Collaborative practice in health care occurs when a member of the health care team consults with another member to provide patient care. Collaboration most often occurs between doctors and nurses. “Collaboration is defined as a relationship of interdependence; the ability to work together involves trust and respect not only of each other but of the work and perspectives each contributes to the care of the patient” (Phipps and Schaag, 1995, p. 19). Effective collaborative practice amongst all health care team members leads to continuity of care, professional interdependence, quality care and patient satisfaction and decreased costs. Ongoing collaboration between health care members results in mutual respect, trust and an appreciation of what each individual brings to the overall goal in rendering care to the client. The following vignette will provide the foundation for the discussion of collaborative care, differentiating between nursing diagnosis and collaborative problems, and potential barriers to successful collaboration.
JG is a 74 year old married Hispanic male diagnosed with colon cancer. He had a history of prosthesis placement of his left lower leg; he is ambulatory. He is a diabetic on oral medications. He worked as a farm laborer. He lives with his wife she does not speak English she is a homemaker. He has a son who lives nearby and a nephew who periodically visits him. JG can understand some English. He does have some difficulty expressing his health concerns to the staff because of his limited vocabulary. His son or nephew brings JG to his clinic appointments. He receives weekly chemotherapy at the outpatient oncology clinic. The day I cared for JG he arrived at the clinic accompanied by his nephew. This was week seven of his treatment. His clothing was dirty, he smelled of stool, his fingernails were dirty, hair uncombed, he appeared to be dehydrated. He reported bowel movements of eight stools per day with complaints of occasional abdominal cramping. He denied nausea or loss of appetite. He stated that he was very tired and was not able to do much at home.
His main concern was the frequency of his bowel movements. He reports having to go to the bathroom two to three times during the night and has episodes of soiling the bed. He reports that sometimes he does not feel the urge to go. JG was wearing adult diapers. He expressed concern that it was getting expensive for him to purchase. The nephew confirmed that JG toileting has created a problem in the home. His nephew verbalized that JG had medication for diarrhea but ran out of it and he did not have the money to purchase the medication. When questioned why he was using a wheelchair he stated that his foot hurt to walk the distance from the lobby to the treatment room. He mentioned that it was probably due to an ingrown toe nail. He also asked how he could obtain a wheel chair for his personal use at home. Physical assessment revealed that he had a necrotic area on the ball of his left foot with surrounding redness, lost 12 pounds in six weeks, poor skin turgor, hyperactive bowel sounds, and his blood pressure was slightly lower than baseline.
In the ambulatory chemotherapy setting, the clients do not always see their physician every time they receive treatment. The nurse must ascertain when to collaborate with the physician on issues regarding the patients status, response to treatment, or toxicities that may be life threatening. It is essential that the nurse is capable to communicate effectively her-(Be careful with gender bias, nurses come in both genders.) observations to the physician.
Collaborative problems are detected from the nurse’s assessment of the patient. The nurse’s monitoring of the patient status is to evaluate physiological complications that may threaten the patient’s integrity. Management of collaborative problems will include implementing physician prescribed and nurse prescribed actions to curtail escalation of the problem and preventing patient harm. From the nurse’s assessment, she also formulates a nursing diagnosis. The nursing diagnoses are stated in the form of the problem, the etiology and the symptoms that the nurse observes. Nursing diagnosis can include a current or potential problem, an at risk problem, or a wellness diagnosis. Nursing diagnosis provides the framework from which the nurse begins to devise a plan of care and nursing interventions.
In the case of JG, there were two collaborative problems identified. Two problems I collaborated with physician, these were:
1. JG is experiencing toxicity from the chemotherapy. There is potential for electrolyte imbalance, circulatory collapse.
2. The necrotic area on his foot was a new development in his condition. There is potential complication for infection
The collaborative problems discussed with JG physician and nurse quickly resolved. JG did not receive his chemotherapy. He was given an injection of sandostatin LR to help minimize his diarrhea; a stat basic metabolic panel was obtained; and he was given intravenous hydration with potassium. The doctor made a referral to JG podiatrist for the next day to assess the integrity of his left foot.
Listed are four, but not all, possible nursing diagnosis obtained from my assessment.
1. Diarrhea related to chemotherapy manifested by hyperactive bowel sounds and eight loose stools.
2. Bowel incontinence related to loss of rectal sphincter control and chemotherapy manifested by fecal odor, fecal staining of clothing, urgency.
3. Altered Nutrition related to colon cancer manifested by diarrhea, abdominal cramping.
4.Ineffective management of therapeutic regimen related to JG lack of knowledge of his disease manifested by his inability and unwillingness to manage his symptoms.
Considering JG comments regarding his finances, his overall physical appearance and the comments from his nephew, I decided to consult with the social worker. I felt that a home visit or a thorough investigation of JG home situation was warranted.
The social worker was able to arrange for in home support, and helping the patient with insurance issues so he could obtain the needed supplies. I did not think to enlist the participation of the dietician. In retrospect, the dietician would have been a valuable resource to assess JG caloric intake and recommendations for optimal nutrition.
I felt that the above incident demonstrated collaboration amongst health care providers. The physician in this case was receptive to the nurse’s observations with respect to her capabilities of accurate assessment of the patient’s condition and potential complications. This is not always the case, barriers to collaboration are also inherent in the health care industry. Barriers occur in patient situations where the physician is not sympathetic or does not trust the nurse’s evaluation of patient condition. The nurse may have feelings of inferiority, lack of confidence and does not appropriately collaborate with the physician correct information.
Conflicts in the goals desired for the patient is often cited as a barrier to collaboration. I recall an incident of a male patient diagnosed with metastatic breast cancer. His appearance was that of an individual who had been in a Nazi concentration camp. The nurse wondered why the physician was treating this man aggressively. In her mind, this patient was not an appropriate candidate to receive the particular treatment that was ordered. She feared the patient would not tolerate such an aggressive schedule and that it was pointless to put this poor man through treatment. The patient was diagnosed two years ago. He is still receiving treatments, he has gained weight and in October of last year he hiked to the summit of Mt. Whitney.
Role conflict is another major barrier to collaboration. To deliver cost effective care, many institutions utilize nurse practitioners and physician assistants. Role conflict arises when practitioners have opposing views or expectations (Blais, Hayes, Kozier, & Erb, 2002). Role conflict and can lead to litigation. According to Resnick, physicians hesitate to collaborate informally with Nurse Practitioners for fear of being held liable for the actions of the Nurse Practitioner (Resnick, 2004). Clear definition of roles for practitioners is essential to prevent misunderstanding.
In conclusion, collaborative practice is the gold standard that health care practioners should strive towards. The nurse is central in determining the patient issues that warrant collaboration and she must be able to effectively communicate her observations. Collaborative practice minimizes complications that could lead to tragic outcomes. The ultimate goal of collaborative practice is to provide the quality service that each patient under our care deserves.
Blais, K.K., Hayes, J. S., Kozier, B. & Erb, G. (2002). Professional nursing practice:
Concepts and perspectives (4th ed.). New Jersey: Prentice Hall.
Phillps, W.J., & Schaag, H.A. (1995). Persepctives for health and illness. In Phipps, W.J, Cassmeyer, V.L., Sands, J. E., Lehman, M.K(Eds.), Medical surgical nursing concepts and clinical practice, p. 19. St. Luis, MO: Mosby.
Resnick, B. (2004). Limiting litigation risk through collaborative practice. Geriatric Times,
5(4), 33. Retrieved March 21, 2004 from EBSCOhost database.