Chapter 13CollaborationThe American Nurses Association (ANA) d.docx

Chapter 13
Collaboration
The American Nurses Association (ANA)
defines collaboration as “recognition of the expertise of others
within and outside the profession, and referral to those other
providers when appropriate. Collaboration involves some shared
functions and a common focus on the same overall mission”
(2010b, p. 40). This is a critical competency required to practice
in any healthcare setting today or to participate in any aspect of
healthcare delivery—critical for effective patient-centered,
quality care. The increased emphasis on using interprofessional
teams to meet the patient’s needs across the continuum of care
requires collaboration. Team members and different healthcare
providers must be able to work together; recognize strengths
and limitations; respect individual responsibilities and
expertise; and maintain open, effective communication.
Nurses who have long worked on teams should be familiar with
teamwork. Despite this, there continues to be a separation
between physicians and nurses, who often work in silos.
Nurses and physicians need to work together to ensure that the
patient receives the care that is required when it is required.
Collaboration involves cooperative effort among all healthcare
providers offering care for a patient. This will result in more
effective decision making with healthcare professionals working
together to accomplish identified outcomes. This is not easy to
do. There are professional issues, territory issues, conflicting
goals, inadequate communication, and multiple differences;
however, despite all of this, effective and efficient care requires
collaboration. The system is just too complex to function well
without collaboration. The nurse is often the person who must
lead the effort to ensure collaboration occurs.
Key Definitions Related to Collaboration
Collaboration is a cooperative effort that focuses on a win-win
strategy. To collaborate effectively, each individual needs to

recognize the perspective of others who are involved and
eventually reach a consensus of a common goal(s). The ANA
notes that collaboration involves recognition of expertise and
some shared functions (2010a, 2010b). The ANA’s Nursing:
Scope and Standards of Practice(2010b) and the Nursing
Administration Scope and Standards of Practice (2009) also
identify the need for collaboration, emphasizing that all nurses
are expected to collaborate. The American Organization of
Nurse Executives (AONE) also includes the need for
collaboration in its descriptions of leadership competencies, as
described in Appendix A.
Key concepts related to collaboration are partnership,
interdependence, and collective ownership and responsibility.
Considering these concepts helps in understanding the impact of
collaboration. Collaboration is also a process. It is not stagnant
but rather changes, which requires staff to make adjustments to
collaborate with others as situations change. The American
Association of Critical-Care Nurses’ nurse competencies in its
Synergy Model™ states: “working with others (e.g., patients,
families, healthcare providers) in a way that
promotes/encourages each person’s contributions toward
achieving optimal/realistic patient/family goals; involves intra-
and interdisciplinary work with colleagues and the community”
(American Association of Critical-Care Nurses, 2014). Most
people can remember experiences when working with others
where the work just seemed to flow with less stress and good
communication. This probably means that the people working
together were collaborating.
Collaboration should be a positive experience, but this is not
always the case. If it is not positive, it will not be effective. If a
group of nurses were surveyed, it would be surprising to get a
consensus that collaboration was always a positive experience.
Often attempts at collaboration mean struggle, conflict, and
sometimes ineffective results. Some research has been
conducted to assess the effectiveness of collaboration. The
Institute of Medicine (IOM) recognizes the importance of

collaboration in its rules to guide healthcare provider behavior
in the 21st-century healthcare system (2001). The 10th rule,
cooperation among clinicians, emphasizes, “cooperation in
patient care is more important than professional prerogatives
and roles” (p.93). To meet this rule, staff need to collaborate
and use effective teamwork, which is weak in the healthcare
delivery system.
The Future of Nursing: Leading Change, Advancing
Health (Institute of Medicine, 2011) includes collaboration in
its content. For example, by noting that nursing leadership
competencies need to be applied in “a collaborative
environment” (p.8) and “future, primary care and prevention are
central drivers of the healthcare system where interprofessional
collaboration and coordination are the norm” (p.2). In its
recommendations for priorities in research that focus on
teamwork, the report lists “identification of the main barriers to
collaboration between nurses and other healthcare staff in a
range of settings” (p.275).
Barriers to Effective Collaboration
As noted by the IOM, working in isolation with concern for
only your own profession is not effective; however, nursing also
has much work to do to improve the image of nursing and
nursing leadership. Salmon (2007) comments that
“improvements in care quality and safety will simply not
happen with nurses working by themselves. To take it a step
beyond what may seem obvious, it can’t happen just by adding
physicians to the equation. It’s going to take the partnered
engagement of other clinicians, health administrators, and,
ultimately, the public” (p.117). Given these issues, how does
the nursing profession arrive at the right balance, one that
focuses on nursing and its professional role and needs, while
simultaneously developing nurses who can work collaboratively
with others to meet positive patient outcomes? Collaboration
requires an interactive process. If staff are not willing to
interact or have any other barrier to interaction, collaboration
cannot take place. Lack of understanding about the roles and

responsibilities of others and lack of respect for what others
have to contribute interferes with effective collaboration. How
much do nurses know about what physicians or social workers
or physical therapists or others do and vice versa? If there is
distrust, collaboration is hindered because distrust affects
willingness to share information, which is an integral
component in the collaborative relationship. Collaboration has
an impact on whether or not a team is effective or ineffective as
team members need to work with each other to develop effective
teams and also need to work with others external to the team.
Conflict may arise as teams and individual staff work together.
Conflict and conflict resolution are discussed in more detail
later in this chapter. Although each nurse must develop
individual expertise, this expertise must come together with
others’ expertise. Few nurses really can work effectively in
isolation. Nursing is a profession that requires contact with
others—patients, other nursing staff, other healthcare
professionals, families, community members, and so on.
Competencies and Strategies to Achieve Effective Collaboration
The increased emphasis on interprofessional teams to meet the
patient’s needs across the continuum of care requires effective
use of collaboration. The very nature of a team implies that
there is more than one idea or approach and not all can usually
be accomplished. Decisions need to be made, and this is where
collaboration comes into play. It is important to remember that
collaboration is also a critical factor in the nurse-patient
relationship. Nurses need to actively pursue patient
collaboration to ensure that patients are involved in their own
care—patient-centered care. The nursing profession has long
emphasized patient participation in planning care and in patient
education. Collaboration is also important in the development of
effective management. To be effective in collaboration, staff
require a number of skills:
· Communication skills are critical. Verbal skills are the focus;
however, in some instances written communication is also
important when information and process are described in written

format.
· Staff members also need to be aware of their own feelings, as
was discussed in some of the leadership theories such as
emotional intelligence.
· Staff need to be able to make decisions to solve problems
effectively.
· As is discussed in this chapter, coordination is also important
when collaborating with others.
· Conflicts will arise, which may interfere with collaboration.
Staff need to develop negotiation skills to be used in resolving
difficult conflicts.
· Assessment skills are needed to collect and analyze
information as collaborative relationships develop. Box 13-
1 highlights these skills.
Collaborative care is central to the success of efficient,
outcome-driven care. With the complex healthcare system,
specialization of many healthcare professionals, variety of
healthcare settings, complex reimbursement systems,
technology, and new drugs, collaboration is the only way that
patients will receive quality, cost-effective care. Today the
healthcare system is an interdependent system with multiple
settings and a variety of healthcare professionals, who are
dependent on one another. Delivery of care in this complex
system requires sharing of information, analysis, critical
thinking, clinical judgment, reasoning, clear communication,
and ability to use team problem solving. These activities are
integral to successful care as the nurse works with many
different healthcare providers, within many different healthcare
settings, and with the patient and family to ensure quality, cost-
effective care for the patient.
Collaborative planning recognizes that collaboration has a
positive effect on achieving patient outcomes (Institute of
Medicine, 2001). Collaborative planning requires that all parties
agree on the mission and goals of the partnership so they have
common expectations. All members
Box 13-1 Collaboration: Skills Needed

· Effective communication
· Awareness of personal feelings
· Problem solving
· Negotiation
· Assessment
· Recognition of expertise: Self and others
of the collaborative effort need to commit to open and honest
communication, which is essential to sharing. This can be
difficult in some HCOs, components of an organization such as
specific units or departments, and for some individuals. Those
who fear competition and are concerned about power will
struggle with the need to share.
Regular evaluation needs to be built into collaborative planning.
This evaluation should not only focus on the content of the
planning but also on the process—how the collaborative
relationship is working. This is something that is often
neglected. Power, which is discussed later in this chapter, is
related to collaboration. Usually some of the partners in a
relationship have more power than others. When partners work
through the collaborative planning process, some issues, such as
weak communication, level of commitment, expertise, and an
understanding that working together is better than working
against one another, may interfere with the process.
Recognizing these potential issues should be a priority to
prevent barriers to success. What can be done to prevent them?
Clear communication about purpose, particularly identifying
issues from the past that may affect the collaborative planning,
can help to clear up misconceptions. Team members need to
accept the importance of effort and commit to it. All efforts
should be made to keep team members committed. Evaluation
data about the collaborative effort can help to improve team
functioning.
Application of Collaboration
What is gained from collaboration? The complex healthcare
delivery system requires many competencies, and no one
healthcare profession has all of the necessary competencies to

provide all the care that is required. Effective interprofessional
teams and collaboration are critical. The IOM report on nursing
(2004) identifies practices that have an impact on the delivery
system, and these practices require collaboration to be effective.
The practices are to create and maintain trust throughout the
organization, deploy staff in adequate numbers, create a culture
of openness so errors are reported, involve staff in decision
making pertaining to work design and work flow, and actively
manage the change process.
How do healthcare professionals develop the skills necessary
for effective collaboration? There is a great need to incorporate
more interprofessional educational experiences in all healthcare
professional education, including nursing (Interprofessional
Education Collaborative, 2011; World Health Organization,
2010). Students from the various healthcare professions need to
have some experiences learning together in the same classroom
and participating in clinical experiences together. Learning
separately makes it very difficult to expect that at the time of
graduation new healthcare professionals will easily collaborate
when they have had limited collaborative experience with other
healthcare professional students or healthcare professionals.
They do not understand or respect the knowledge and learning
experiences of other students or their roles and typical
communication methods and processes. They may not even
value or respect what other healthcare professionals offer to the
team and to the patient. This causes serious problems as new
healthcare professionals begin to work and are then confronted
with working with one another. In addition, nurses need to have
a positive understanding of their own roles and
responsibilities—what they have to offer is valuable—so they
can approach collaboration while understanding that they have
important knowledge and competencies to add to the
collaboration. This, however, must be accomplished not from
the perspective of “I am better than you” but rather “How can
we bring our respective skills and knowledge together to
provide comprehensive, consistent care?” (Chapter 20 discusses

staff education in more detail.)
Interprofessional relationships and activities can result in
positive, collaborative outcomes; however, it is not easy to
establish these relationships and maintain them over time. It
takes time to develop an effective interprofessional
environment. Other recommendations are to set realistic goals
with commitment from all involved professionals, negotiate the
means to meet the goals, avoid battles that serve only as
barriers such as turf battles, and measure success based on
established goals.Coordination
The IOM identifies care coordination as one of the critical
priority areas of care that need be monitored and improved. The
purpose of care coordination is “to establish and support a
continuous healing relationship, enabled by an integrated
clinical environment and characterized by a proactive delivery
of evidence-based care and follow-up” (Institute of Medicine,
2003b, p. 49). Patient-centered care is discussed in Chapter 9;
however, patient-centered care is an important theme throughout
this text. There needs to be greater attention on how care is
coordinated across people, functions, activities, and sites to
provide effective and efficient care that leads to the patient’s
specific desired outcomes. Coordination requires that the nurse
understands patient needs and the resources that are available to
meet these needs. An awareness of the association of costs and
services is part of coordinating patient care. The healthcare
delivery system has become more complex, which has made
communication and coordination more complex, all of which
leads to increased risk of errors. There is greater need for
interprofessional teams. Team members may not always view
the patient, problems, or priorities in the same way, yet it is
critical that the team find a way to work collaboratively to
provide coordinated patient care. Team members need to have a
better understanding of individual responsibilities and stress to
appreciate each other and develop more realistic working
relationships. As noted by the IOM healthcare core competency,
all healthcare professionals need to know how to work in

interprofessional teams (Institute of Medicine, 2003a).
Recognizing this will make coordination less frustrating.Key
Definitions Related to Coordination
Coordination is the process of working to see that “the pieces
and activities fit together and flow as they should” (Finkelman
& Kenner, 2016, p. 328). Effective coordination requires
working across services that are complementary—across
clinicians or settings—to ensure quality care across patient
conditions, services, and settings over time (Institute of
Medicine, 2001). Examples might be physicians, nurses, social
workers, pharmacists, informatics specialists, and
administrators working together to improve documentation
through an electronic medical record or staff from a hospital
and an ambulatory care center working together to coordinate
better care for patients. Coordination is related to collaboration,
and in fact, it is very difficult to do one without the other.
When considering patient care, however, there is a critical
difference between the two. Collaboration with a patient
requires a direct interaction with the patient. Coordination of
care usually takes place before or after patient care is provided,
or it is interwoven in the care process. In the latter situation, a
nurse may ensure that all the plans for the patient’s discharge
are complete or that the various treatment and exam procedures
are scheduled appropriately for the patient’s needs.
Coordination does not mean that the patient is not involved
because patient input is critical to achieve patient-centered care,
but the nurse may do the coordination such as calling for
supplies or making sure a treatment is scheduled when not in
the presence of the patient or while providing direct care. Both
coordination and collaboration are also found daily in staff-to-
staff interactions. Collaboration focuses on solving a problem
with two or more people working toward this goal. Coordination
is done to ensure that something happens such as the provision
of services. The ANA Nursing Administration Scope and
Standards of Practice (2009) includes a standard on
coordination recognizing the need for nurses in

administration/management to be competent in coordination,
which is needed for planning and implementation of plans,
implementation of the management functions, teamwork with
other nurses and interprofessional teams, and is part of effective
communication with staff and patients/families/significant
others. The ANA supports the need for care coordination as an
important component of improving the quality of care and
providing for efficient and effective use of resources. Care
coordination needs to be a critical competency that all
registered nurses demonstrate (American Nurses Association,
2012).Barriers to Effective Coordination
As HCOs and services become more complex and use more
interprofessional teams, team members may not always have the
same view of the patient, problems, or priorities. It is, however,
critical that the team find a way to work collaboratively to
provide coordinated patient care and prevent errors,
disorganized care, and care that does not reach effective
outcomes. Team members need to have a better understanding
of individual responsibilities and their own stress to appreciate
each other and develop more realistic working relationships.
Coordination is also more effective when involved staff have a
better understanding of their respective roles and work stresses.
Recognizing this will make coordination less frustrating. If
resources are not availableApplying Evidence-Based
Practice Evidence for Effective Leadership and PracticeCitation
American Academy of Nursing. (2012, March 5). The
imperative for patient, family, and population centered
interprofessional approaches to care coordination and
transitional care. Policy Brief 3.5.1.2. Retrieved
from http://www.aannet.org/assets/docs/PolicyResources/aan_ca
re%20coordination_3.7.12_email.pdfOverview
The American Academy of Nursing (AAN) praises the Centers
for Medicare & Medicaid Services (CMS) for its support of
evidence-based care coordination and transitional care, which
has been applied to Medicare and Medicaid services. The AAN
recommends that the CMS consider the framework it will use to

implement care coordination and the evidence to support that
framework.Application
This paper from AAN suggests various models and measurement
methods to assist CMS in the implementation of greater use of
care coordination, which requires an interprofessional team
approach.Questions:
1. What are the guiding principles recommended by the AAN?
2. Why is this change important?
3. What models are described? How is measurement included?
4. Analyze the recommendations made by the AAN.
when and in the manner required, this will act as a barrier to
coordination. Staff who are not willing to listen and include
others will find that coordination may not be as successful as
planned. Other barriers are a lack of interprofessional
understanding, lack of resources, and inadequate
communication. Ineffective problem solving is also a critical
barrier. Coordination needs to include the patient and, when
appropriate and agreeable with the patient, the family. If patient
engagement is not present, it is a major obstacle to
care.Competencies and Strategies to Achieve Effective
Coordination
For staff to provide effective coordination, they need to make
decisions to solve problems, plan, use the abilities of other
staff, identify resources required, communicate, and be willing
to collaborate. Delegation often is required, so delegation skills
are important. (See Chapter 15 for more discussion on
delegation.) The nurse also needs to develop evaluation skills to
determine if outcomes are met as well as when to change course
or make adjustments. The skills required for coordination are
the same ones required for collaboration, with the primary goal
of working together to reach agreed-upon goals. Box 13-
2 highlights the skills needed for effective
coordination.Application of Coordination
Coordination is integral to daily operations, short- and long-
range planning, and the daily care process. All of these
activities require coordination of clinical and administrative

resources. The following strategies are helpful in improving
coordination (Finkelman & Kenner, 2016):
· All staff need to understand the importance of coordination.
· All staff should have a clear understanding of purpose and
goals.
· All staff should have knowledge of policies and procedures
with an understanding of what has to be done, by whom, and
how it will help to facilitate coordination.
· Improved organizational performance will depend on
coordination at all levels in the organization.
· Communication needs to be clear and timely.
(See Chapter 14.)
· Orientation and staff development programs should emphasize
the importance of coordination and how to use it.Box 13-
2 Coordination: Skills Needed
· Problem solve
· Plan
· Use abilities of others
· Identify needed resources
· Communicate
· Collaborate
· Delegate
· Evaluate
· Coordination requires effective communication and
collaboration.
· Staff/team members need to appreciate the expertise of other
team members.
· Delegation should be used as needed. (See Chapter 15.)
Health care uses many tools that focus on coordination of care
to ensure patient-centered care. Some of these are case
management, clinical pathways, practice guidelines, and disease
management. To be successful and meet expected outcomes,
these tools or methods also require collaboration with the
patient, patient’s family and significant other, and other
healthcare staff, and they are very useful when coordination is
required. With insurers emphasizing more effective and

efficient care, coordination plays a major role in reaching this
goal. Coordination requires that the nurse understand patient
needs and the resources that are available to meet these needs.
An awareness of the association of costs and services is part of
coordinating patient care. In addition, coordination is a very
important part of management within the healthcare delivery
system. This system has become more complex, which has made
communication and coordination more complex. Coordination is
required to get resources, schedule staff, plan work activities,
implement quality improvement, and perform all types of
management functions. With the growth of informatics in
documentation and decision-making tools, additional methods
are now available and new ones will be developed.
(See Chapter 19.) Figure 13-1 describes one view of
competencies needed to get results.
Negotiation and Conflict Resolution
There may be conflict between professions, but there is also
conflict within the nursing profession and with coworkers. In
these situations, staff members may attack one another by
asserting their position or by criticizing ideas. In some cases,
they attack one another personally. Collaboration is used
frequently to reach an agreement during a conflict. This is often
true with nurse-physician collaboration, though ideally
collaboration should be part of all of their interactions. Nurse-
physician relationships are complex. There is overlapping focus
in that both are concerned about the patient, though each may
come from different points of view, which is not always
understood or appreciated. There is also some confusion about
roles, which can lead to problems. In some cases there is a
certain amount of competition, which really is a sad statement;
the goal should be focused on what is best for the patient and
not what is best for individual staff or individual professions.
Conflict can never be eliminated in organizations; however,
conflict can be managed. Typically conflict arises when people
feel strongly about something. Conflicts may take place
between individual staff, within a unit, or within a department.

They may be interunit and interdepartmental, affect the entire
HCO, or even occur between multiple organizations, between or
within teams or units, or between an HCO and the community.
When people disagree, this may lead to conflict—having views
that are different and do not seem to be easy to resolve
(MindTools®, 2014a).
Key Definitions Related to Conflict
There are three types of conflict: individual, interpersonal, and
intergroup/organizational (MindTools®, 2014a).
· Individual conflict. The most common type of individual
conflict in the workplace is role conflict, which occurs when
there is incompatibility between one or more role expectations.
When staff do not understand the roles of other staff, this can be
very stressful for the individual and affects work. Staff may be
critical of each other for not doing some work activity when in
reality it is not part of the role and responsibilities of that staff
member, or staff members may feel that another staff member is
doing some activity that really is not his or her responsibility.
· Interpersonal conflict. This conflict occurs between people.
Sometimes this is due to differences and/or personalities;
competition; or concern about territory, control, or loss.
· Intergroup/organizational conflict. Conflict also occurs
between teams (e.g., units, services, teams, healthcare
professional groups, agencies, community and a healthcare
provider organization, and so on). Sometimes this is due to
competition, lack of understanding of purpose for another team,
and lack of leadership within a team or across teams within an
HCO.
Gets Results
A leader’s ultimate purpose is to accomplish organizational
results. A leader gets results by providing guidance and
managing resources, as well as performing the other leader
competencies. This competency is focused on consistent and
ethical task accomplishment through supervising, managing,
monitoring, and controlling of the work.
Prioritizes, organizes, and coordinates taskings for teams or

other organizational structures/groups
· Uses planning to ensure each course of action achieves the
desired outcome.
· Organizes groups and teams to accomplish work.
· Plans to ensure that all tasks can be executed in the time
available and that tasks depending on other tasks are executed
in the correct sequence.
· Limits overspecification and micromanagement.
Identifies and accounts for individual and group capabilities and
commitment to task
· Considers duty positions, capabilities, and developmental
needs when assigning tasks.
· Conducts initial assessments when beginning a new task or
assuming a new position.
Designates, clarifies, and deconflicts roles
· Establishes and employs procedures for monitoring,
coordinating, and regulating subordinates’ actions and
activities.
· Mediates peer conflicts and disagreements.
Identifies, contends for, allocates, and manages resources
· Allocates adequate time for task completion.
· Keeps track of people and equipment.
· Allocates time to prepare and conduct rehearsals.
· Continually seeks improvement in operating efficiency,
resource conservation, and fiscal responsibility.
· Attracts, recognizes, and retains talent.
Removes work barriers
· Protects organization from unnecessary taskings and
distractions.
· Recognizes and resolves scheduling conflicts.
· Overcomes other obstacles preventing full attention to
accomplishing the mission.
Recognizes and rewards good performance
· Recognizes individual and team accomplishments; rewards
them appropriately.
· Credits subordinates for good performance.

· Builds on successes.
· Explores new reward systems and understands individual
reward motivations.
Seeks, recognizes, and takes advantage of opportunities to
improve performance
· Asks incisive questions.
· Anticipates needs for action.
· Analyzes activities to determine how desired end states are
achieved or affected.
· Acts to improve the organization’s collective performance.
· Envisions ways to improve.
· Recommends best methods for accomplishing tasks.
· Leverages information and communication technology to
improve individual and group effectiveness.
· Encourages staff to use creativity to solve problems.
Makes feedback part of work processes
· Gives and seeks accurate and timely feedback.
· Uses feedback to modify duties, tasks, procedures,
requirements, and goals when appropriate.
· Uses assessment techniques and evaluation tools (such as
AARs) to identify lessons learned and facilitate consistent
improvement.
· Determines the appropriate setting and timing for feedback.
Executes plans to accomplish the mission
· Schedules activities to meet all commitments in critical
performance areas.
· Notifies peers and subordinates in advance when their support
is required.
· Keeps track of task assignments and suspenses.
· Adjusts assignments, if necessary.
· Attends to details.
Identifies and adjusts to external influences on the mission or
taskings and organization
· Gathers and analyzes relevant information about changing
situations.
· Determines causes, effects, and contributing factors of

problems.
· Considers contingencies and their consequences.
· Makes necessary, on-the-spot adjustments.
Figure 13-1 Competency: Gets results and associated
components and actions
Source: U.S. Army. (2006). Army leadership: Competent,
confident, and agile. Retrieved
from http://fas.org/irp/doddir/army/fm6-22.pdf
When conflict occurs, something is out of sync, usually due to a
lack of clear understanding of one another’s roles and
responsibilities. Sometimes conflict is open and obvious, and
sometimes it is not as obvious; this latter type may be more
destructive as staff may be responding negatively without a
clear reason. Everyone has experienced covert conflict. It never
feels good and increases stress quickly. Distrust and confusion
about the best response are also experienced. Acknowledging
covert conflict is not easy, and staff will have different
perceptions of the conflict since it is not clear and below the
surface. Overt conflict is obvious, at least to most people, and
thus coping with it is usually easier. It is easier to arrive at an
agreement when overt conflict is present and easier to arrive at
a description of the conflict.
The common assumption about conflict is that it is destructive,
and it certainly can be. There is, however, another view of
conflict. It can be used to improve if changes are made to
address problems related to the conflict. The following quote
speaks to the need to recognize that conflict can be viewed as
an opportunity.
When I speak of celebrating conflict, others often look at me as
if I have just stepped over the credibility line. As nurses, we
have been socialized to avoid conflict. Our modus operandi has
been to smooth over at all costs, particularly if the dynamic
involves individuals representing roles that have significant
power differences in the organization. Be advised that well-
functioning transdisciplinary teams will encounter conflict-
laden situations. It is inevitable. The role of the leader is to use

conflicting perspectives to highlight and hone the rich diversity
that is present within the team. Conflict also provides
opportunities for individuals to present divergent yet equally
valid views that allow all team members to gain an
understanding of their contributions to the process. Respect for
each team member’s standpoint comes only after the team has
explored fully and learned to appreciate the diversity of its
membership.
(Weaver, 2001, p. 83)
This is a positive view of conflict, which on the surface may
appear negative. If one asked nurses if they wanted to
experience conflict, they would say no. Probably behind their
response is the fact that they do not know how to handle
conflict and feel uncomfortable with it. However, if you asked
staff, “Would you like to work in an environment where staff at
all levels could be direct without concern of repercussions and
could actively dialogue about issues and problems without
others taking comments personally?” many staff would most
likely see this as positive and not conflict. Avoidance of
conflict, however, usually means that it will catch up with the
person again, and then it may be more difficult to resolve. There
may then be more emotions attached to it, making it more
difficult to resolve.
Causes of Conflict
Effective resolution of conflict requires an understanding of the
cause of the conflict; however, some conflicts may have more
than one cause. It is easy to jump to conclusions without doing
a thorough assessment. Some of the typical causes of conflict
between individuals and between teams/groups are “whether
resources are shared equitably; insufficient explanation of
expectations, leading to performance being questioned;
unexplained changes that disturb routines and processes and
that team members are not prepared for; and stress resulting
from changes that team members do not understand and may see
as threatening” (Finkelman & Kenner, 2016, p. 336).
Two predictors of conflict are the existence of competition for

resources and inadequate communication. It is rare that a major
change on a unit or in an HCO does not result in competition for
resources (staff, financial, space, supplies), so conflicts arise
between units or between those who may or may not receive the
resources or may lose resources. Causes of conflict can be
varied. An understanding of a conflict requires as thorough an
assessment as possible. Along with the assessment, it is
important to understand the stages of conflict.
Stages of Conflict
There are four stages of conflict that help describe the process
of conflict development (MBA, 2014):
1. Latent conflict. This stage involves the anticipation of
conflict. Competition for resources or inadequate
communication can be predictors of conflict. Anticipating
conflict can increase tension. This is when staff may verbalize,
“We know this is going to be a problem,” or may feel this
internally. The anticipation of conflict can occur between units
that
Figure 13-2 Stages of conflict
accept one another’s patients when one unit does not think that
the staff members on the other unit are very competent yet must
accept orders and patient plans from them.
2. Perceived conflict. This stage requires recognition or
awareness that conflict exists at a particular time. It may not be
discussed but only felt. Perception is very important as it can
affect whether or not there really is a conflict, what is known
about the conflict, and how it might be resolved.
3. Felt conflict. This occurs when individuals begin to have
feelings about the conflict such as anxiety or anger. Staff feel
stress at this time. If avoidance is used at this time, it may
prevent the conflict from moving to the next stage. Avoidance
may be appropriate in some circumstances, but sometimes it just
covers over the conflict and does not resolve it. In this case the
conflict may come up again and be more complicated. Trust
plays a role here. How much do staff trust that the situation will

be resolved effectively? How comfortable do staff members feel
in being open with their feelings and opinions?
4. Manifest conflict. This is overt conflict. At this time the
conflict can be constructive or destructive. Examples of
destructive behavior related to the conflict are ignoring a
policy, denying a problem, avoiding a staff member, and
discussing staff in public with negative comments. Examples of
constructive responses to the conflict include encouraging the
team to identify and solve the problem, expressing appropriate
feelings, and offering to help out a staff member. (Figure 13-
2 highlights the stages of conflict.)
Prevention of Conflict
Some conflict can be prevented, so it is important to take
preventive steps whenever possible to correct a problem before
it develops into a conflict. A staff team or HCO that says it has
no conflicts is either not aware of conflict or prefers not to
acknowledge it. Prevention of conflict should focus on the
typical causes of conflict that have been identified in this
chapter. Clear communication, known expectations, appropriate
allocation of resources, and delineation of roles and
responsibilities will go a long way toward preventing conflict.
If the goal is to eliminate all conflict, this will not be successful
because it cannot be done.
Since not all conflict can be prevented, managers and staff need
to know how to manage conflict and resolve it when it exists. It
is important to identify potential barriers that can make it more
likely that a situation will turn into a conflict or will act as
barriers to conflict resolution. First and foremost, if all staff
make an effort to decrease their tension or stress level, this will
go a long way in preventing or resolving conflict. In addition to
this strategy, it is important to improve communication,
recognize team members as members with expertise, listen and
compromise to get to the most effective decision given the
available data, understand the roles and responsibilities of
team/staff members, and be willing to evaluate practice and
team functioning.

Conflict Management: Issues and Strategies
Conflict management is critical in any HCO. When conflicts
arise, then managers and staff need to understand conflict
management issues and strategies. The major goals of conflict
management are as follows:
1. To eliminate or decrease the conflict
2. To meet the needs of the patient, family/significant others,
and the organization
3. To ensure that all parties feel positive about the resolution so
future work together can be productive
Powerlessness and Empowerment
When staff experience conflict, powerlessness and
empowerment, as well as aggressiveness and passive-
aggressiveness, become important. When staff members feel
that they are not recognized, appreciated, or paid attention to,
then they feel powerless. What happens in a work environment
when staff feel powerless? First, staff members do not feel they
can make an impact; they are unable to change situations they
think need to be changed. Staff members will not be as creative
in approaching problems. They may feel they are responsible for
tasks yet have no control or power to effect change with these
tasks. The team community will be affected negatively, and
eventually the team may feel it cannot make change happen.
Staff may make any of the following comments: “Don’t bother
trying to make a difference,” “I can’t make a difference here,”
and “Who listens to us?” Morale deteriorates as staff feel more
and more powerless. New staff will soon pick up on the feeling
of powerlessness. In some respects, the powerlessness really
does diminish any effort for change. As was discussed
in Chapter 3, responding to change effectively is very important
today. In addition, when staff feel powerless, this greatly
impacts the organizational culture.
Power is about influencing decisions, controlling resources, and
affecting behavior. It is the ability to get things done—access
resources and information, and use them to make decisions.
Power can be used constructively or destructively. The power a

person has originates from the person’s personal qualities and
characteristics, as well as the person’s position. Some people
have qualities that make others turn to them—people trust them,
consider their advice helpful, and so on. A person’s position,
such as a team leader or nurse manager, has associated power.
Power is not stagnant. It changes as it is affected by the
situation. There are a number of sources of power. Each one can
be useful depending on the circumstances and the goal. An
individual may have several sources of power. The common
sources of power include the following:
· Legitimate power. This power is what one typically thinks of
in relation to power. It is power that comes from having a
formal position in an organization such as a nurse manager,
team leader, or vice president of patient services. These
positions give the person who holds the position the right to
influence staff and expect staff to follow requests. Staff
members recognize that they have tasks to accomplish and job
requirements. It is important to note that a leader must have
legitimate power. This is a critical concept to understand about
leadership and power. However, it takes more than power to be
an effective leader and manager. The leader must also
demonstrate competency.
· Reward power. A person’s power comes from the ability to
reward others when they comply. Examples of reward power
include money (such as an increase in salary level), desired
schedule or assignment, providing a space to work, and
recognition of accomplishment.
· Coercive power. This type of power is based on punishment
initiated when a person does not do what is expected or
directed. Examples of punishment may include denial of a pay
raise, termination, and poor schedule or assignment. This type
of power leads to an unpleasant work situation. Staff will not
respond positively to coercive power, and this type of power has
a strong negative effect on staff morale.
· Referent power. This informal power comes from others
recognizing that an individual has special qualities and is

admired. This person then has influence over others because
they want to follow the person due to the person’s charisma.
Staff feel valued and accepted.
· Expert power. When a person has expertise in a particular
topic or activity, the person can have power over others who
respect the expertise. When this type of power is present, the
expert is able to provide sound advice and direction.
Box 13-3 Types of Power
· Legitimate
· Reward
· Coercive
· Referent
· Expert
· Informational
· Persuasive
· Informational power. This type of power arises from the
ability to access and share information, which is critical in the
Information Age.
· Persuasive power. This type of power influences others by
providing an effective point of view or argument (Finkelman &
Kenner, 2016). (Box 13-3 highlights the types of power.)
All HCOs experience their own politics, and this usually
involves some staff trying to gain power, hold on to power, or
expand power. As has been said, power can be used negatively,
and this can also lead to the unethical use of power or not doing
the right thing with the power. Chapter 2 discusses examples of
ethical issues. There is no doubt that there are managers who
use their power to control staff, as well as staff who use power
to control other staff, but this is not a healthy use of power.
Rather, it is a misuse of power and does not demonstrate
nursing leadership.
A self-appraisal of a person’s personal view of power allows the
individual to better understand how the person uses power and
how it then affects the person’s decisions and relationships.
This can lead to more effective responses to change during
planning and decision making, coping with conflict, and the

ability to collaborate and coordinate.
Empowerment is often viewed as the sharing of power;
however, it is more than this. “To empower is to enable to act”
(Finkelman & Kenner, 2016). Power must be more than words;
it must be demonstrated. Participative decision making
empowers staff but only if staff really do have the opportunity
to participate and influence decisions. Recognizing that one’s
participation is accepted makes a difference. True empowerment
gives the staff the right to choose how to address issues with the
manager.
Should all staff be empowered? A critical issue to consider
when answering this question is whether or not staff can
effectively handle decision making. This implies that staff
members need leadership qualities and skills to make sound
decisions and participate together collaboratively. They need to
be able to use communication effectively. When staff members
are selected, all these factors become important. Empowerment
is not gained just by being a member of the staff, but rather
staff members become empowered because they are able to
handle it. Management who want to empower staff must transfer
power over to the staff, but management must first feel
confident that staff can handle empowerment.
When staff are empowered, some limits or boundaries need to
be set, or conflict may develop. Some of these boundaries are
established by the HCO’s policies, procedures, and position
descriptions; education and experience; standards; and laws and
regulations (for example, state nurse practice acts). The
manager must be aware of these boundaries and establish any
others that may be required (for example, direct involvement of
staff in the selection process for new equipment). If staff
members are involved in the decision making, then they should
first be given a list of several possible equipment choices that
meet the budgetary requirements and criteria to use in the
evaluation process. It is critical that the manager make clear the
boundaries, or staff members will feel like their efforts are
useless if their suggestions are rejected because they were not

given the boundaries. Setting staff up by not giving them full
information leads to poor choices and is not effective. What
does this mean? Roles and responsibilities need to be clearly
described, and if they change, they need to be discussed. At the
same time, the nurse manager or the team leader must not
control, domineer, or overpower staff. This type of response is
usually seen in new nurse managers or team leaders who feel
insecure. Ineffective use of empowerment can be just as
problematic as a lack of empowerment.
Although empowering oneself may seem like an unusual
concept, it is an important one. The amount of power a person
has in a relationship is determined by the degree to which
someone else needs what the other person has. Anger is related
to expectations that are not met, and when these expectations
are not met, the person may act out to gain power. It is the
responsibility of the nursing profession to communicate what
nurses have to offer to patient care and to the healthcare
delivery system, but individual nurses also need to understand
what they have to offer as nurses. To have an impact, this
communication and development must be ongoing.
Empowerment can be positive if the strategies that are used to
gain empowerment are constructive (for example, gaining new
competencies, speaking out constructively, networking, using
political advocacy, increasing involvement in planning and
decision making, getting more nurses on key organization
committees, improving image through a positive image
campaign, and developing and implementing assertiveness).
There are many other strategies that can result in empowerment
that improves the workplace and the nurse’s self-perception.
Aggressive and Passive-Aggressive Behavior
Aggressive and passive-aggressive behavior can interfere with
successful conflict resolution and might even be the cause of
conflict. When staff members are hostile to one another, the
team leader, or the nurse manager, anxiety rises. Hostile
behavior can be a response to conflict. It is important to
recognize personal feelings. The first response should be to get

emotions under control and communicate control to the hostile
staff member. The nurse manager or team leader may be the one
who is hostile, which makes it even more complex and requires
assistance from higher-level management. It is hoped someone
will recognize the need to bring the situation under control and
try to move to a private place. Demonstrations of open conflict
with hostility should not take place in patient or public areas. If
the suggestion to move to a private area does not work and the
situation continues to escalate, simply walking away may help
set some boundaries. Cool down time is definitely needed.
There are many times when more information is really required
before a response can be given. If this is the case, everyone
concerned needs to be told that when information is gathered,
the issue or problem will then be discussed. No one should be
pressured to respond with inadequate information as this will
lead to ineffective decision making and may lead to further
hostility. It is critical that after further assessment is completed
there be additional discussion and a conclusion.
When there are conflicts with patients and families, what is the
best way to cope? Many of the same strategies mentioned earlier
can be used. Safety is the first issue, as it must be maintained. It
is never appropriate to allow patients or families to demonstrate
anger inappropriately. When this occurs, someone needs to set
reasonable limits that are based on an assessment of the
situation. There may be many reasons for anger and
inappropriate behavior, such as pain, medications, fear and
anxiety, psychosis, dysfunctional communication, and so on.
Staff need to avoid taking things personally as this will
interfere with thoughtful problem solving. When one gets
defensive or emotional, interventions taken to resolve a conflict
may not be effective. Active listening is critical to cope with
emotions. If a different culture is involved, then this factor
needs to be considered. (For example, some cultures consider it
appropriate to be very emotional, and others do not.) In the long
term, clear communication is critical during the entire process.
How Do Individual Staff Members Cope With Conflict?

Not everyone responds to conflict in the same way, and
individuals may vary in how they respond dependent on the
circumstances. Four typical responses to conflict are avoidance,
accommodation, competition, and collaboration (MindTools®,
2014a).
· Avoidance occurs when a person is very uncomfortable and
cannot cope with the anxiety effectively. This person will
withdraw from the situation to avoid it. There are times when
this may be the most effective response, particularly when the
situation may lead to negative results, but in many situations
this will not be effective in the long term. This response might
occur when a staff member is in conflict with a manager and
disagrees with the manager. The staff member must consider
whether it is worthwhile to disagree publicly. Typically
avoidance occurs when one side is perceived as more powerful
than the other. It is a helpful approach when more information
is needed or when the issue is not worth what might be lost.
· A second response is accommodation. How does this occur?
The person tries to make the situation better by cooperating.
The critical issue may not be resolved or not resolved to the
fullest satisfaction. The goal is just to eliminate the conflict as
quickly as possible. Accommodation works best when one
person or team is less interested in the issue than the other. It
can be advantageous as it does develop harmony, and it can
provide power in future conflict since one party was more
willing to let the conflict deflate. Later interaction may require
that the other party cooperate.
· A third response is competition. How does this work? Power is
used to stop the conflict. A manager might say, “This is the way
it will be.” This closes further efforts from others who may be
in conflict with the manager.
· Collaboration is the fourth response, which has been discussed
in this chapter. This is a positive approach, with all parties
attempting to reach an acceptable solution, and in the end, both
sides feel they won something. Collaboration often involves
some compromise, which is a method used to respond to

conflict.
Using the best conflict resolution style can make a difference in
success. There are many ways that a conflict can be resolved.
When conflict occurs, each person involved has a personal
perspective of the issue and conflict. Today there is more
conflict in the healthcare delivery environment with increased
workplace stress that may lead to misunderstandings,
ineffective communication, and reduced productivity and
dysfunctional organizations, as noted in the Institute of
Medicine reports (2001, 2004).
Gender Issues
Are there differences in the ways in which women and men
negotiate? There are differences in how women and men
approach leadership issues such as conflict (Greenberg, 2005).
Men tend to negotiate to win, while women focus more on what
is fair. It is believed that this is related to the way children play
through sports and activities. Women will make an effort to
reach win-win solutions. Men will test the limits that have been
set more overtly than women, so it is important for women to
ensure that limits are set and maintained. It is important, despite
the differences described, to avoid stereotyping.
Nurse-Physician Relationships
Though the nurse-physician relationship should be the strongest
relationship that nurses have to meet the needs of the patient, it
frequently is not. Both sides have a role in the inadequacies of
this relationship. Conflict does occur and this conflict can act as
a barrier to effective patient care. Collegial relationships are
those where there is equality of power and knowledge. In
contrast, collaborative relationships between nurses and
physicians focus on mutual power, but typically the physician’s
power is greater. The nurse’s power is based on the nurse’s
extended time with patients, experience, and knowledge. In
addition to power, this relationship requires respect and trust
between the nurse and physician. Due to these factors, it is a
complex relationship.
Nurses have long worked on teams, mostly with other nursing

staff. However, the nurse-physician relationships have become
more important in the changing healthcare environment with the
greater emphasis on interprofessional teams. Nurse-physician
interactions and communication have been discussed for a long
time in healthcare literature.
Physicians, however, are not the only healthcare providers
nurses must work with while they provide care. (For example,
nurses work with other nursing staff, social workers, support
staff, laboratory technicians, physical therapists, pharmacists,
and many others.) There are also other members joining the
healthcare team such as alternative therapists (massage
therapists, herbal therapists, acupuncturists, etc.), case
managers, more actively involved insurers, and so forth. The
future will probably bring other new members into the
healthcare delivery system. Nurses need to develop the skills
necessary to participate effectively on the team, which requires
collaboration, communication, coordination, delegation, and
negotiation. Communication and delegation are discussed in
other chapters. It is difficult to practice today in any healthcare
setting without experiencing interprofessional interactions such
as nurse to physician. Effective teams:
· work together (collaborate).
· recognize strengths and limitations.
· respect individual responsibilities.
· maintain open communication.
Positive professional communication is critical. Both sides
should initiate positive dialogue rather than adversarial
positions. Cooperation and collaboration are also integral to the
success of this relationship. A frequent question discussed in
the literature is “Why is there conflict between nurses and
physicians?” The structure of work is different for physicians
and for nurses, and this has an impact on understanding,
communicating, collaborating, and coordinating. This
perspective identifies the key elements as sense of time, sense
of resources, unit of analysis, sense of mastery, and type of
rewards as described by the following:

· The nurse is focused on shorter periods of time, and time is
usually short, with frequent interruptions. The physician’s sense
of time focuses on the course of illness.
· If a physician gives a stat order, the physician has problems
understanding what might interfere with the nurse’s making this
a priority. There is a lack of understanding of the nurse’s work
structure.
· Physicians often are not concerned with resources, though this
is certainly changing as physicians recognize that there may be
a shortage of staff as well as issues about costs and
reimbursement for care. They, however, may not be willing to
accept these factors as relevant when their patients need
something. There are, of course, other resources such as
equipment availability, supplies, and funds that can cause
problems and conflicts. Nurses are typically more aware of the
effect that these factors have on daily care and the work that
needs to be done.
· Unit of analysis is another factor; for example, nurses are
caring for groups of patients even though care is supposed to be
individualized. Physicians may not have an understanding of
this if they have only a few patients in the hospital.
· Physicians also do not have an understanding of nursing
delivery models, and often nurses themselves are not clear
about them. This affects nurses’ ability to explain how they
work.
· The sense of reward is different. Nurses work in a task-
oriented environment and typically get paid an hourly rate.
Most physicians are not salaried and are independent
practitioners, though some are employees of the organization
(hospital, clinic, and so on).
Conflict and verbal abuse are related. Verbal abuse occurs in
healthcare settings between patients and staff, nurses and other
nurses, physicians and nurses, and all other staff relationships.
This abuse can consist of statements made directly to a staff
member or about a staff member to others. A common complaint
from nurses regards verbal abuse from physicians. In addition to

impacting quality care, verbal abuse affects turnover rates and
contributes to the nursing shortage, so it is has serious
consequences.
How can this problem be improved? A critical step is to gain
better understanding of each profession’s viewpoint and
demonstrate less automatic acceptance of inappropriate
behavior. This requires that management become proactive in
eliminating negative communication and behavior. Some
hospitals have tried a number of strategies to deal with verbal
abuse. The IOM recommends increased interprofessional
approaches to care delivery and the need for increased
Case Study A Verbal Explosion Leads to Confrontation of a
Problem
As a nurse manager in a busy operating room (OR), you have to
ensure that all staff are collaborating and communicating well.
In the past six months, you have noticed more problems with
poor communication between nurses and physicians, which had
an impact on the quality of care. Nurses are also frequently
complaining that they are “second-class citizens” in the
department. The number of last-minute call-ins has increased by
25% over the past six months, causing staffing problems. Today
was the last straw when a nurse and a surgical resident had a
shouting match in the hallway. The nurse left the encounter
crying, and the resident said he would not work with the nurse
anymore. The nurse manager went into the OR medical
director’s office. They have had a positive collaborative
relationship over several years. She went in and said, “We have
a problem!” As she described the problems, he said, “I was
unaware there was so much tension and lack of collaboration.
Why didn’t you tell me this earlier?”
Questions:
1. How would you respond to the medical director’s question?
2. What do you and the medical director need to do?
3. How can you avoid this being a we/they situation?
4. How will you involve all staff?
5. What can you do about the powerlessness the nurses feel?

interprofessional education among health professions so all
health professions are prepared to work together on teams
(2003a). What can nurses do about this? One suggestion is to
improve their knowledge base and thus develop more self-
confidence. Another problem is that nurses think they must
resolve all problems and “make things” work correctly when
this may not be realistic. The nurses then become scapegoats.
Verbal abuse, no matter who—physician or nurse—is doing it,
should not be tolerated. Those involved need to be approached
in private to identify the need for a change in behavior. Staff
needs to be respected. The AONE Guiding Principles for
Excellence in Nurse-Physician Relationships is found
in Box 13-4.
Application of Negotiation to Conflict Resolution
Negotiation is the critical element in making conflict a
nightmare or an opportunity. Negotiation can be used to resolve
a conflict, and some types of negotiation, such as mediation,
can be very structured. When two or more people or
organizations disagree or have opposing views about a problem
or solution, a conflict exists. To resolve the conflict, the
involved people need to discuss resolution in a manner that is
acceptable to all involved. Although it does not have to take
long, in some cases it may be very long, such as what might
occur in a union-employer negotiation for a contract. Conflict
resolution includes the use of a variety of skills and strategies.
As the process begins, it is important to clarify all of the issues
and parties who are involved in the conflict. Performance or
potential outcomes should be established early in the process.
Questioning is important throughout resolution. For example, it
is important to ask about behaviors that started the conflict and
how to avoid them in the future. Management needs to be clear
about expectations and provide these in writing, which helps to
decrease conflict over critical issues. Since conflict is
inevitable, all staff nurses will encounter it. Knowing how to
manage conflict will be of great benefit to the individual nurse
as well as improve the working environment and ability to

better reach patient outcomes.
Patients should not become part of staff or organizational
conflicts, and there is risk that this may occur. Consider these
examples:
· The interprofessional team cannot agree on a treatment
approach and must do this by the end of the team meeting.
· A patient’s insurer refuses to allow the patient to stay two
more days in the hospital. As the hospital’s nurse case manager,
you must work with the insurer representative to reach a
compromise.
· Staffing in a hospital has been reduced, and the nurses are
convinced that the new staffing level will be unsafe for patients.
Something must be done to resolve this issue.
· A home healthcare agency learned that the Medicare contract
has changed and specific patients will receive fewer visits.
How can these examples be resolved satisfactorily so the quality
of care does not suffer and staff still work together
collaboratively? Finding a mentor to discuss the process as well
as vent feelings may be helpful. Developing negotiation skills
makes conflicts easier to handle and less stressful. Nurses who
become involved in unions will find that negotiation skills are
also very important. If negotiation is not used effectively, all of
these conflict examples can lead to major problems for the
patient and/or staff.
When approaching conflict resolution, it is important to
recognize that both sides contributed to the conflict. One side
cannot have a conflict by itself; it takes at least two. Consider
how each side has contributed to the conflict. Another critical
issue is to carefully consider if this is the time and place to
address the conflict. When the environment is too emotional,
conflict resolution will be difficult. Stepping back or taking a
break may be the best position to take. The following are
strategies that can be used to negotiate effectively
(MindTools®, 2014b):
· Negotiate for agreements—not winning or losing. Clearly state
that your desire is to find a solution and to work together.

· Separate people from positions.
· Establish mutual trust and respect.
· Avoid one-sided or personal gains.
· Allow time for expressing the interests of each side/party.
· Listen actively during the process, and acknowledge what is
being said; avoid defending or explaining yourself.
Box 13-4 Aone Guiding Principles for Excellence in Nurse-
Physician Relationships
Introduction to the Guiding Principles
Excellent working relationships between nurses and physicians
are key to creating a productive, safe, and satisfying practice
environment. The patient and the patient’s family benefit from
care delivered by a team practicing within this environment.
Senior leadership in healthcare organizations must support the
development of excellent relationships and, more importantly,
create an environment that sustains and nurtures these critical
relationships.
Guiding Principles for Excellence in Nurse-Physician
Relationships
Institutions that are committed to establishing and maintaining
environments that promote excellence in the nurse/physician
relationship adhere to the following principles.
1. Interdisciplinary collaborative relationships are promoted,
nurtured and sustained.
2. This requires that practitioners be proficient in
communication skills, leadership skills, problem solving,
conflict management, utilizing their emotional intelligence, and
functioning within a team culture.
3. Excellence in relationship building begins with hiring,
continues with learning and developing together and is
reinforced over time.
4. The organization has specific systems for reward,
recognition, and celebration.
5. The organization supports the “Platinum Rule” with a
specific Professional Code of Conduct that includes a system to
support it. A “No Tolerance” standard exists for those unable to

adhere to the Code.
6. The organization creates and supports a “Just & Fair”
environment.
7. The work of all professional caregivers is seen as
interdependent and collegial.
8. Cross-discipline job discovery is supported and encouraged.
9. Patient-focused care and better patient outcomes are the
organizing force behind creating a collaborative environment.
Implementation Guidelines
Interdisciplinary collaborative relationships are promoted,
nurtured and sustained.
10. Nurses and physicians are given formal training in
communication skills, leadership development, problem solving,
conflict management, development of emotional intelligence,
and team functions. Education and training is provided to
nurse/physician teams and is not discipline specific.
11. Specific education is provided in team building.
12. Organization governing bodies and committees have
representative members from all disciplines.
13. Nurse/physicians leadership teams are identified to lead the
work at the unit level. (Microsystem Management)
14. All organizational task forces include representatives from
those stakeholders closest to the issue.
15. Interdisciplinary collaborative relationships are assessed,
unit-by-unit. Each unit has a development and improvement
plan for continued growth of the relationship.
16. Teams develop common values for their interdisciplinary
collaboration.
17. Teams develop common language for their interdisciplinary
collaboration.
18. Nurse/physician collaborative champions are identified at
the hospital and unit level.
Excellence in relationship building begins with hiring,
continues with learning and developing together and is
reinforced over time together and is reinforced over time.
19. Nurses and physicians work collaboratively to identify the

behaviors that they want in team members.
20. Employees, both nurse and physician, are hired using
behavioral interviewing to ascertain a good fit with the
organization, teams, values, culture, and behavioral
expectations.
21. Nurses and physicians do 360 degree performance reviews.
22. Credentialing criteria includes behavioral attributes and
expectations, as well as clinical skills.
23. The Graduate Medical Education competencies are used as
hiring criteria and for performance review.
24. Education and team training is done in work teams, as
described in the Institute of Medicine reports.
25. Personal accountability for demonstrating team behaviors is
rewarded.
The organization has specific systems for reward, recognition,
and celebration.
26. There is alignment of purpose among the disciplines
regarding reward/recognition & celebration.
27. Mechanisms for reward and recognition are easy to access.
28. Performance appraisal is linked to patient satisfaction
measurements.
29. Awards, recognition and celebration are public and visible
and across disciplines and teams—Example: Physicians identify
the Nurse of the Year; Nurses identify the Physician of the
Year.
30. Rewards and Recognition programs promote team
accomplishments.
The organization supports the “Platinum Rule” with a specific
Professional Code of Conduct that includes a system to support
it. A “No Tolerance” standard exists for those unable to adhere
to the Code.
31. The Golden Rule states: “Do unto others as you would have
them do unto you.” The Platinum Rule states: “Do unto others
as they would have you do for /unto them.” Thus, this principle
speaks to treating others as they want to be treated, not
necessarily how you would want to be treated.

32. Code of Conduct Guidelines/Policies exists for all
professionals that outline behavioral expectations.
33. Work improvement plans and measures hold the team
accountable, not just individual.
34. Individual professional codes of ethics/conduct are known
and honored.
35. Contacts and processes/procedures for the impaired
professional are easily accessible to all staff.
36. There are identified coaches and mentors for the
professionals on site in the hospital to help with performance
issues.
37. All professionals receive team training that focuses on
communication skills and processes.
38. Processes exist to identify and address conflict situations
before they become a crisis and/or deteriorate.
The organization creates and supports a “Just & Fair”
environment.
39. There is a systems approach to management and decision-
making.
40. Internal trends and reporting processes are
multidisciplinary.
41. Language for reporting and safety is analyzed to assure that
it is “Just & Fair”.
42. Processes exist for multidisciplinary critical incident
debriefing.
43. Decision-making tools are used that support the “Just &
Fair” processes, such as the “Just Model”.
44. The processes outlined in the patient-safety literature that
creates cultures of safety are used as blue prints for culture
changes.
45. Remedial training is offered when needed.
The work of all professional caregivers is seen as
interdependent and collegial.
46. The culture of team includes all disciplines providing care
on a unit.
47. Behavioral expectations are defined for all disciplines.

Cross-discipline job discovery is supported and encouraged.
48. All disciplines are educated in the role/responsibility of
their colleagues.
49. Opportunities for shadowing different professions are
encouraged.
Patient-focused care and better patient outcomes are the
organizing force behind creating a collaborative environment.
50. Work is directed toward identifying and measuring those
outcomes that are sensitive to the function of collaboration.
51. Patients and families are appointed to internal committees.
52. Patient-centeredness is a key focus for processes.
Source: From AONE Guiding Principles For Excellence In
Nurse–Physician Relationships. Copyright © 2005 by American
Organization of Nurse Executives. Used by permission of
American Organization of Nurse Executives.
· Use data/evidence to strengthen your position.
· Focus on patient care interests.
· Always remember that the process is a problem-solving one,
and the benefit is for the patient and family.
· Clearly identify the priority and arrive at common goal(s).
· Avoid using pressure.
· Identify and understand the real reasons underlying the
problem.
· Be knowledgeable about organizational policies, procedures,
systems, standards, and the law, applying this knowledge as
needed.
· Try to understand the other side, and ask questions and seek
clarification when unsure or uncertain; understanding the other
side first before explaining yours increases effectiveness.
· Avoid emotional outbursts and overreacting if the other party
exhibits such behavior; depersonalize the conflict.
· Avoid premature judgments, blame, and inflammatory
comments.
· Be concrete and flexible when presenting your position.
· Be reasonable and fair.
There are some conflicts that require a third-party negotiator to

reach a more effective resolution. This is needed when there is
no opportunity for cooperative problem solving and objectivity
is required. “Mediation is an informal and confidential way for
people to resolve disputes with the help of a neutral mediator
who is trained to help people discuss their differences. The
mediator does not decide who is right or wrong or issue a
decision. Instead, the mediator helps the parties work out their
own solutions to problems” (U.S. Equal Employment
Opportunity Commission, 2014). Mediators are facilitators, not
decision makers (as in the case of arbitrators). In mediation, the
people with the dispute have an opportunity to tell their story
and to be understood, as well as to listen to and understand the
story of the other party. A key factor in mediation is the need
for all parties to willingly participate in the process. The
mediator guides the process and discussion. Certain guidelines
are established for the discussion that all parties must follow
throughout the process (for example, allowing each party time
to speak and complete a statement without interruption, calling
for a break when needed, enforcing time-limited meetings,
substantiating comments with facts, and so on). With these
guidelines and the presence of a mediator, this type of
negotiation can result in positive outcomes. It provides
protection for both sides.

Chapter 13CollaborationThe American Nurses Association (ANA) d.docx

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