Team Collabora- service orientation and fit with the industrial age of
tion Scale (AITCS) to assist in this determination, and it assembly-line thinking. We teach nursing students to
has been further revised by Orchard et al. (2010). The complete a total assessment related to whatever nursing
AITCS is a 48-item instrument that uses a five-point theory underpins their programme. But if we wish to be
rating scale and is comprised of four subscales: coor- truly patient centred the assessment of patients needs
dination, cooperation, shared decision-making and for care should come from patients (McCormick et al.
partnership and has an internal consistency range from 1999). Using a collaborative approach means we only
0.83 to 0.90 and Cronbachs a = 0.89 for the total relate our assessment to the problems with which the
instrument (Orchard et al. 2010). It provides the means patient wishes our assistance. We often ask very sensi-
for team members to gain an understanding of how tive information from patients before a trusting rela-
collaborative they are, thus providing a means to tionship has been established, and then collect excess
address areas where further group work may be needed. information at the commencement of our first patient
The greater the collaboration is among members, the encounter. Much of this collected information is dis-
higher the level of perceived empowerment within the carded in our planning as not relevant to patients care
team. needs. This is both discourteous to patients and a sig-

252 2010 The Author. Journal compilation 2010 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 248257
Interprofessional collaborative practice

nificant time waster for nurses and other health pro- road for true patient-centred care (Reeves 2009). In
fessionals. If patient-centred care is our goal, then team practice, a primary health team care provider can
would it not make more sense for an interprofessional become the connector with the patient between all the
collaborative team to sit down and determine what other providers in teams or collaborative groups for
generic approach to information and assessment data provision of the patients care. Connectors can work
collection all members need in common? The benefits of with patients in identifying issues patients wish to be
this team approach means any team member who be- addressed and convey these to relevant colleagues who
gins a relationship with a patient can ask and obtain the in turn can assist in meeting expressed needs. Such a
collaborative teams initial information. As other health model does require all health providers understanding
professionals begin to work with patients they can then each others roles, knowledge and skills and a clear
build onto the base information and data. Nurses can understanding of agreed upon team functioning
still obtain their unique data sets, above the generic including accountability for accepted responsibilities
level, by developing augmented assessment approaches within care plans.
as can other health professionals in each of their When institutions create vision statements that emu-
expertise areas. late the values underpinning both collaborative team
practice and patient-centred care and these in turn are
operationalized into principles and guidelines. All pro-
Collaborative care planning
viders gain clear guidelines for team functioning facili-
When we discuss the concept of collaborative care tating the movement of health providers between teams
planning, many health providers present the lack of and across units while supporting an institutionally
time available to them for this process. At the same based philosophy of patient-centred collaborative
time, the literature talks about time wasters: nurses practice.
report telephone tagging physicians to clarify orders
for drugs or tests or questioning why consultations for
other services are ordered (Sadler 2003, Valanis et al. Responsibility and collaborative care
2003, Cato 2005). A further time waster is the com- planning
pression of care time nurses have on day-shifts when
At this point you are likely raising alarm bells in your
patients require tests and treatments in other depart-
head regarding liabilities around practice competencies.
ments. Independent planning for these services negates
To address such concerns we need to consider the fun-
any understanding of time limitations on the other care
damental responsibilities of each health professional.
provider when schedules are set on a service and not a
Nurses as health professionals are regulated in their
care basis. Further impediments to effective care is the
practice providing expectations for demonstration of
dropping in of specialists, from not just medicine but
competence within specified practice standards. Dem-
nursing and other professional fields, with no under-
onstration of competence is tied to accountability for
standing of the ongoing plan for patients care. The
the quality of care provided. All other health profes-
patient is also often left out of such discussions. Can we
sionals have similar requirements. Thus, even in col-
change these dynamics? Can existing institutional
laborative teams there is individual responsibility and
structures re-develop streamlining of information about
accountability for those aspects of care that each pro-
patients care across all parties from the beginning of the
fessional assumes. In Canada the Canadian Medical
encounter through to collaborative practice? Clearly, if
Protective Society4 (2006) has issued a set of questions
team practice is not the norm in an institutional care
to reduce physicians medico-legal risks when practicing
area, expecting this type of a turnaround cannot be
within collaborative teams. These being:
achieved without significant service disruptions.
Health care providers who comprise care teams for Are the roles and responsibilities of each team
complex patients needs can only support collaborative member clearly defined, based on their scope of
practice if institutions are prepared to provide profes- practice and also the individuals knowledge, skill,
sional development sessions. Sessions need to be and ability?
designed to help team members develop common Does every team member know his or her role and
approaches for working together whether in-person or the role of other team members?
through electronic means. Taking time out of practice
to focus on collaborative team development has the 4
Organization providing legal liability coverage for physi-
potential to improve interactions and begin to pave the cians.

2010 The Author. Journal compilation 2010 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 248257 253
C. A. Orchard

How will health-care decisions be made? Who is communication). Such programmes must integrate
responsible and therefore accountable for health- patient representatives into any collaborative team
delivery decisions? development. We have used both standardized pa-
Is there a quality assurance mechanism to monitor the tients from our medical school programme and also
team function? real patients who reflect health problems commonly
What are the anticipated health-care outcomes the treated by the team members, who can enact case
team is striving to achieve? scenarios to assist teams in the development of their
Has the patient remained an integral if not a central practice model.
member of the team? Collaborative interprofessional patient-centred prac-
Is there a sound policy and procedural framework in tice can become the norm in a health organization when
place to define and support the team function? administrators and managers support and assess
Does the team have sufficient resources to achieve the employees and visiting physicians in conforming to
desired health outcomes? agency established expectations for working together
Who will coordinate care, manage the team and collaboratively to enhance patient care.
ensure efficient and effective communication among
team members and across teams? (CMPA 2007)
Where is the nurse within collaborative
In collaborative practice, nurses, as well as every teams?
other health professional on the team, have individual
The nurse is one of the key individuals in all teams.
responsibility for their practice and a shared responsi-
Most patients with complex health needs require col-
bility for care provided within team practice. Given the
laborative teams comprised of nurses, physicians,
above, developing a team-based plan of care, including
dietitians and social workers as the core group and then
the patient and/or family member, requires a clearly
others are added depending on the context and setting.
developed set of structures, procedures and processes.
When rehabilitation is part of the care plan physio-
These sets of team practices cannot evolve from those
therapists, occupational therapists and speech language
who are constantly providing care, but need to be
pathologists are often part of the team. When mental
developed within an agency-provided continuing edu-
health issues need to be addressed a clinical psycholo-
cation programme. Thus, institutional administrations
gist, psychiatrist and a mental health advanced practice
must provide the time, support and space to allow
nurse may be part of the team. In community-based
practitioners to come together for effective collabora-
teams the groups often expands to non-health profes-
tive team work to be successful.
sionals to meet patient needs.
An example of an approach we have used includes a
Nurses are the largest number of professionals in
commitment to 24 hours release time for all team
health systems. Hence, they are always members of
members including: 12-hours to access a set of four
collaborative teams. Nurses bring both their unique
on-line Team Development Modules5 accessed asyn-
nursing knowledge and ability to work with other
chronously. Followed by a series of facilitated face-to-
professionals. When patients care needs to be shared
face workshops of 2-hours each delivered over
across another profession, the nurse must be able to
6 weeks beginning with: (1) setting goals for their
function within collaborative relationships.
team; (2) articulation of team members roles, skills
When the subject of interprofessional collaborative
and responsibilities within the team; (3) discussing
practice occurs in nursing conversations, a fear fre-
how their team will function, (4) developing a team
quently stated is that nursing will be neutralized by this
model of practice within their care context and setting
movement. If nurses learn to clearly articulate the key
(inclusive of patients and relatives); (5) assessing
role they bring to a collaborative team then the likelihood
effectiveness of team functioning; and (6) testing
of nursing losing its role is highly unlikely. But if nurses
model of team practice in a simulated care case. This
continue to remove themselves and remain persistent
is a significant organizational investment in develop-
isolationists from moving in the collaborative practice
ment but our early research demonstrates higher sat-
direction, other professionals will assume many of the
isfaction and empowerment in practice by both health
nurses roles, albeit not their totality and holistic range
professionals and patients (B. Markam 2009 personal
now provided. To move into collaborative discussions,
nursing must demonstrate an openness to address theo-
5
Available through the Institute for Interprofessional Health ries and models of practice provided by other professions
Sciences Education http://www.onlineipe.com. and support acceptance of shared models of practice

254 2010 The Author. Journal compilation 2010 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 248257
Interprofessional collaborative practice

which Mintzberg (1997) refers to as a third way. This with extensive assessment parameters required of every
means we cannot take our current nursing theory models patient cannot be sustained. Tanner (2006a,b) and
and force others into them. However, the richness that more recently Locsin and Purnell (2009) are providing
our theories provide, having arisen from a wide variety of such discourse.
social and physical sciences, can be a benefit. Presenting Nurses are better educated than in the past nurses
the breadth that nursing theories embrace can assist in have the intellect to challenge existing assumptions
exploring collaborative practice models enhanced by about our practice, and the ability to critically address
nursing contributions. At the same time we must be open practices and transform these into our current com-
to other theories and models of practice proposed by munication age, our professional focus on relationships
consensus of all team members as the basis of with others is a key to shaping how interprofessional
collaborative practice. Nurses must also re-focus our collaborative practice can move to become the norm of
expert-dominated approach to patient care. Gallant all health services practice. Such a transformation will
et al. (2002) report on conflicting evidence about the take a willingness to challenge the foundations of what
willingness of nurses to relinquish their power to pa- shapes our nursing profession. Our newer approaches
tients. For collaborative practice that is patient-centred to use of pluralism -incorporating both quantitative and
relinquishing our power over patients is essential. qualitative approaches -and integration of all patterns
of knowing to guide our research is adding richness to
answer key questions (Chinn & Kramer, 2009). Rather
Conclusion
if we take a radical shift in our thinking from nurse as
All professionals, including nurses, must move away expert to patient as expert of their lives and nurses as
from a service-oriented delivery. Delivery of care that assistants to their needs; and if nurses are prepared to
focuses on our expert practice, to a patient-centred and change our assessment from the nurse deciding what to
patient-controlled approach to their care. Shifting our assess, to what the patient wants us to assess, we can
way of interacting with patients from telling to lis- create more meaningful relationships with our patients,
tening and finally moving from multi-disciplinary their families and other health providers involved.
development of care plans to co-development of plans Munhill (2009) suggests that we practice what she
of care with our patients. terms unknowing that is suspend our beliefs and be
open to hearing others in collaborative practice that
The challenge for nursing as a profession is
includes all those involved in anothers care (2009). If
continuing to expand our unique knowledge
nurses learn to consistently articulate our roles,
development to generate evidence supporting
knowledge and skills to other professional colleagues
nursings unique contribution to patient care.
and patients role valuing of each other is theorized to
While at the same time supporting a strong
occur (Orchard et al. 2005). According to Sullivan
research thrust related to gaining the evidence
(1998) collaboration involves coordination, coop-
about the impact of interprofessional patient-
eration, shared decision-making and partnerships
centred collaborative care on patient outcomes.
with all those involved. Learning to communicate
The current practice situations in which most nurses interprofessionally can only enhance the value of
find themselves are untenable. We must create scholarly knowledge, skills and evidence that nurses bring to an
discourse related to our current nursing practices, and interprofessional team interaction. Let us adopt a
the conceptual frameworks we force ourselves to stay change for the betterment of those who are the recipi-
within. The pervasive evidence around nursing levels of ents of our care and fulfill the dream that was put for-
burnout and occupational health problems than ever ward by Carroll-Johnson:
seen in modern times must force a re-thinking of how
Imagine a world where each groups expertise is
we practice (Garrett & McDaniel 2001, Aiken et al.
held in regard, offered, and shared as the need
2002, Laschinger & Leiter 2006). There is an almost
arises. Imagine a time when the patient can deter-
silent discourse challenging the way we have practiced,
mine which kinds of practitioners he or she needs
since Orlando put forward her theory of nursing in
or wants, and then imagine a system that makes
1972 identifying the focus of inquiry for a professional
those professionals available (2001, p. 619).
nurse is the immediate experience of the patients and
whether or not the patient requires the nurses help In closing, are you a persistent isolationist, or do you
(Schmieding 1983, p. 77). A theory that was adopted want to become more of a collaborator? The decision
and entrenched as the nursing process and this coupled resides within each nurse.

2010 The Author. Journal compilation 2010 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 248257 255
C. A. Orchard

Daly W.M. & Carnwell R. (2003) Nursing roles and levels of practice:
Acknowledgements a framework for differentiating between elementary, specialist and
advancing nursing practice. Journal of Clinical Nursing 12 (2),
I wish to express my sincere thanks to all my nursing and 158167.
other health professional colleagues, who have assisted in DAmour D. & Oandasan I. (2005) Interprofessionality as the field of
helping me to conceptualize this paper. And further to all the interprofessional practice and interprofessional education: an
patients who so openly explained what it is like to be a patient emerging concept. Journal of Interprofessional Care 19 (supp), 1.
within our existing health systems. DAmour D. & Oandasan I. (2005) Interprofessionality as the field of
interprofessional practice and interprofessional education: an
emerging concept. Journal of Interprofessional Care 19 (Suppl. 1),
820.
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