Nurse-Physician Leadership: Insights Into Interprofessional Collaboration

Using an interprofessional competency framework to enhance collaborative pediatric nursing education and practice

Background

Interprofessional education (IPE) provides healthcare students with the knowledge and skills necessary to provide safe and effective collaborative care in a variety of clinical settings. Inclusion of IPE in nursing curricula is required for program accreditation in Canada; a variety of learning strategies at varied levels are used to meet this requirement. As this formal requirement only occurred over the last decade, development, facilitation, and evaluation of IPE interventions are ongoing.

Purpose

The purpose of this study was to examine if exposure to an introductory IPE activity influenced third-year undergraduate nursing students’ perceived ability to practice competent interprofessional collaboration (IPC).

Methods

The introductory IPE activity included ten-hours of interactive lectures and related case studies, grounded in the National Interprofessional Competency Framework, delivered by various healthcare professionals in a third-year nursing theory and clinical course. Following completion of the courses, quantitative data were collected via the Interprofessional Collaborative Competencies Attainment Survey (ICCAS) which was used to evaluate nursing students’ change in competencies for IPC. Frequencies, percentages, and means were used to analyze the demographic data, the Cronbach’s alpha coefficient was used to evaluate the internal reliability of the ICCAS, and paired t-tests were conducted to measure the difference from pre- to post-participation for all 20 items and 6 subscales of the ICCAS.

Results

Study participants (n = 111) completed the ICCAS at the end of the courses to measure change in six competencies. The survey results indicated improvements in all competencies following the IPE activity.

Conclusions

The significant findings demonstrate that exposure to introductory IPE activities, involving nursing students and other healthcare professionals, hold promise for enhancing IPC in pediatric clinical settings. These findings can be used to inform the development of formal IPE interventions.

Nurses' role in accomplishing interprofessional coordination: Lessons in 'almost managing' an emergency department team

AIM

To describe how nurse coordinators accomplished day-to-day interprofessional coordination in an Australian emergency department team, drawing some lessons for the design of nurse coordinator roles in other settings.

BACKGROUND

Previous studies have examined leadership within nursing teams, and there are a growing number of registered nurses employed as care coordinators. There is limited literature on how the day-to-day coordination of interprofessional teams is accomplished, and by whom.

METHOD

Nineteen semi-structured interviews with emergency department registered nurses, doctors and nurse practitioners analysed thematically.

RESULTS

Three themes describe how coordinators accomplished interprofessional coordination: task coordination and oversight, taking action to maintain patient flow and negotiating an ambiguous role.

CONCLUSION

Better-defined nurse coordinator roles with clearer authority and associated training are essential for consistent practice. However, accomplishing interprofessional coordination will always require the situated knowledge of the complex nursing-medical division of labour in the workplace and the interpersonal relationships that are only gained through experience.

IMPLICATIONS FOR NURSING MANAGEMENT

The design of nurse coordinator roles must include the thorny question of 'who leads' interprofessional teams in the day-to-day coordination of tasks. New and inexperienced nurses may not have the necessary situated knowledge or interpersonal relationships to succeed. However, such roles offer an important development opportunity for future nurse managers.

Evaluating the clinical dyad leadership model: a narrative review

PURPOSE

Dyadic leadership models, in which two professionals jointly lead and share unit responsibilities, exemplifies a recent trend in health care. Nonetheless, much remains unknown about their benefits and drawbacks. In order to understand their potential impact, we conducted a review of literature evaluating dyad leadership models in health systems.

DESIGN/METHODOLOGY/APPROACH

Our narrative review began with a search of PubMed, CINAHL, Web of Science and Scopus using key terms related to dyads and leadership. The search yielded 307 articles. We screened titles/abstracts according to these criteria: (1) focus on dyadic leadership model, i.e. physician-nurse or clinician-administrator, (2) set in health care environment and (3) peer-reviewed with an evaluative component of dyadic model. This yielded 22 articles for full evaluation, of which six were relevant for this review.

FINDINGS

These six articles contribute an assessment of (1) teamwork and communication perceptions and their changes through dyad implementation, (2) dyad model functionality within the health system, (3) lessons learned from dyad model implementation and (4) dyad model adoption and model fidelity.

RESEARCH LIMITATIONS/IMPLICATIONS

Research in this area remains nascent, and most articles focused on implementation over evaluation. It is possible that some articles were excluded due to our methodology, which excluded nonEnglish articles.

PRACTICAL IMPLICATIONS

Findings provide guidance for health care organizations seeking to implement dyadic leadership models. Rigorous studies are needed to establish the impact of dyadic leadership models on quality and patient outcomes.

ORIGINALITY/VALUE

This review consolidates evidence surrounding the implementation and evaluation of a leadership model gaining prominence in health care.

Impact of a hospital unit-based leadership triad on key performance metrics

We piloted a triad leadership model consisting of a unit-based hospitalist medical director, nurse manager, and case manager on five medical inpatient units. The purpose of this explanatory case study was to determine what, if any, impact the triad team would have on commonly measured operational and quality metrics: observed to expected length of stay, likelihood to recommend the hospital, hand-washing compliance, all-cause 30-day readmission rates, percent of discharges by noon, and percent of discharge to skilled nursing facilities. Over the course of a year triad units demonstrated improvement in most metrics in comparison to the baseline period. While trends for the metrics were favorable, most striking was a statistically significant improvement in the observed to expected length of stay ratio (1.25 to 1.15, p < 0.001) which is the organization's most widely used marker for efficient hospital patient flow.As a result of these sustained operational, safety, quality, and financial performance metrics the model is being generalized to other medical as well as surgical units, including our observation unit. Intangible benefits include creating leadership development path for hospitalist, nursing, and case management colleagues.

Rural Homecare Nurses' Challenges in Providing Seamless Patient Care in Rural Japan

Homecare nurses manage patients with extreme homecare dependence through interprofessional collaboration. The quality of the collaboration depends on situations, and the difficulties of homecare nurses are complicated in rural settings because of a few healthcare resources. This study determined rural homecare nurses' difficulties during interprofessional collaboration in providing seamless patient care. Focus groups, followed by one-on-one interviews, were conducted with 13 rural homecare nurses working in rural Japan. Using thematic analysis, four themes were extracted: collaboration with physicians, the collaboration with the government, the collaboration with care workers, and the collaboration among hospital nurses. Rural homecare nurses have difficulties in their working relationships with other professionals, with vague definitions of each professional's roles and responsibilities, and with information-sharing. Interprofessional education and information-sharing should respect rural professional and cultural backgrounds. Respect can accomplish mutual understanding among professional care, leading to seamless patient care in rural home care.

Challenges and success strategies for dyad leadership model in healthcare

The use of a dyad leadership model involving a physician co-leader and a co-leader with a different background, the dyad co-leader, is gradually increasing in Healthcare Organizations (HCOs). There is a paucity of empirical studies on various aspects of this model. This study's aim was to identify challenges and strategies for success in the dyad leadership model in healthcare. Through a mixed-methods approach utilizing focus groups, surveys, and semi-structured interviews, perceptions of 37 leaders in one HCO at different hierarchical levels were analysed based on their lived experiences. The challenges and success strategies spanned personal, interpersonal, and organizational domains. The areas requiring attention included mindsets, competencies, interpersonal relationship, support, time, communication, and collaboration. In addition, the importance of organizational context addressing its structure, strategy, operations, and culture was highlighted. The findings from this study may be used for praxis, development, and implementation of dyad leadership.

Leader empowering behaviour: relationships with nurse and patient outcomes

PURPOSE

This study aims to test a model examining the impact of leader empowering behaviour on experienced nurses' self-efficacy, interprofessional collaboration, job turnover intentions and adverse patient outcomes.

DESIGN/METHODOLOGY/APPROACH

Structural equation modelling in Mplus was used to analyse cross-sectional survey data from experienced nurses in Alberta, Ontario, and Nova Scotia, Canada (n = 478).

FINDINGS

The results supported the hypothesized model: (164) = 333.021, p = 0.000; RMSEA = 0.047; CFI = 0.965; TLI = 0.959; SRMR = 0.051. Indirect effects were observed between leader empowering behaviour and nurses' assessment of adverse events and leader empowering behaviour and nurses' job turnover intentions through interprofessional collaboration.

RESEARCH LIMITATIONS/IMPLICATIONS

Leader empowering behaviour plays a role in creating collaborative conditions that support quality patient care and the retention of experienced nurses.

PRACTICAL IMPLICATIONS

The findings will be of interest to academic and hospital leaders as they consider strategies to retain experienced nurses, such as nurse manager selection, development and performance management systems.

ORIGINALITY/VALUE

The influx of new graduate nurses to the nursing profession and changing models of care requires the retention of experienced nurses in the workforce. The findings suggest that leader empowering behaviour and interprofessional collaboration are important factors in supporting quality patient care and stabilizing the nursing workforce.

Teamwork Essentials for Hospitalists

Teamwork is essential to providing high-quality patient care. Hospital settings pose important challenges to teamwork. Measurement is key to understanding baseline performance and assessing whether teamwork is improving. The authors recommend a multifaceted approach, using a combination of complementary interventions with an ultimate goal that improved teamwork translates into improved patient outcomes.

Complexity Science Fosters Professional Advanced Nurse Practitioner Role Emergence

This article discusses role emergence from master's-prepared nurse practitioners to Doctor of Nursing Practice (DNP) innovative leaders who utilize Complexity science to impact health care organizations. DNP leaders are in position to disrupt linear traditional leadership and embark on new ideas for improvements in care delivery, organizational system processes, and policies within health care. Complexity science provides the necessary theoretical framework for nurse executives and stakeholders to interact with DNP leaders by engaging in collaborative efforts, cultivating communication from point of service providers to administrators, and coordinating interdisciplinary teams to approach gaps in practice, clinical issues, health care policy, and organizational sustainability. The DNP leader is aware that health care organizations are complex adaptive systems, continuously changing. These require skilled and knowledgeable leaders to support growth within an uncertain environment, and bring evidence to practice while promoting organizational wellness.

Transformational Leadership Principles and Tactics for the Nurse Executive to Shift Nursing Culture

Nurse executives must embody the principles of transformational leadership to meet the leadership imperative of achieving high-quality outcomes in this ever-changing healthcare environment. This article describes the 4 domains of transformational leadership and provides pragmatic examples a nurse executive used to impact culture, outcomes, and the journey to Magnet designation. The strategies were utilized to support enculturation of Magnet principles by engaging clinical nurses, nursing leadership, and colleagues. Helping clinical nurses understand the alignment of their existing practice and values to the Magnet standards was ultimately a successful strategy.

Perceptions of Iranian emergency department directors of interprofessional leadership: an interview study

The aim of this study was to explore the viewpoints of Iranian health-care team directors regarding factors that are influential in leading an interprofessional team in the emergency department. The study was conducted using in-depth individual interviews and inductive content analysis. The study took place in the emergency departments of three teaching hospitals in Tehran. We used purposeful criterion sampling and interviewed 15 health-care team directors including 12 emergency medicine specialists and 3 nursing directors. Each interview lasted 60 to 90 minutes. All interviews were recorded and transcribed verbatim. Participants' statements were used to freely generate the initial data codes (open coding). Then, the initial codes were arranged into subcategories, which were later grouped together into categories. Finally, by comparing and contrasting categories, three main categories were identified: (a) effectiveness of the team-based leadership, (b) strategies of advancing interprofessional collaboration, and (c) weakness in overcoming team challenges. In the present study, the main factors that affected developing interprofessional collaboration in the Iranian emergency department were the development and support of leadership at the team and organizational levels, and implementation of staff development strategies at the individual and team levels.

Redesigning systems to improve teamwork and quality for hospitalized patients (RESET): study protocol evaluating the effect of mentored implementation to redesign clinical microsystems

Background

A number of challenges impede our ability to consistently provide high quality care to patients hospitalized with medical conditions. Teams are large, team membership continually evolves, and physicians are often spread across multiple units and floors. Moreover, patients and family members are generally poorly informed and lack opportunities to partner in decision making. Prior studies have tested interventions to redesign aspects of the care delivery system for hospitalized medical patients, but the majority have evaluated the effect of a single intervention. We believe these interventions represent complementary and mutually reinforcing components of a redesigned clinical microsystem. Our specific objective for this study is to implement a set of evidence-based complementary interventions across a range of clinical microsystems, identify factors and strategies associated with successful implementation, and evaluate the impact on quality.

Methods

The RESET project uses the Advanced and Integrated MicroSystems (AIMS) interventions. The AIMS interventions consist of 1) Unit-based Physician Teams, 2) Unit Nurse-Physician Co-leadership, 3) Enhanced Interprofessional Rounds, 4) Unit-level Performance Reports, and 5) Patient Engagement Activities. Four hospital sites were chosen to receive guidance and resources as they implement the AIMS interventions. Each study site has assembled a local leadership team, consisting of a physician and nurse, and receives mentorship from a physician and nurse with experience in leading similar interventions. Primary outcomes include teamwork climate, assessed using the Safety Attitudes Questionnaire, and adverse events using the Medicare Patient Safety Monitoring System (MPSMS). RESET uses a parallel group study design and two group pretest-posttest analyses for primary outcomes. We use a multi-method approach to collect and triangulate qualitative data collected during 3 visits to study sites. We will use cross-case comparisons to consider how site-specific contextual factors interact with the variation in the intensity and fidelity of implementation to affect teamwork and patient outcomes.

Discussion

The RESET study provides mentorship and resources to assist hospitals as they implement complementary and mutually reinforcing components to redesign the clinical microsystems caring for medical patients. Our findings will be of interest and directly applicable to all hospitals providing care to patients with medical conditions.

Trial registration

NCT03745677. Retrospectively registered on November 19, 2018.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4116-z) contains supplementary material, which is available to authorized users.

Perioperative accountable care teams: Improving surgical team efficiency and work satisfaction through interprofessional collaboration

The purpose of this performance improvement project was to design, implement and evaluate an interprofessional education initiative intended to improve surgical team efficiency, communication and work satisfaction. The development of interprofessional perioperative accountable care teams in three surgical specialties, cardiothoracic, neurosurgery and orthopedics, demonstrated a reduction in turnover time, increased staff, patient and surgeon satisfaction, and increased operating room (OR) revenue generated by the surgical specialties within one year of implementation.

A Thematic Analysis of Self-described Authentic Leadership Behaviors Among Experienced Nurse Executives

OBJECTIVE

The aim of this study is to understand the behaviors experienced nurse executives use to create healthy work environments (HWEs). The constructs of authentic leadership formed the conceptual framework for the study.

BACKGROUND

The American Association of Critical-Care Nurses recommends authentic leadership as the preferred style of leadership for creating and sustaining HWEs. Behaviors associated with authentic leadership in nursing are not well understood.

METHODS

A purposive sample of 17 experienced nurse executives were recruited from across the United States for this qualitative study. Thematic analysis was used to analyze the in-depth, semistructured interviews.

RESULTS

Four constructs of authentic leaders were supported and suggest unique applications of each including self-awareness (a private and professional self), balanced processing (open hearted), transparency (limiting exposure), and moral leadership (nursing compass).

CONCLUSIONS

Authentic leadership may provide a sound foundation to support nursing leadership practices; however, its application to the discipline requires additional investigation.

Managing processes of inpatient care and treatment: Swedish healthcare process managers' descriptions

PURPOSE

The purpose of this paper is to establish a knowledge bank for the development of overall hospital processes. Description and analysis are used to show how process managers experience their situation and the various possibilities it offers for active management in the context of managing processes of inpatient care and treatment at Swedish hospitals.

DESIGN/METHODOLOGY/APPROACH

A qualitative and explorative design with open-ended interviews with 12 process managers at three Swedish hospitals was used. Transcribed interviews were analysed by means of latent content analysis.

FINDINGS

The two main categories emerging from the analysis were characteristics of process leadership and prerequisites of process management. Quality, relational and knowledge dimensions, and structure, time and information dimensions emerged as their respective sub-categories. The overall theme describes the interdependence between leadership characteristics and the prerequisites necessary for effective process management.

RESEARCH LIMITATIONS/IMPLICATIONS

No generalizations could be made from the results of the qualitative interview studies but a deeper understanding of the phenomenon was reached, which in turn can be transferred to similar settings.

ORIGINALITY/VALUE

This study contributes qualitative descriptions of leadership characteristics and the prerequisites necessary for active process management in the context of managing processes of inpatient care and treatment at Swedish hospitals, a subject that has not been investigated earlier.

Intensity of interprofessional collaboration among intensive care nurses at a tertiary hospital

OBJECTIVES

To measure the intensity of interprofessional collaboration (IPC) in nurses of an intensive care unit (ICU) at a tertiary hospital, to check differences between the dimensions of the Intensity of Interprofessional Collaboration Questionnaire, and to identify the influence of personal variables.

METHOD

A cross-sectional descriptive study was conducted with 63 intensive care nurses selected by simple random sampling. Explanatory variables: age, sex, years of experience in nursing, years of experience in critical care, workday type and work shift type; variable of outcome: IPC. The IPC was measured by: Intensity of Interprofessional Collaboration Questionnaire. Descriptive and bivariate statistical analysis (IPC and its dimensions with explanatory variables).

RESULTS

73.8% were women, with a mean age of 46.54 (±6.076) years. The average years experience in nursing and critical care was 23.03 (±6.24) and 14.25 (±8.532), respectively. 77% had a full time and 95.1% had a rotating shift. 62.3% obtained average IPC values. Statistically significant differences were found (P<.05) between IPC (overall score) and overall assessment with years of experience in critical care.

CONCLUSIONS

This study shows average levels of IPC; the nurses with less experience in critical care obtained higher IPC and overall assessment scores.

Nurse-physician collaboration in an academic medical centre: The influence of organisational and individual factors

Ineffective physician-nurse collaboration has been recognised to adversely impact patient and organisational outcomes, and some studies suggest an underlying factor may be that nurses and physicians have different perceptions of interprofessional collaboration (IPC). The objectives of this study were to evaluate for a difference in the perception of IPC between physicians and nurses and to explore potential contributing factors at the individual and organisational levels to any observed difference. Data including measures of perceptions of IPC were collected from a convenience sample of resident physicians (n = 47), attending physicians (n = 18), and nurses (n = 54) providing care for internal medicine patients in a large tertiary care academic medical centre. Regression analysis revealed significantly lower perceptions of IPC scores for nurses in comparison to the scores of both the resident and attending physician groups (p = .0001 for both). Although demographic and workload factors also differed by profession, only profession and workload remained significant in regression analysis. Given the known relationships between effective physician-nurse collaboration and superior patient and organisational outcomes, better defining the individual and organisational predictors of IPC scores may support development of more effective interventions targeting improvements in IPC.

The influence of empowerment, authentic leadership, and professional practice environments on nurses' perceived interprofessional collaboration

AIM

The aim of this study was to examine the influence of structural empowerment, authentic leadership and professional nursing practice environments on experienced nurses' perceptions of interprofessional collaboration.

BACKGROUND

Enhanced interprofessional collaboration (IPC) is seen as one means of transforming the health-care system and addressing concerns about shortages of health-care workers. Organizational supports and resources are suggested as key to promoting IPC.

METHODS

A predictive non-experimental design was used to test the effects of structural empowerment, authentic leadership and professional nursing practice environments on perceived interprofessional collaboration. A random sample of experienced registered nurses (n = 220) in Ontario, Canada completed a mailed questionnaire. Hierarchical multiple regression analysis was used.

RESULTS

Higher perceived structural empowerment, authentic leadership, and professional practice environments explained 45% of the variance in perceived IPC (Adj. R² = 0.452, F = 59.40, P < 0.001).

CONCLUSIONS

Results suggest that structural empowerment, authentic leadership and a professional nursing practice environment may enhance IPC.

IMPLICATIONS FOR NURSING MANAGEMENT

Nurse leaders who ensure access to resources such as knowledge of IPC, embody authenticity and build trust among nurses, and support the presence of a professional nursing practice environment can contribute to enhanced IPC.

The Long Way Toward Cooperation: Nurses and Family Physicians in Northern Germany

To better understand why cooperation between health care professionals is still often problematic, we carried out 25 semistructured face-to-face expert interviews with physicians and nurses in different rural and urban areas in northern Germany. Using Mayring's qualitative content analysis method to analyze the data collected, we found that doctors and nurses interpreted interprofessional conflicts differently. Nursing seems to be caught in a paradoxical situation: An increasing emphasis is placed on achieving interprofessional cooperation but the core areas of nursing practice are subject to increasing rationalization in the current climate of health care marketization. The subsequent and systematic devaluation of nursing work makes it difficult for physicians to acknowledge nurses' expertise. We suggest that to ameliorate interprofessional cooperation, nursing must insist on its own logic of action thereby promoting its professionalization; interprofessional cooperation cannot take place until nursing work is valued by all members of the health care system.

Unit-based interprofessional leadership models in six US hospitals

The landscape of hospital-based care has shifted to place greater emphasis on improving quality and delivering value. In response, hospitals and healthcare organizations must reassess their strategies to improve care delivery in their facilities and beyond. Although these institutional goals may be defined at the executive level, implementation takes place at local sites of care. To lead these efforts, hospitals need to appoint effective leaders at the frontlines. Hospitalists are well poised to take on the role of the local clinical care improvement leader based on their experiences as direct frontline caregivers and their integral roles in hospital-wide quality and safety initiatives. A unit-based leadership model consisting of a medical director paired with a nurse manager has been implemented in several hospitals to function as an effector arm in response to the changing landscape of inpatient care. We provide an overview of this new model of leadership and describe the experiences of 6 hospitals that have implemented it.

Anonymity: An Impediment to Performance in Healthcare

Many teaching hospitals employ a care team structure composed of a broad range of healthcare providers with different skill sets. Each member of this team has a distinct role and a different level of training ranging from attending physician to resident, intern, and medical student. Often times, these different roles lead to greater complexity and confusion for both patients and nursing staff. It has been demonstrated that patients have a great degree of difficulty in identifying members of their care team. This anonymity also exists between nursing staff and other care providers. In order to better understand the magnitude of anonymity within the teaching hospital, a ten-question survey was sent to nurses across three different departments. Results from this survey demonstrated that 71% of nurses are “Always” or “Often” able to identify which care team is responsible for their patients, while 79% of nurses reported that they either “Often” or “Sometimes” page a provider who is not currently caring for a given patient. Furthermore, 33% of nurses felt that they were either “Rarely” or “Never” able to recognize, by face and name, attending level providers. Residents were “Rarely” or “Never” recognized by face and name 37% of the time, and interns 42% of the time. Contacting the wrong provider repeatedly leads to de facto delays in medication, therapy, and diagnosis. Additionally, these unnecessary interruptions slow workflow for both nurses and members of the care team, making hospital care less efficient and safe overall. Technological systems should focus on reducing anonymity within the hospital in order to enhance healthcare delivery.