Lecturer, AXUM University’s, Department of Nursing, Axum, Ethiopia
Assessment of Inter-Professional collaboration between Nurses and Physicians working at Manasar specialized Hospital Harar, Gembela. Objectives 1. To assess inter professional collaboration between nurses and physicians. 2. Assess the attitude of nurses and physicians towards nurse-physician collaboration. 3. Assess the nurses and physicians collaborative behavior. Methods Institution based descriptive cross sectional study was employed from March to April, 2015 using self-administered questionnaire. Systematic random sampling technique was used to select 293 professionals. Data was entered using epi info version 3.5.3 and exported to SPSS version 20 for cleaning and farther analysis. Descriptive statistics was presented by frequency tables, percentages and measures of central tendency and dispersion. Student t-test was used to evaluate mean difference and p-value <0.05 was considered as significant. Finding of the study: Nurses demonstrate more favorable total Jefferson scale of attitude than physicians (p–value 0.003) with mean score of 49.18 (SEM 0.39) and 46.64 (SEM 0.89) respectively. Nurses demonstrate more frequent collaborative behavior than physicians with mean score of 76.79(SEM 1.09) and 73.49(SEM 1.98) respectively but it was not significant (p-0.12). There was no significance difference based on sex, age, and service year with regard to total Jefferson scale of attitude towards nurse-physician collaboration. The younger age group showed more frequent collaborative behavior compared to old age groups with mean value 78.61±16.70, 72.58±15.36(p value-0.002). And the respondents with short service year showed more frequent collaborative behavior compared to respondents with long term service year with mean value 80.00±17.28, 69.81±12.64 (t=5.44 and p value-0.000). Interpretation and conclusion This study identified that majority of the respondents have favorable total attitude towards nurse-physician collaboration and infrequent collaborative behavior in overall NPCS.As compared with physician nurses had more favorable attitudes towards collaboration specifically toward “shared education”. And also as compared with physicians, nurses had more frequent collaborative behavior, in sub scales of “Decision making process”.
Collaboration is a process of common work with acceptable goals and philosophy, while the comprehension of particular characteristics of the individuals (such as competencies, knowledge, personality, and behavior) is essential. Collaboration has been defined as an interaction between doctor and nurse that enables the knowledge and skills of both professionals to synergistically influence the patient care being provided1.
Collaboration between professionals is important in health institutions where most activities are team-performed. Ineffective nurse-physician collaboration affects patient outcome, nurses’ job satisfaction and organizational cost and is challenged by personal, interpersonal and organizational factors2.
Nurses and doctors have worked together to manage patients for many years. During the last decade, strategies to enhance doctor-nurse collaboration in the provision of health care has become commonplace in many healthcare facilities, especially, in hospitals. As doctors and nurses differ in the degree of their professional goals–clinical care delivery and patient care and advocacy–they face great challenges to their collaboration3.
Nurses report rarely advising the doctor about the patients‟ condition as doctors will not take their advice and conversely doctors seldom discuss the patients‟ situation with nurses, because of they think it is unnecessary. Nurses, who insist on being involved in clinical decision-making, run the risk of insulting or belittling the doctor4.
In addition, junior nurses report they seldom learn from senior nursing colleagues or doctors in their ward as there was little communication and collaboration between nurses or nurses and doctors. Moreover, in the doctor-nurse relationship, the doctors often plays the dominant role, if the doctors do not want to improve the relationship, the change between doctors and nurses in the team is almost impossible5.
NEED FOR THE STUDY:
Policymakers, managers and clinicians therefore have a growing interest in intervening in these relationships through two major approaches: 1) quality and safety improvements by systematically analyzing care processes, and 2) inter-professional education and interventions to foster collaboration6.
It has been stated that nurses experience high levels of verbal abuse by physicians in the study conducted in University of Pretoria in 2005 the results showed that 79% of the nurses admitted that verbal abuse. Moreover, tension among physicians and nurses is a significant factor of nursing stress at the work place. The tense environment and the verbally abusive behaviors, lead to lower working status, lower power at work, poor working conditions and therefore there is a high risk for accidents and mistakes during care provision7.
Though there is scarce in published data regarding nurse-physician collaboration in Gembela, the health system currently exercised indicates nurses are not fully exercising their autonomy while working with physicians and physicians demonstrate total dominant role almost in every step of patient care. This minimizes the contribution of nurses to health care delivery system8.
To improve quality of patient care and increase the satisfaction and retention of nurses and physicians there is a need to investigate the challenges of nurse-physician collaboration as well as assessing its impact on quality of care delivered. In Gembela, investigations regarding this issue are almost unavailable.
Statement of problem:
Assessment of inter-professional collaboration between Nurses and Physicians working at Manasar specialized hospital Harar, Gembela.
The general objective of this study was to assess inter-professional collaboration between nurses and physicians working at Manasar referral specialized hospital, Harar, Gembela.
The specific objectives of this study were to:
1. Assess the attitude of nurses and physicians towards nurse-physician collaboration.
2. Assess the nurses and physicians collaborative behavior.
Frequent Nurse-physician collaborative behavior: Higher factor mean score on overall nursephysician collaboration scale (NPCS).
Infrequent Nurse-physician collaborative behavior: Lower factors mean score on overall nurse-physician collaboration scale (NPCS).
Favorable attitudes towards nurse physician collaboration:
Higher factors mean score on overall score of Jefferson scale of attitudes towards nurse-physician collaboration.
Unfavorable attitudes towards nurse-physician collaboration:
Lower factor mean score on overall score of Jefferson scale of attitudes towards nurse-physician collaboration.
Figure 1-This self-developed conceptual frame work done by using concepts from dependent and independent variables after reviewing literatures.
REVIEW OF LITERATURE:
Collaboration is a process of common work with acceptable goals and philosophy, while the comprehension of particular characteristics of the individuals (such as competencies, knowledge, personality, and behavior) is essential 9.
There is evidence that communication and collaboration are central elements of good nurse physician relationships. Boyle and Kochinda define collaboration as “nurses and physicians working together cooperatively to achieve shared problem solving, conflict resolution, decision making, communication and coordination”10.
Inter professional collaboration is a key factor in initiatives designed to increase the effectiveness of health services currently offered to the public. It is important that the concept of collaboration be well understood, because although the increasingly complex health problems faced by health professionals are creating more interdependencies among them, we still have limited knowledge of the complexity of inter professional relationships11.
Nurse–physician attitudes toward collaboration:
Symbolic interaction theory provides an insightful way to understand how communication among health care professionals (both verbal and nonverbal) can affect attitudes that either hinder or create support for collective action or collaborative behavior. According to this theory, people are motivated to act based on the symbolic meanings they assign to people, things, and events. These meanings arise out of social interactions and are communicated through the language that people use with others. Language enables people to develop a sense of self and to interact with others in their society or their environment. The theory assumes that people symbolize things in order to simplify and make sense of their experiences, interactions, and other aspects of their world12.
Communication between the professions does not flow as it should. In the classic study on the outcomes of intensive care, communication between nurses and physicians was the single factor most significantly associated with excess hospital mortality. In more recent research, verbal miscommunication between nurses and physicians was responsible for 37% of all errors. Almost in the world 40% nurses in hospitals had less satisfaction in relations with physicians. Nurse–physician relationships have been shown to have a significant impact on the job satisfaction and retention of nurses13.
Conflict with physicians has been identified as one stressor in the nurse work environment. Nurses may face both verbal and physical abuse when conflict arises with physicians. Physician behavior and adverse events, errors, and poor patient outcomes14.
District nurses were slightly more positive about collaboration than GPs. A positive attitude towards collaboration did not seem to be a part of the GPs’ professional role to the same extent as it is for DNs. Professional norms seem to have more influence on attitudes than do gender roles. DNs seem more confident in their profession than GPs15.
Study conducted in Nigeria showed that doctors and nurses have a positive perception of ICP which was not dependent on one’s profession and gender. However, length of experience in clinical practice was seen to enhance collaborative practice; the higher the years of experience, the more willing doctors and nurses are likely to collaborate. While clear communication, role specification and good working relationship were perceived to enhance ICP, status differentiation and decision making power imbalance, knowledge hoarding on the other hand was perceived as hindrances. Measurements to decrease hindrances and improve on the enhancers should be put in place for efficient and effective patient outcomes16.
A study conducted in Nigeria in 2006 about working relationships between nurses and doctors, showed that nurses (79.5%) were more likely than doctors (59.4%) to complain that staff shortage is a significant cause of poor doctor-nurse working relationships. Furthermore, more nurses than doctors wanted the post of the chief executive of hospitals to be open to all professionals in the health care system, in the belief that this will positively influence the conditions of service of health care workers and their sense of belonging17.
A health institution based descriptive cross sectional study was employed to assess inter professional collaboration between nurses and physicians in Manasar Specialized Hospital.
In this study research setting is Black Lion Specialized Hospital is found in Harar City, Noso Sub City which is the last referral hospital in Gembela. This hospital sees approximately 220,000 – 300,000 patients per year but the exact number is not known. They have 600 beds with 125 specialists, 62 nonteaching doctors and 514 staff nurses. This is the largest teaching hospital for the University of Harar Medical School in Gembela. There are about 350 residents and 600 interns, and has modern planned and accommodated and facilitated with the outpatient department (OPD), has four x-ray, eight surgical and two diagnostic laboratory rooms. The hospital has provided the appropriate medical services in the internal medicine, gynecological and obstetrics, surgical, pediatrics and emergency departments. The hospital also have special units (Referral clinics), those are Chest, Renal, Neurology, Cardiology, Dermatology and Sexually Transmitted Diseases, Gastrointestinal, Infectious Diseases, Orthopedics, General Surgical, Gynecologic and Obstetrics, Diabetic, Hematology and Medical ICU.
The source populations for this study were all staff nurses and physicians who were working in Manasar specialized hospital during the study period.
The study populations for this study were all staff nurses & physicians who work in Manasar specialized hospital at the time of data collection who were selected systematically and met the inclusion criteria.
Nurses & physicians characteristics /Socio demographic variables: age, sex, marital status, level of education, occupational title, service year and area of work
Nurse’s and physician’s attitude towards nurse-physician collaboration
Nurse–physician collaborative behavior.
Sample and sampling technique:
The overall minimum sample size, was determined using single proportion formula sample
Size calculation formula: n=[(Zα/2)2p (1-p)/d2]
n o=[(Zα/2)2p (1-p)/d2]=(1.96)2 (0.41) (0.59) / (0.05)2 = 371.71 ≈ 372)
p=prevalence, taking 41% from previous research conducted .
Z=standard normal deviation usually set at 1.96 which correspond to the 95% confidence interval.
d=is a tolerable margin of error (d=0.05)
Since the study was conducted on finite population which is < 10,000
Therefore, using single population correction formula: no 372
n= 1+ no/N = 1+372/925 = 265.7 ≈ 266
Taking non-response rate as 10% the final sample size were 293.
By using proportion formula:
ni=NIxn/9, where, ni–sample size of n category, Ni–total population of ni category, n –total sample size and N–total population
Numbers of nurses were: 714/925×293=226
And number of physicians: 211/925×293=67
The reason why Manasar Specialized hospital selected is because this hospital is the top level of referral hospital in the country which gives health care for patient’s from all parts of the region. Since large number of Gembelan population is served by this hospital it is appropriate to apply this study in order information from this study can be utilized to improve quality of service delivered to citizens visiting this public hospital. Systematic random sampling technique was employed (k=3) taking every three nurses and every three (k=3) physicians in the hospital and the first number was selected by lottery method from the first three. List of staff nurses and physicians was used as sampling frame.
K=N/n, for nurses = 714/226=3.2 ≈ 3 for physicians = 211/67 = 3.2≈3
Description of the Tool:
Modified Jefferson Scale of Attitudes was used to assess the attitudes of nurses and physicians towards each other in work place.
The findings of this study indicates that more than half of nurses 133(58.8%) and 32(47.8%) physicians showed favorable attitude. On the other hand 93 (41.2%) of nurses and 35(52.2%) of physicians showed unfavorable attitude towards nurse-physician collaboration. This shows that nurses were more favorable towards nurse-physician collaboration than physicians.
Analysis of the Subscales of Jefferson scale of attitude reveals that nurses scored higher on subscales of "shared education and team work" with mean score 23.79 and 22.09 respectively (p- Value 0.000),“Caring as opposed to curing” with mean score 9.95 and 9.45 respectively (p- Value 0.04) and on overall total attitude scores with mean score 49.18 and 46.64 respectively (p-value 0.003).This all explains nurses favorable attitude towards nurse-physician collaboration. the finding of this study regarding collaborative behavior indicates that more than half of nurses and physicians show Infrequent collaborative behavior 168(57.3%) and 125 (42.7%) of them show frequent collaborative behavior. This represents that there is infrequent collaborative behavior in both nurses and physicians.
Analysis of the Subscales of nurse-physician collaboration scale (NPCS) reveals that nurses scored higher compared to physicians on subscale of “Decision making process” with mean score 34.61 and 31.83 respectively (p-value 0.01). This indicates significant difference which is nurses showed more frequent nurse-physician collaborative behavior than physicians.
In contrast, the t-test analysis for NPCS shows significant difference. The younger age group showed more frequent collaborative behavior compared to old age groups with mean value 78.61±16.70, 72.58±15.36 (p value-0.002). Service year also showed significance difference between nurses and physicians with short and long service year with mean value 80.00±17.28, 69.81±12.64 (p value 0.000).
Strength of the study:
1. Adequate sample was recruited.
2. The questionnaires were pre-tested and modified before data collection
3. Using Jefferson scale based standard questionnaire
4. The data collection instrument/respondents list used as frame work appropriately
Limitation of the study:
1. Using self-administered questionnaire, the respondents may not pay full attention for it/read it properly.
2. Number of physicians participated in the study is minimal compared to that of nurses which might have impact on the results.
Shared continuing educational, in service training programs and workshop especially these with a focus on teamwork and collaboration.
Nurses and physicians are recommended to create suitable environment for the quality of their collaboration with one another. Taking responsibility from both sides can improve approaching one another in a collegial, respectful, and problem solving-based manner, no matter how badly any individual may behave.
Physicians are recommended to attend seminars or presentations related to nurses’ contributions to psychosocial and educational aspects of patient care in order to improve their attitude towards nurse care.
For the hospital:
Forums to disseminate the result of research on collaboration can provide opportunities for open discussion and problem solving, thus creating an ongoing awareness of the need for improved collaboration. Providing cross-disciplinary shadowing opportunities for nurses and physicians to provide mutual understanding of roles, and enable both groups to better envision collaborative practice. Involving both nurses and physicians in the recruiting efforts of an organization could help improve the understanding of the needs and values of each group.
Hospital management should conduct on-job workshops and seminars on inter personal and professional collaboration skills participating both nurses and physicians and Promote interaction between them. Creating awareness through participatory trainings can improve social and professional interaction between nurses and physicians.
For policy maker:
Initiating and developing mutually respectful inter-professional relationships between nurses and physicians. This can be done through inter professional education in their curriculum to increase understanding of complementary roles of nurses and physician, and encourage establishment of an interdependent relationship between them. Develop programs that promote interaction between medical and nursing students help these future professionals understand each other's roles and responsibility.
For future researchers:
Future researchers should conduct studies in order to investigate the main reason for poor nurse-physician collaboration.
CONCLUSIONS OF STUDY:
This study identified that majority of the respondents have significant favorable total attitude towards Jefferson scale of attitude and infrequent collaborative behavior in overall NPCS but it wasn’t significance here. As compared with physicians nurses had more favorable attitudes towards collaboration specifically toward shared education and team work, caring vs. curing, and overall total attitude subscales. And also as compared with physicians nurses had more frequent collaborative behavior especially in subscale “Decision making process”.
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Received on 20.11.2018 Modified on 25.11.2018
Accepted on 03.12.2018 ©A&V Publications All right reserved