The ability to work collaboratively has been highlighted in the professional Code of Conduct (NMC 2002a) as an essential part of a nurse’s role. There is an expectation that a nurse will work co-operatively with other professionals, respecting their skills, expertise and contributions.Additionally, a nurse must communicate effectively to share knowledge, skills and expertise in order to work efficiently with other team members, whilst maintaining high standards of care (NMC 2002a). Nurses who seek to enrich their practice need to have a greater understanding of what it means to work collaboratively, not just with other professionals but primarily with patients and their carers(Fatchett 1996). This active involvement of patients in their care lies at the heart of current government policy (DOH 2001a, 2001b). Whilst the aim of collaborative working is that it should lead either to health gains or improved patient outcomes, it must be noted that there is, according to Ross and Mackenzie (1996), insufficient evidence to date to substantiate this view – an interesting finding given that policy and practice place such emphasis on collaborative working.
The following case study of a hypothetical family in receipt of primary care will be used to contextualize the issues being discussed.
Elmer King, aged 35 years, is black British of Caribbean origin but grew up in London. He is unemployed, suffering from schizophrenia and carries sickle cell trait. His partner Ann, aged 32 years, is white British. She also carries sickle cell trait. She has a part-time night cleaning job for a large local firm.
Malcolm Roberts, aged 13 years, is the son of Ann’s first partner. He is timid and small for his age. He ‘gets picked on’ by other children at school and has recently been complaining of stomach aches and not wanting to go to school.
Louise King, aged 8 ye
ars, has sickle cell disease and has had a lot of absence from school because of sickle cell crises.
Alice King, aged 11 months, is wheezy and suffers from severe infantile eczema. She was bottle-fed from birth and weaned very early. She has attended for developmental checks. Her hearing and vision are satisfactory but there is concern about delayed motor development.
Ann recently scalded her leg badly. She says she accidentally knocked over a full pot of freshly made tea. She has been self-treating the wound for a few days and has only just visited her general practitioner (GP) as the wound is now ‘rather smelly’ and her leg is very red.
The family live in an urban area of a large city. Their accommodation, which they rent, is a small terraced house with two bedrooms and a small garden at the rear.
In considering issues relating to Elmer, Ann and their family there is the potential for a number of different people to be involved in order to provide the appropriate services to meet the family’s health and social needs.
IMPLICATIONS OF GOVERNMENT POLICY FOR COLLABORATION
Over the past 15 years, government health and social policy has constantly reinforced the need for primary health care and teamwork to meet the challenges of a changing population and of ‘life- style related disease in the community’ (Ross and Mackenzie 1996: p.78). In 1986 the Cumberlege Report (DHSS 1986) noted that numerous health and social care professionals were ‘beating the same pathway’ to patients. The results were confusion for the patients and their carers and duplication of services. It was considered that the service provision was fragmented and the potential for missing health needs was significant. Through a series of government policies (DOH 1987, 1989a, 1989b, 1990, 1996, 1997, 1999a, 1999b), teamwork, collaboration and a partnership approach to care have become central to the provision of care in the community. There is recognition of a need to move away from the traditional boundaries of health and social care towards the development of multi- professional teams working throughout hospital and primary care settings.
The NHS and Community Care Act 1990 brought together the social services and health services to provide ‘seamless care’ to people in their own homes or in homely settings. The Act provided a ‘planning framework’ to enable different agencies to work together, to consult and collaborate at every level (Audit Commission 1992). This ‘bringing together’ was further strengthened in the subsequent government report, Primary Care-Led NHS (DOH 1996). It was envisaged that multi-disciplinary, multi-professional, inter-agency teams of people would be working together. In a time of diminishing resources and increasing demand they would provide an effective, high-quality care that would be needs led and not merely a blanket provision.
It was the change of government in 1997 that brought about recent changes of policy in the National Health Service, but the need for partnership and collaborative working has remained a significant feature – in fact has been emphasized more strongly. One of six key underpinning principles outlined in The New NHS: Modern, Dependable (DOH 1997) was to involve the National Health Service in partnership with other agencies in the provision of social and health care, with the needs of the patient at the centre of the care process. The increasing emphasis on the role of primary health care teams has come about as a result of ever-increasing hospital costs alongside government recognition of their importance as gate-keepers to health care (Fatchett 1996). The more recent NHS Plan (DOH 2000) has contributed to this shift in emphasis to a needs-led service – one that encompasses collaboration, joint working and partnership. Fatchett (1996) has attributed the increase in popularity to collaboration to a number of causes.
- A growth in the complexity of health and welfare services.
- Expansion of knowledge and subsequent increase in specialization.
- A perceived need for the rationalisation of resources
- A need to reduce the duplication of care
- The provision of a more effective, integrated and supportive service for both users and professionals
The greater complexity of technology and treatment has placed tremendous pressure upon practitioners to have the necessary knowledge and competencies to meet the needs of patients with complex care needs. There have been a number of recent public inquiries into incidents involving people who have been diagnosed as mentally ill. Government response has been to seek to improve the co-ordination of care for such individuals, with an increased emphasis on the role of the primary health care teams (Secker et al. 2000).
As highlighted in the previous section, the reasons given for collaborative working would seem to be extensive and significant, but what does it actually mean? The word ‘collaborate’ is derived from the Latin collaborare which means ‘to labour together’. This notion of working together has been highlighted by Ovretveit (1997) in the sense of collaboration between organisations or individuals working together or acting jointly. In addition, the notion of exchange is evident in Armitage’s definition (1983), defining collaboration as being the exchange of information between individuals involved in the delivery of care, which has the potential for action or joint working in the interests of a common purpose.
This definition would seem to be quite straightforward, but it could also be seen to be referring exclusively to professionals delivering care without reference to the patients and their carers. Interestingly enough, the issue about being professionally driven could be inferred from policy documentation (DOH 1992). Here collaboration is seen as a ‘partnership of individuals and organisations formed to enable people to increase their influence over the factors that affect their health and well being’, a view more recently expressed in The NHS Plan (DOH 2000) and Liberating the Talents (DOH 2002).
The issue of collaboration having the potential to be professionally driven is of particular importance when considering a partnership approach between practitioners, patients and their carers. Henneman et al. (1995) suggest that when individuals are involved in collaboration their relationship is non- hierarchical. Power is shared on the basis of knowledge and expertise rather than role or title. In other words, collaborative working needs to involve a redistribution of power within the health care team (Soothill et al.1995).
THE INTERFACE OF COLLABORATIVE CARE
In considering the needs of Elmer, Ann and their family there will be a need to relate to and work with each member of the family as well as networking with a range of diverse groups, including social services, and voluntary agencies. The interface may be at different levels, according to the actual requirements of care. Armitage (1983) identified a taxonomy of levels of collaboration that moves from a situation where people communicate without meeting to a situation where people work together. For example, issues of child protection and bullying that could be associated with Alice and Malcolm might be dealt with by the health visitor and the school nurse, who might also involve such other agencies as social workers, the police and the judiciary. The GP and the practice nurse may be involved with the care of Ann’s wound and for Elmer’s maintenance medication. In this way referrals from one agency to another regarding the family might occur without any need for a meeting. However, if the care is to be effective it might be that each of the agencies involved would need to come together and meet with the family to resolve difficulties, duplication and problems. Similarly, two agencies might be more involved than others and take the lead in the care whilst informing the remaining agencies of progress.
A framework for classifying collaboration by Gray (1989, cited in Huxham 1996) suggests that there are two dimensions: factors that motivate people to collaborate and the goal or anticipated outcome of the collaboration. Gray further suggested that there are four types of collaboration: appreciative planning, dialogues, collective strategies and negotiated settlements. Although Gray is concerned specifically with business organisations, her classification of the four types of collaboration could also be applied to health care situations.
The different types of collaboration as identified by Gray can be seen at a micro level, as in the King family. The exchange of information is one of the key features in the King family’s situation (appreciative planning). Each of the different practitioners involved with Elmer, Ann and the family care need to communicate (dialogues) their knowledge of the situation in order to arrive at a shared vision. They need to provide an arena for exploring solutions to the problems identified by the patients and their carers, resolve difficulties (negotiated settlements) and reach agreement about a plan of care (collective strategies). Thus the collaborative process will pass through three phases: problem solving, direction setting and implementation (Gray 1989, cited in Huxham 1996).
At a broader macro level, working in partnership and collaborative care means ensuring that the structure of the organisation is sufficiently flexible to support patients and enable them to function. The implementation of health improvement programmes (HIPs) is seen as providing the ‘strategic glue’ that binds the different services together in new working partnerships between users and health service providers, including statutory and non-statutory (Gillam and Irvine 2000). In addressing the needs of local populations through HIPs there is an emphasis upon primary care staff to work across practice and professional boundaries with colleagues in Social Services, Education and Housing. In this way, people with the relevant knowledge and skill, including the patients and their carers, will be able to carry out the appropriate care.
SKILLS NEEDED TO COLLABORATE EFFECTIVELY
Previous sections of this chapter have discussed why it is important to work collaboratively, what it means to collaborate and with whom we need to collaborate. This section is about how we collaborate – in particular the skills needed to collaborate effectively. Using the case study of Elmer, Ann and their family, scenarios will be drawn out to demonstrate the range of skills that are fundamental to effective collaboration.
Hornby and Atkins (2000) are clear in establishing that the sole purpose of collaboration is to provide optimum help. In their discussion on collaborative processes and problems, they identified a range of attitudes and skills necessary for good practice. It is these that will be identified and integrated in an examination of this complex family situation.
Thompson (1996) states that working with others involves engaging with other people person- to-person. However, before we can do this we have to have a good understanding of ourselves in terms of ‘how we are perceived by other people, our characteristic responses and reaction and our own needs’ (p. 234).
Hornby and Atkins (2000) suggest that collaborative attitudes may be clustered under the concepts: reciprocity,flexibility and integrity.
- Reciprocity is based on respect and concern for individuals and the development of mutual understanding and mutual trust.
- Flexibility is the readiness to explore new ideas and methods of practice and an open attitude to change. It is about working in partnership with clients and colleagues and not about positions of power.
- Professional integrity places the client’s needs first and not those of the individual practitioner. Integrity, according to Hornby and Atkins, demands that practitioners examine their own defensive practices and separatist tendencies.
This scenario highlights the importance of collaborative attitudes. In considering the issues of reciprocity, flexibility and professional integrity, you may have covered the following issues.
Reciprocity. The practice nurse has shown genuine concern and empathy for Elmer. She has begun to build up a relationship with him during his routine appointments and her knowledge of his condition has led her to feel genuine concern. In the busy schedule demanded by the appointment system at the surgery, it would be easy to label Elmer as a ‘DNA’ (did not attend) and be somewhat dismissive of any follow-up. Mutual trust is beginning to develop between the practice nurse and Elmer and the fact that she has been unable to contact him on the phone, has led her to feel that ‘something is wrong’.
Flexibility. The practice nurse has shown by her actions that she sees Elmer as an equal partner in his care. Her approach is one of working towards concordance (see DOH 2001a) as opposed to compliance. She would be keen to consider other methods of practice, depending on Elmer’s needs.
Professional integrity. The practice nurse has demonstrated the importance she places on meeting Elmer’s needs – it would have been easy for her to become irritated by Elmer’s ‘DNA’. In terms of her role within the practice and the other patients she has been more prepared to consider what is wrong with Elmer than her own position at that time. However, she should also realise that she is not alone in being able to provide support for Elmer. She is a member of a wider primary health care team, some of whom might be better placed to follow up Elmer’s situation. In this way she would be demonstrating her awareness of her own role and its boundaries whilst respecting the roles of the others in the team.
Consider what reciprocity, flexibility and professional integrity would mean in relation to the following scenario.
Elmer usually attends the health centre for his regular depot injections from the practice nurse. He has not attended for the second injection and the nurse is very concerned about Elmer. She has tried to contact him by telephone but the number is unobtainable – in fact it has been cut off due to non-payment of bills.
Elmer’s community mental health nurse would probably be the first colleague to contact regarding his schizophrenia and depot medication. She might also want to discuss the situation with her health visitor colleague, who would know the family because of visiting Ann and baby Alice. Both these colleagues would be able to discuss Elmer’s financial situation with him and seek further support from the social worker, should he wish it. She could also contact the school nurse responsible for the schools that Louise and Malcolm attend just to ensure that the children have the opportunity to share any concerns if they wish and to monitor their situation.
In summary, this scenario demonstrates how important it is to have a positive attitude to collaboration not only with patients but also with colleagues.
In addition to collaborative attitudes, Hornby and Atkins (2000) highlight the importance of collaborative skills and see these as relational, organizing and assessment skills – all essential elements for effective collaborative working.
Relational skills include open listening, empathy, communicating and a helping manner, in other words putting people at their ease.
Open listening means hearing without stereotyping, and using direction purely for the purpose of hearing more rather than less. It requires the ability to tolerate distress and anxiety without resorting to coping methods that restrict the client’s communications. It means being alert to the feelings that may be involved when individuals seek and receive help and being aware of the effect on people of finding themselves as a service user. It is about facilitating the expression of relevant emotions and being able to empathise whilst at the same time retaining the necessary objectivity when meeting patients’ needs.
Empathy, according to Thompson (1996), is the ability to appreciate the feelings and circumstances of others even though we do not necessarily share them. It is about being sensitive to differences and avoiding making stereotypical assumptions. In order to avoid discrimination and disadvantage, it is essential that patients’ differing requirements are met.
Clements and Spinks (1994) stress the importance of treating others, whether as individuals or in groups, fairly, sensitively and with courtesy, regardless of who they may be. Further, they identify the following skills, knowledge and attitudes, which are applicable to almost any situation:
• keeping within the law
• thinking about the consequences
• not believing myths
• a desire to be fair
• openness to different ideas
• reflective thinking
• using appropriate language
• knowing about the issues
• treating people as individuals
• not seeing alternative cultures as a threat
Open communicating means conveying what seems to be relevant, including feelings as well as facts and opinions, without becoming defensive. Where trust is lacking, defensive processes and protective devices are likely to come into operation. Open communicating also relates to the need for professional confidentiality (NMC 2002b). For further information about confidentiality see Cornock (2001).
A helping manner, according to Hornby and Atkins (2000), is the ability to manifest personal concern and professional confidence without superiority, thus enabling patients, carers and practitioners to function at their best in a working relationship. The role of carers should not be taken for granted nor undervalued: the practitioner must be as concerned for their wellbeing as for that of the patient. This feeling of being valued may not automatically result in an increased participation but it can at least bring emotional benefit to both carer and patient. Facilitating patients’ and carers’ expressions of their feelings is a skill which can often increase understanding of a situation, resolve blocks to progress and relieve tension and distress.
In terms of relational skills, for example open listening, communication and a helping manner, what do you feel are some of the issues in the following scenario?
The district nurse has received a referral from the GP regarding visiting Mrs King, who has recently scalded her leg. She has been self-treating the wound for several days and it has now become infected. The district nurse has not had any previous contact with Mrs King.
Mrs King has a night-time cleaning job for a large local supermarket and with her family commitments is not able to attend the health centre. The district nurse knocks hard on the door and eventually Mrs King appears in her nightie, looking cross. She was asleep and Elmer, who should have been looking after baby Alice, has gone out.
You may have considered some of the following points. At the initial referral it would have been helpful if the GP had indicated that Mrs King worked ‘nights’. Even though she could not confirm her visit by telephone the district nurse should have been able to make a visit at a time more convenient for Mrs King which intruded less on her need to sleep during the day. It might have averted the initial ‘angry’ meeting. However, once in this somewhat confrontational position, the district nurse needs to be able to acknowledge the situation as a whole and her role in it. She needs to be receptive to Mrs King’s irritation and demonstrate her open listening skills. It would be easy to become defensive and use closed questions as a means of restricting Mrs King’s communication. Skills in open communication are essential in order to build a trusting relationship between practitioner and patient. A helping manner is demonstrated by concern for the individual patient within the wider family context. This example shows how important it is for the practitioner to view a situation from a holistic perspective rather than from a limited task viewpoint. In an uncomfortable atmosphere the practitioner could well have undertaken a specific task and then left, limiting her concern solely to Mrs King’s leg.
Organising skills identified by Hornby and Atkins (2000) are those required to implement the principles of essential collaboration. These include establishing networks, setting up meetings, devising appropriate patient/carer referral systems, and managing changes within the work context. Professional boundaries need to be clearly defined and agreed. Henneman et al. (1995) maintain that collaboration requires individuals to have both a clear understanding of their own role and an understanding and respect for the roles of others.
When individual team members are clear about their own roles and boundaries and those of others in the team, the most appropriate person can then support Elmer and his family – otherwise gaps in their support could appear. The complex situation presented by Elmer’s family requires an effective application of skills. The family, the GP, practice nurse, receptionist, community mental health nurse, district nurse and school nurse have already been indicated as each having a role to play. Clearly, networking with others in such a situation is crucial. The primary health care team meeting could prove to be a valuable forum where issues would be shared, future support for the family clarified, and the key worker identified. A lack of organisational skills could prevent a full and accurate picture of the family’s needs being completed.
Assessment skills represent the final element of collaborative skills as identified by Hornby and Atkins (2000). Assessment, according to Thompson (1996), is a complex and multi-faceted process. A high level of interpersonal skills is required when undertaking a holistic assessment, and in complex situations assessment skills involving a range of perspectives may be appropriate. When different agencies have overlapping boundaries sometimes the patient can experience difficulty in finding that which is most suited to meeting his/her needs. At the same time it is not always possible for one practitioner to have sufficient in-depth knowledge of the various contributions of other agencies. Practitioners need to know enough about a range of services to be able to select the most appropriate one for any given situation and also when to refer the patient. Thus, the demands on the practitioner include not only a wide range of knowledge and a high level of assessment skills but also a freedom from defensive or separatist attitudes (Hornby and Atkins 2000). Whilst there is a desire to move towards a single assessment process, currently different professionals have their own methods for documenting assessment (NMC 2002b). It is the pooling of this information that is so important to ensure that all the pieces of information fit together.
The final section of this chapter focuses on interprofessional relationships, thus drawing together some of the wider issues already alluded to.
Mackay et al. (1995) have asserted that working interprofessionally involves crossing traditional professional boundaries, being prepared to be flexible in considering a range of views and having a willingness to listen to what colleagues from other disciplines are saying. Each group brings different skills and solutions to the health care problem with which they are presented. In some decisions the contribution of one professional group needs to take precedence over others, which underlines the need for flexibility in decision making. Interprofessional working, as mentioned earlier, raises the question of redistribution of power within teams. So many fundamental changes are taking place within primary care that perhaps now is an opportune moment to challenge established and entrenched attitudes.
Collaboration between professionals and between service agencies is currently regarded as the cornerstone of the development of community care in the UK. However, only recently have mechanisms of collaboration been subject to evaluation as a means of demonstrating effectiveness. Molyneux (2001) attempted to do just this in her study of interprofessional team-working by identifying and evaluating the positive characteristics of team working. Three main themes emerged:
• Motivation and flexibility of staff. Personal qualities of staff such as flexibility, adaptability and lack of professional jealousy enabled team members to work across professional boundaries.
• Communication within the team. Findings identified regular and frequent team meetings and agreement on the communication strategies, for example shared records, within the team as central to effective team working.
• Opportunities for creative development of working frameworks. Encouragement and opportunities need to be provided for staff working together to enable them to develop creative methods of working which meets their patients’ needs.
It is in the sharing of knowledge and skills in a collaborative way that the common goal of holistic care is more likely to be achieved with ultimate benefits to the patient and family. (Shields et al. 1995). Essential to the success of collaborative working is a defined mechanism for making decisions. Problems can occur where a team does not have a clear and agreed process. Ovretveit (1993) points out that conflict can arise unless differences are aired and worked through in a creative and fair way. Unstructured decision making procedures waste time, cause conflict and resentment and can lead to team break down.
In summary, collaborative working is an ideal that essentially seeks to ensure that the best interests of the patient are protected. It is a never-ending process in which the patient, relatives and carers must increasingly be supported to play a central role in making their own contribution to decisions affecting their lives. Collaborative working is, therefore, one step on the way to fully informed decision making in meeting the needs of patients and their carers and delivering effective and efficient community health care.