Nurs Admin Q

Vol. 32, No. 1, pp. 40–48

Interdisciplinary Collaboration
for Healthcare Professionals
Lori Fewster-Thuente, MSN, RN;
Barbara Velsor-Friedrich, PhD, RN

Interdisciplinary collaboration has the capacity to affect both healthcare providers and patients.
Research has shown that the lack of communication and collaboration may be responsible for as
much as 70% of the adverse events currently reported. The purpose of this article is 2-fold: to exam-
ine factors that may influence interdisciplinary collaboration and consequently patient outcomes
and to examine the relationship between interdisciplinary collaboration and King’s theory of goal
attainment as a theory to support the phenomenon of interdisciplinary collaboration. Key words:
communication, goal attainment, healthcare professionals, interdisciplinary collaboration

I NTERDISCIPLINARY COLLABORATION
is a vital phenomenon to healthcare
providers and patients. The level of collab-
An equally important purpose of this article
is to examine a theory that has the potential
to both support and improve nurse-physician
oration that takes place among providers collaboration. Currently, there are no specific
can directly impact patient outcomes. Joint structured models or theories found in the
Commission currently reports that almost literature that provide a base for interdisci-
70% of patient adverse events cite the lack of plinary collaboration. This article will exam-
collaboration and communication between ine the relationship between the concept of
providers as a main cause of error.1 An interdisciplinary collaboration and King’s the-
increase in nurse-physician collaboration and ory of goal attainment. Historically, the theory
communication can improve both patent of goal attainment has focused on the interac-
outcomes2–6 and provider satisfaction.7,8 tion between the nurse and the client; how-
The purpose of this article is to exam- ever, King stated, “it can be used not only by
ine factors that may enhance or inhibit in- nurses with their patients but by any individ-
terdisciplinary collaboration, which, in turn, ual in any interactions with other profession-
may impact patient and nursing outcomes. als” (I. King, personal communication, April
Factors such as gender, age, culture, and 11, 2006).
level of education of the nurse or physician The theory of goal attainment has been
can directly impact the perceived level of used to guide nursing practice and research
collaboration.8–10 for approximately 30 years. King’s theory
has been used by nurses, administrators, and
other healthcare providers in more than 13
countries.11 As one can see, this theory has
depth and scope beyond bedside nursing.
From the Marcella Niehoff School of Nursing, Loyola
University Chicago, Chicago, Ill. The theory has also been used with nurs-
ing administration12,13 and to guide nursing
We thank Dr Imogene King for her expertise and guid-
ance in the creation of this article. curricula.14 King’s theory has been tested in
research and used in every patient popula-
Corresponding author: Lori Fewster-Thuente, MSN, RN,
Loyola University Chicago, 6525 North Sheridan Rd, tion from infants to the elderly. Specific mod-
Chicago, IL 60626 (e-mail: llfewster@hotmail.com). els such as the Wicks family health model15
40
 Interdisciplinary Collaboration for Healthcare Professionals 41

and the Advance directive decision making shared planning and decision-making, team
model16 have been derived from it to guide approach, contribution of expertise, shared
nursing practice.11 The theory has helped responsibility, nonhierarchical relationships,
develop research instruments and facilitated and shared power based on knowledge and
other middle-range theories such as the The- expertise.”22
ory of Group Power.12 Use of the theory The term teamwork is often used as a syn-
of goal attainment to foster interdisciplinary onym to collaboration.23 However, the litera-
collaboration with the intended outcome of ture shows that teamwork is 1 attribute of a
improved patient and nursing outcomes is collaborative relationship.24,25 Topics such as
presented. joint practice, communication, and collegial-
ity are similar to collaboration but have differ-
REVIEW OF LITERATURE ent meanings and will, therefore, not be ad-
dressed in this article.26
A review of the literature reveals similar def- The review of literature did not reveal
initions among clinicians on the definitions of a specific theory that was used to sup-
collaboration. As stated by Lindeke and Siek- port or encourage interdisciplinary collabo-
ert, “Collaboration is a complex process that ration. Although not specifically developed
requires intentional knowledge sharing and to address interdisciplinary collaboration, the
joint responsibility for patient care.”17 transaction process of King’s theory of goal
The American Nurses Association18 defines attainment, when used by healthcare pro-
collaboration in nursing by looking at 4 main fessionals, results in collaboration among
components: nurses, physicians, and allied healthcare
• a partnership with mutual valuing professionals.
• recognition of separate and combined
spheres of responsibility THE THEORY OF GOAL ATTAINMENT
• mutual safeguarding of legitimate inter-
ests of each party King27 developed a conceptual system,
• recognized shared goals which consists of 3 interacting systems: per-
In healthcare, collaboration is defined as sonal, interpersonal, and social. Each system
“a complex phenomenon that brings together contains its own defining concepts. The per-
two or more individuals, often from different sonal system includes individuals interacting
professional disciplines, who work to achieve with their environment and incorporates the
shared aims and objectives.”19 This definition concepts of growth and development, self,
was chosen as the working definition as it in- space, time, perception, and body image. The
cludes other disciplines and how they work interpersonal system involves human beings
to reach a common goal. interacting with one another in a variety of
There also seems to be a consensus among environments. The concepts associated with
authors regarding the defining attributes of the interpersonal system are communication,
the concept of collaboration. Attributes of interaction, role, stress, and transaction.
collaboration include shared power based Societal systems consist of groups of 2 or
on knowledge, authority of role, and lack more individuals interacting, each working in
of hierarchy.20 Wells et al21 determined the its role, toward a collective goal. Healthcare
following attributes related to collaboration: organizations are an example of a social
open communication, cooperation, assertive- system that consists of groups of those
ness, negotiation, and coordination. As a individuals in society who interact with one
result of a concept analysis, Henneman et al another for a common purpose, the better
determined that the following attributes were patient care. There are groups within groups
associated with collaboration: “joint venture, in each hospital, such as a palliative care team
cooperative endeavor, willing participation, in an oncology ward, which set goals with
42 NURSING ADMINISTRATION QUARTERLY/JANUARY–MARCH 2008

individual patients and families, and work Nurse-(physician) interactions are characterized by
toward achieving those goals. The concepts verbal and nonverbal communication in which in-
of a social system are power, status, authority, formation is exchanged and interpreted by trans-
and decision making.27 actions in which values, needs and wants of each
Utilizing this conceptual system as the member of the dyad (team) are shared, by percep-
tions of the nurse, (physician), and the situation, by
foundation, King developed the theory of
self in role of nurse, self in role of (physician), and
goal attainment. Briefly stated, the theory other stressors influencing each person and the sit-
of goal attainment addresses the interactions uation in time and space.28
of nurses with their clients to achieve health
outcomes and attain goals. King determined, Healthcare providers seek to improve the
“The focus of nursing is human beings inter- health of their patients. However, health can
acting with their environment leading to a be a multidimensional goal for both providers
state of health for individuals, which is their and patients, and may have different mean-
ability to function in social roles.”27 ings for different people. Although King’s the-
The theory of goal attainment utilizes the ory of goal attainment is focused on nurs-
concepts of perception, communication, in- ing, in which it is the work of nursing
teraction, and transaction. It is an interaction- to help patients optimize their resources to
transaction process in which nurses and achieve maximum potential for daily living,
clients interact to mutually define and set other healthcare professionals also participate
goals. They proceed through the transac- in that work. The path to improved health
tion phase, the means by which to achieve through collaboration and goal attainment is
goals, toward goal attainment.13 Nurses work besieged with barriers that both patients and
to help individuals maintain or regain their providers must attempt to overcome every
health and return to their highest level of day. It is important to know and understand
functioning.27 the barriers in order to overcome them.
The interactions between team members
and the client are what contributes to the BARRIERS
strength of the process. Interactions are de-
fined as “process of perception and communi- The barriers to goal attainment between
cation between person and environment and nurses and clients are the same as the barri-
between person and person, represented by ers to collaboration among members of the in-
verbal and non-verbal behaviors that are goal- terdisciplinary healthcare team. The review of
directed.”27 These interactions cause all in- literature discussed the following barriers to
volved to feel respected and positive about collaboration: patriarchal relationships, time,
the mutual goals set. gender, culture, and lack of role clarification.
The interaction-transaction process can These barriers can also inhibit the ability to set
be used in any interaction with 1 or more and attain goals. A discussion of these barriers
individuals in healthcare situations. When follows.
this process is utilized by the members of the
interdisciplinary teams, within the theory of Patriarchal relationship
goal attainment, the result is collaboration The primary relationship in the theory of
and hopefully the best patient outcome. goal attainment is between the nurse and
It is through interdisciplinary collabora- the client in which the nurse is the author-
tion and patient communication that goals ity figure. Historically, the nurse-physician re-
for client’s health outcomes are developed lationship has been one of hierarchy and
and implemented. In the following quote power with the balance of power going to the
substituting “physician” or other healthcare physician. The literature regarding this topic
provider for “client,” interdisciplinary collab- dates back to 1967 when Dr Stein wrote a
oration is supported when overlaid with the hallmark article, “The Doctor-Nurse Game.”29
theory of goal attainment. In this article, the relationship between the
 Interdisciplinary Collaboration for Healthcare Professionals 43

doctor and the nurse was described as one As collaboration is a vital step in the attain-
where the nurse played a very subservient ment of goals, it is imperative that time is al-
role to the physician. Although advances have lotted for team members, including the client,
been made, this type of portrayal is fea- to collaborate.4,31
tured still today in television and films. In Because of the nursing shortage, nurses to-
this model, it is difficult for collaboration to day have larger patient loads and a limited
occur. amount of time to spend with each patient.
Revenue generation amplifies the patriar- These factors may not allow for mutual goal
chal relationship. As physician services are setting or attaining. The use of the services
billed separately, it is easy to see that physi- of temporary or agency nursing staff may
cians contribute to the bottom line of the or- cause additional confusion as the nurse may
ganization. The work of nursing is generally not be aware of the organization’s practices
compiled into the overall hospital bill. Accord- and policies. In addition, the organization may
ing to Fagin,30 the direct impact to the bot- not have a structured communication process
tom line puts the balance of power in favor that allows the team members to discuss pa-
of the physician. Collaboration can take place tient situations and set appropriate goals. To
only when hierarchy is not present, and ev- add to the situation, more nurses are work-
eryone’s knowledge is valued and taken into ing part-time and, therefore, may not know pa-
account. tients or physicians as well, and may not feel
The patriarchal relationship is important comfortable approaching a physician they do
to study as physicians are seen as the lead- not know. Combine part-time workers with
ers of the interdisciplinary team. Therefore, it increased patient loads, and there is little time
is important to understand their perspective for healthcare providers to interact with each
and imperative that they participate in the re- other and their patients.32 Collaboration re-
search. As noted in the Baggs et al8 study, lack quires trust, and to build trust, people need
of time or interest is the reason why many time for interaction.
physicians have chosen not to participate in Utilizing King’s theory, Rundell33 studied
interdisciplinary collaborative research. Wells the interaction of patients and nurses in an in-
et al21 found that physician participation is a tensive care step-down unit and found com-
statistically significant element to successful munication between the two increased as the
execution of interdisciplinary collaboration. time spent in the unit increased. Time is re-
Goal attainment is a mutual process be- quired on the part of both, the patient and the
tween any 2 individuals who have formed a provider. Providers who take time to commu-
relationship such as a nurse and a client. The nicate with their patients can help clarify the
nurse has the knowledge base and expertise roles that they each play.
to work in collaboration with the patient to
develop health-related goals and, therefore, is
in the position of power. Nurses who are un- Lack of role clarification
comfortable in leading and directing patients Because of the nursing shortage and eco-
may feel a conflict over the role they play in nomic changes, unlicensed assistive person-
the patient’s care. Similarly, a patient who is nel are providing a great deal of patient care
used to being in the position of power may that was previously rendered by nurses. Physi-
have difficulty in working with a healthcare cian roles too are changing. Druss et al34
provider who may be younger or seem inex- found that by 1997, 36% of outpatient care
perienced. was provided by nonphysician clinicians such
as advanced practice nurses and physician as-
sistants. This is up from 30.6% in 1987.
Time Lack of role clarification is difficult for
Time, or lack of it, was also found to be a providers. Without distinct role boundaries as
barrier to collaboration and goal attainment. to who has responsibility for the patient, it is
44 NURSING ADMINISTRATION QUARTERLY/JANUARY–MARCH 2008

difficult to determine with whom one would ducted, which studied the female nurses’
collaborate. The collaboration between the (n = 197) responses to physician gender.35
team members and their patients is a result of The authors found that when both the physi-
the transactions that occurred. Transactions cians and nurses were female, the level of
occur when human beings are observed in- collaboration was higher and the balance of
teracting with their environments.27 It is each power more equal. The study also found that
person, acting in his or her role with the nurses were less likely to confront a male
client, that helps complete a step toward goal physician. This fact reinforces the dominant
attainment. The interaction of these roles and role of the male physician. The study did not
the mutual goals that result together form the explore why nurses were less likely to con-
interdisciplinary collaboration. front male physicians.
Interdisciplinary collaboration plays an im- A study by Wear et al10 supported the con-
portant role in eliminating errors, duplica- cept that female nurses are more collabora-
tions in care, and clarifying of roles. When tive with female physicians. The results from a
collaboration takes place among the nurse, qualitative survey showed that female nurses
client, and physician, each person under- reported higher level collaboration with fe-
stands the goals and the process through male physicians than with male physicians.
which to attain those goals. Gender issues between providers and pa-
In addition, lack of role clarification can tients still occur today. For example, elderly
make it difficult for patients to know who is women, now a large population of patients,
caring for them. Many of the patient goals can may not be comfortable with a male nurse
be worked on by other personnel than the providing their care. Conversely, a man from
nurse; that is, a patient goal is to be ambula- a male-dominated country may not take direc-
tory; therefore, the certified nursing aide may tion from a female nurse or physician.
assist the patient in a walk. However, the goals Culture issues are similar to gender issues
need to be mutually determined by the patient in that they are based on misunderstanding
and the interdisciplinary team; therefore, it is or the lack of knowledge. These issues tend
important for patient understanding and com- to occur when people have preconceived no-
fort to know the team members and the roles tions about how things should be, as opposed
that they fulfill. to how they are.
It remains a common misunderstanding
among patients that roles are clarified by gen-
der. The misunderstanding is that a female Culture
healthcare provider who comes into a pa- The final barrier to collaboration to be dis-
tient’s room must be a nurse and the male cussed is culture. Culture can be discussed
provider is a physician. from a country, organizational, professional,
or an individual perspective.9,22,36 The United
States has a culture that values autonomy, in-
Gender dependence, and free thinking. This mindset
Historically, women were nurses and men can impact the client’s desire to take direc-
were physicians. However, as healthcare tion from the healthcare provider as to the
evolves, more men are becoming nurses, and types of goals to be set. In addition, when the
more women are becoming physicians. Al- provider and client are from different cultures
though men represent only 7% of the nursing or speak different languages, many issues can
population, medicine is almost equally repre- occur: lack of translators, difference in ideas
sented by both men and women.10 for goals, and lack of understanding regarding
However, the impact of male physician’s various cultures and religious practices.
dominance over female nurses still comes The disciplines of medicine and nurs-
into play. A vignette-based survey was con- ing are rooted in vastly different theoretical
 Interdisciplinary Collaboration for Healthcare Professionals 45

frameworks that impart a culture for the care part that healthcare teams who fail to collab-
each provides. These ideas strongly contrast orate have increased mortality and failure-to-
with collaboration. Headrick et al36 found rescue (deaths within 30 days of admission
healthcare professionals to be autonomous in among patients who experienced specific
their work. However, the international study complications) rates. Accreditation agencies
by Hojat et al9 found that US physicians, al- such as the Joint Commission have now put
though still dominant, were less hierarchy- collaboration practice guidelines into place
based than those in other countries. for healthcare organizations and are requiring
In addition to a country’s culture, each their implementation for accreditation.39 The
individual organization has its own culture. organizations are graded on such things as in-
If the organizational culture is one that terdisciplinary practice plans.
promotes hierarchy, there is likely to be little Negative patient outcomes related to col-
collaboration. However, if the organizational laboration have also been found by Baggs
culture models and rewards collaborative et al.8 In this study, it was determined that the
behavior, there is more of a chance that lower the level of nurse-reported collabora-
collaboration will occur. An article by Arford tion, the higher the risk of a negative outcome
discussed the accountability organizations such as readmission to the intensive care unit
have to create a climate of collaboration. or mortality. This point is also supported by
The values and beliefs of the organization the theory of goal attainment in that patient
are echoed in team members’ desire to goals cannot be attained if collaboration does
collaboration and communication.37 not take place.
Barriers such as patriarchal relationships, A study by the Patient Safety Culture and
time, gender, lack of role clarification, and Teamwork40 surveyed high-risk area nurses
culture can have a negative impact on pa- in the intensive care unit, emergency depart-
tient outcomes. There can be many poten- ment, and operating room (n = 261). The
tially harmful outcomes to patients when such survey measured the levels of communication
barriers inhibit providers and patients from and collaboration of nurses with physicians
collaborating. On the flip side, there can be and other staff members. The survey of nurses
positive outcomes for patients and providers found that almost 70% felt the quality of col-
when collaboration takes place and goals are laboration with physicians was low or merely
attained. adequate. However, to keep patients safe, al-
most all nurses surveyed felt that commu-
nication and collaboration were at par with
PATIENT OUTCOMES skill. They further discovered that 85% of the
respondents felt that more input should be
The goal of interdisciplinary collaboration garnered from team members when making
is to achieve the positive health outcomes for patient-care decisions.
patients. The theory of goal attainment is also The strongest evidence that supports the
focused on positive health outcomes, as these idea that interdisciplinary collaboration and
outcomes are a direct measure of the quality the theory of goal attainment can impact pa-
of care provided.28 Interdisciplinary collabo- tient outcomes positively is found in the cur-
ration and goal attainment are related as col- rent literature. A randomized controlled trial
laboration is necessary to attain the desired was conducted by Curley et al,6 in which pa-
goals and reach these outcomes. tients and staff were randomized to 6 wards.
Lack of collaboration can have a negative ef- Three wards received an intervention that
fect on patient outcomes. Organizations such included daily interdisciplinary rounds. Dur-
as the Institute of Medicine and Joint Commis- ing these rounds, patient-care decisions were
sion have published many studies and reports made jointly by nurses, therapists, and physi-
such as To Err Is Human,38 which discuss in cians in cooperation with the patient. The
46 NURSING ADMINISTRATION QUARTERLY/JANUARY–MARCH 2008

other three served as the control group. between nurses’ level of dissatisfaction and
Although no differences in mortality were nurses’ perception of unequal decision mak-
found, there was a statistically significant de- ing. However, in this study, lack of collabora-
creased length of stay and reduced hospital tion did not correlate to retention issues.
charges. A large cross-sectional survey of 820 nurses
Higgins7 conducted a prospective correla- and 621 patients revealed that on units where
tional study of collaboration related to pa- nurses report positive working relationships
tient outcomes. The study tested 4 hypothe- with physicians, there was a significantly
ses, of which 1 was found to be statistically lower burnout rate for nurses. In addition, pa-
significant. Higgins found that the nurses’ per- tients from these same units were twice as
ception of collaboration with physicians pos- likely to be “highly satisfied” with their care.5
itively correlated with their level of satisfac- Studies have revealed the positive out-
tion regarding their decision-making process comes of interdisciplinary collaboration for
of when and where to transfer a patient (cor- providers and patients. A significant theory,
relation coefficient of 0.28, P = .000). These such as the theory of goal attainment, can
patients were found to have fewer readmis- guide practice and support the concept of in-
sions to the intensive care unit, decreased terdisciplinary collaboration. There are a few
length of stay, and decreased mortality. practices that have demonstrated increased
Use of the transaction process in the the- interdisciplinary collaboration.
ory of goal attainment is imperative for posi-
tive patient outcomes. Research findings have
shown that the collaboration that results from INTERVENTIONS TO ACHIEVE
interactions and transactions between pa- COLLABORATION
tients and their healthcare providers results
in goals being set and attained. The theory of Two methods that aid collaboration and
goal attainment can be an important step to incorporate patient goal setting have been
ensure patient safety. studied and published. Curley et al6 intro-
duced, via a randomized controlled trial, an
intervention of daily interdisciplinary rounds,
NURSING BENEFITS which resulted in decreased length of stay
and reduced hospital charges. Those who
The theory of goal attainment benefits conducted daily rounds included a physi-
nurses as well as clients. Patient goal attain- cian, nurse, social worker, nutritionist, and
ment directly correlates to nursing satisfac- pharmacist, and consisted of the healthcare
tion, as a major goal of nursing is to see pa- providers, discussing each patient and setting
tients return to a functional state of health. short-term and long-term goals. The data in-
Nurses are also satisfied when collabora- dicated that this method worked, as patients
tion is sought regarding patient care, and achieved those goals in a shorter time and
are dissatisfied when they are not. A cause were discharged from the hospital.
of nurse dissatisfaction is lack of joint deci- The other method is collaborative practice
sion making. This is an important component order sets for common diagnoses. The use
of collaboration to nurses. Baggs et al8 con- of standardized care plans that are interdis-
ducted a longitudinal descriptive correlation ciplinary in nature and have been developed
study, using the Collaboration and Satisfaction by interdisciplinary teams increases the daily
about Care Decision questionnaire to survey collaboration among providers and provides
healthcare providers and their patients. The goals for patients with similar diagnoses.
sample included nurses (n = 150), attending The quasi-experimental study conducted by
physicians (n = 82), residents (n = 74), and Wells et al21 found that these paths provide
patients (n = 1432). A correlation was found a means of collaboration and communication
 Interdisciplinary Collaboration for Healthcare Professionals 47

between providers and patients, in both the the healthcare system to achieve quality care
development and the implementation of the of individuals and groups in communities.
paths. The research thus far has found positive pa-
These 2 interventions, while having pos- tient outcomes associated with positive nurse-
itive results, have been limited in their im- physician relationships. To date, however, the
plementation. A structured approach that fo- interventions to achieve collaboration have
cuses on mutual goals being set and attained been limited in scope and dimension. The ap-
may lead to significant positive patient out- plication of the concepts of the goal attain-
comes. ment theory can provide a framework for in-
terdisciplinary collaboration to move forward
SUMMARY in improving outcomes and reducing adverse
events. Future recommendations can include
Healthcare providers have recognized that testing the use of the transaction process with
interdisciplinary collaboration is essential in healthcare professionals.

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