Response to "A Conceptual Model of Collaborative Nurse-Physician Interactions: The Management of Traditional Influences and Personal Tendencies"
Baggs, Judith Gedney PhD, Rn, Scholarly Inquiry for Nursing Practice
Corser provides an up-to-date review of the research and conceptual literature about nurse-physician collaboration. His beginning assumption that, "a comprehensive understanding of nurse-physician working relationships would not likely be obtained from the current professional literature," was probably not a fortuitous start for his search. His second assumption, that nurses work in clinical settings with new and increasing time constraints and patient acuity, however, is absolutely correct. These clinical changes must be taken into account in any new investigation of collaboration. The review also is informed by the author's belief, with which I agree, that few nurses and physicians are aware of how strongly historical "organizational, educational, or interpersonal traditions" influence their routine interactions with each other.
Corser identifies several important considerations for researchers concerned with collaboration in health care. First, he identifies the level of complexity of patient care as a key environmental variable related to collaboration. This variable has been too little attended to in much earlier work on the topic. He appears to agree with Lamb (1991) that complexity leads to more collaboration. The organizational theorist, Thompson (1967), stated the relationship somewhat differently, indicating that when situations are more complex, there is an increased need for collaboration. Just how complexity relates to collaboration and, in turn, to patient outcomes, is not yet clear.
In a recent study of the relationship between nurse-physician collaboration in making the decision to transfer patients to a less intense level of care from three intensive care units (ICUs; a medical ICU [MICU], a surgical ICU, and a community hospital mixed medical-surgical ICU), influence of complexity was assessed (Baggs et al., in press). In that study the unit that had the sickest, most at-risk, and therefore most complex patients (the MICU) was the only unit where there was a significant relationship between reports of collaboration and better patient outcomes. When nurses reported more nurse-physician collaboration in decision making, patients were less likely to die or be readmitted to the unit during that hospital stay. This finding replicated earlier work conducted in another MICU (Baggs, Ryan, Phelps, Richeson, & Johnson, 1992).
It may be that complexity of patients makes it easier to demonstrate the effects of collaboration, just as Lamb (1995) has noted that case management studies should target the most complex patients to demonstrate a change in outcomes. In the study just discussed, complexity did not appear to lead to more collaboration. Nurses and physicians practicing in the unit with the highest patient complexity did not report more collaboration than providers in the other units (Baggs et al., 1997). On the other hand, at the organizational level in this same recent study (Baggs et al., in press), there was perfect rank order correlation between unit level collaboration scores (based on organizational policies supportive of collaboration) and patient outcomes. The unit with the most organizational collaboration policies, also the unit with the most complex patients, had the best patient outcomes; the one with the fewest supports had the poorest patient outcomes.
It is unclear whether in the research cited above organizational supports for collaboration led to better outcomes or the complexity of the patients somehow "exposed" the relationship of outcomes and support for collaboration or both. In any event, both the organizational environment and complexity are important elements in influencing collaboration and related patient outcomes. Both complexity and organizational policies and procedures are part of the conceptual model developed by Corser.
A second important observation made by Corser concerns the use of the Thomas conflict resolution model (1976), which has been used to develop definitions for collaboration by a number of nurse researchers. …