Collaborative Trust and Decision Making

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					                                                                  Interdisciplinary Nursing Home Practice:                                                                                                                    Advocate Health Care

                           Collaborative Trust and Decision Making
                                                    Jill O’Brien, Ph.D.* and Donald R. Martin, Ph.D. College of Communication, DePaul University, Chicago
                                            Judith A. Heyworth, M.D., CMD and Nancy R. Meyer, MSN, APN, CNS-BC, Advocate Health Care, Geriatrics, Chicago

                                                                                                     Foundations of Collaboration
Collaboration is a joint and cooperative enterprise that integrates the individual perspectives and expertise of various team members. Components fundamental to successful professional collaborations in healthcare include, but are not limited to, mutual trust
and respect; joint problem identification; regular interpersonal interactions among team members; focused staff meetings to address concerns; clearly stated and understood mission, vision, and values; common practice philosophies and goals; adequate
support (internal and external); ongoing team education; effective reward and recognition systems; and shared decision making

There are two foundational elements upon which higher-level competencies are built: trust and shared decision making. Without these two basics, collaborative aspirations falter. Professional trust is manifested by shared decision making. Collaboration
depends on team members’ communication skills. Healthcare organizations that nurture joint decision making derive benefits in patient health outcomes, in retention, in cost containment, and in satisfaction.

                                       Central Questions and Purpose                                                                                                                        Methodology
This study focused on the communication-based negotiation of collaboration when nurses and physicians work together in               Participants: Eight NPs (7 women, 1 man) and five MDs (4 women, 1 man) from a single practice group caring for patients at
the setting of a nursing home.
                                                                                                                                     40 nursing homes in a large practice group located in / near a large Midwestern city.
Central questions included:                                                                                                          Procedure: Each participant underwent a semi-structured interview (60 to 90 minutes). Interviewers used open-ended
    • How do NPs and MDs define actions that contribute to mutual trust and respect in behavioral terms?                             questions, encouraged participants to provide examples or tell stories to clarify concepts, and asked about understandings
    •    How is shared decision making demonstrated by an NP-MD healthcare team in a NH practice environment?                        derived from experience in previous practice(s) as well as from the current collaborative relationships.
    •    What similarities and differences exist between NPs and MDs concerning behaviors that demonstrate trust and                 Analysis: Interviews were tape-recorded and transcribed. Data within the two topical areas were divided into thematic
         respect or truly shared decision making?                                                                                    categories—a process called open coding. The constant-comparative method guided categorization and conceptual labeling
                                                                                                                                     of data around emergent themes (Strauss & Corbin, 1998). Principles of sufficiency and saturation guided identification of
    •    Do NPs and MDs agree on term definitions and on the meaningful behavioral manifestations of these concepts?                 categories. High inter-rater reliability (.80 and above) was achieved.


                                           RESPECT AND TRUST                                                                                                               SHARED DECISION MAKING
NP/MD conceptual similarities                                                                                                      NP-MD conceptual similarities
NPs and MDs demonstrated similar understanding of the concepts of trust and respect. Both physicians and NPs perceived             NPs and MDs agreed that decision making should use existent facts and apply clear situational & clinical criteria. Shared
quality care as imperative; both believed that professional collaboration would contribute to that end.                            decision making involves practice standards mutually negotiated or endorsed, joint problem solving, paying special heed to

NP/MD divergences in behavioral expectations                                                                                       the insights of the partner most closely affiliated with the case, and selecting a plan calculated to provide high-quality patient

NPs and MDs differed markedly concerning the behaviors expected as manifestations of respect and trust.                            care. Ongoing clinical education, adequate partner interaction (written, oral, or electronic), clear practice standards, and

Thematic differences emerged concerning autonomy, case processing, emotional control, and distinctive partner attributes.          vested authority are all required.

Autonomy versus supervision                                                                                                        NP-MD divergences in behavioral expectations
NPs expected MDs to grant them appropriate professional autonomy within their scope of practice (SoP). Many MDs                    NPs and MDs agreed conceptually about the character of shared decision making but differed about how it was behaviorally
perceived themselves as senior or superior to the NP. Personal insecurity, professional misunderstanding, flawed role              manifested or constrained. Perceptual differences in authority and ongoing education distinguished MDs from NPs.
definitions,and licensing concerns were cited as the basis of behaviors that undermine respect for appropriate NP autonomy.        Authority in relation to autonomy/supervision
MDs consistently reported they respected NPs. NPs felt physicians did not always understand the role of the NP or respect          NPs and MDs agreed about the ideal concept of shared decision making. MDs expected that “NPs must always keep them
their SoP. This pulled NP-MD dyads apart, made NPs begin to distrust MDs, and established negative interaction patterns.           informed about what they were doing because the doctor is responsible.” NPs disagreed. Most NPs in the practice perceived
Mutual case processing versus private analysis: differing values                                                                   themselves as shared decision makers entrusted with much autonomy. MDs agreed that NPs had autonomy appropriate to
NPs and MDs agreed that a partner’s values, traits, and situational judgments contributed to the formation of fundamental          their SoP but believed that physicians had lesser need for the concurrence of their NP partner and broader latitude for
respect and eventual trust, but they diverged in the behavioral expressions deemed most salient. NPs valued MDs who                assertion of independent preferences. Most MDs sought tighter reporting than most NPs considered necessary.
discussed cases. MDs did not perceive such clinical case discussions with an NP partner as helpful                                 Ongoing education
Personal and professional traits: emotional control                                                                                MDs thought the NPs with whom they were paired were strong clinicians & competent communicators. MDs complained
The MD personal trait most valued by NPs was emotional control. MDs did not perceive an NP’s emotional control to be a             about inadequate NP education, NP unwillingness to continue learning, or NP inability to transfer learning from one patient to
problem & did not deem emotional tone to be a noteworthy feature of respect or trust. None of the MDs viewed themselves            another through careful reasoning and application. MDs viewed themselves as educationally superior to NPs and as vested
as requiring better emotive control. According to NPs, negative emotional expression by MDs was present and a hindrance.           with more hierarchical responsibility and authority. The partners did not have parity. Although some individuals consulted with
Distinctive versus interchangeable partner attributes                                                                              each other more frequently, MDs made the final call—even if a patient was seen more frequently by the NP. Shared
A partner’s traits and values mattered more to NPs than to MDs                                                                     decision making was more of an aspiration than the norm within most collaborative NP-MD partnerships when crises arose.
                                                                                                                     Future Directions

These findings provide an impetus for NP-MD team discussions about respect, trust, and shared decision making within collaborative practice, and also have heuristic value—motivating continued investigation into the behavioral expectations of NPs and MDs
as they negotiate collaboration. Areas of conceptual agreement offer encouragement. Areas of divergence elucidate lack of awareness &r insensitivities which may inadvertently undermine team trust, shared decision making, and effective collaboration.
                                                                                                               References – see handout