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Interprofessional misperceptions among physicians and nurses in long-term care facilities Roskam, Albertus Gustaaf 1993

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INTERPROFESSIONAL MISPERCEPTIONSAMONG PHYSICIANS AND NURSESIN LONG-TERM CARE FACILITIESbyALBERTUS GUSTAAF ROSKAMB.A., University of British Columbia, 1982B.N., University of Calgary, 1986A THESIS SUBMITTED IN PARTIAL FULFILLMENT OFTHE REQUIREMENTS FOR THE DEGREE OFMASTER OF SCIENCEinTHE FACULTY OF GRADUATE STUDIES(Department of Health Care and Epidemiology)We accept this thesis as conformingto the required standardTHE UNIVERSITY OF BRITISH COLUMBIAAugust, 1993© Albertus Gustaaf Roskam, 1993In presenting this thesis in partial fulfilment of the requirements for an advanceddegree at the University of British Columbia, I agree that the Library shall make itfreely available for reference and study. I further agree that permission for extensivecopying of this thesis for scholarly purposes may be granted by the head of mydepartment or by his or her representatives. It is understood that copying orpublication of this thesis for financial gain shall not be allowed without my writtenpermission.(Signature) Department of health Care and EpidemiologyThe University of British ColumbiaVancouver, CanadaDate ^August 31^1993DE-6 (2/88)ABSTRACTToday's comprehensive system of health care delivery requires knowledge and skills ofphysicians and nurses that neither profession can provide without collaboration from the other.Without this interprofessional collaboration, patient care will suffer from fragmentation, resultingin confusion and apprehension on the part of the patient. It appears that many benefits can begained from appropriate collaborative team work between physicians and nurses. A systematicreview of the literature shows that collaboration has led to improved patient outcomes such asdecreased morbidity and mortality, and increased patient satisfaction. An increase in jobsatisfaction, as well as a decrease in health care costs are indicated in the literature as additionalbenefits.Unfortunately, many barriers can stand in the way of the development of the realization ofthe collaborative team concept and its many potential benefits. Interprofessional misperceptionshas been indicated in the literature as a barrier. It has been suggested that misperceptions canseriously interfere with any collaborative effort between health professionals.Currently there is no research available on the levels of interprofessional misperceptionsamong the physicians and the nurses in long-term care facilities. To partially fill this void, thisexploratory study has examined the interprofessional misperceptions among physicians and nursesin 13 long-term care facilities in Vancouver, British Columbia For the purpose of this studyinterprofessional misperception has been defined as the difference between one professional'sperception on how the other professional would view an issue, and the viewpoint actuallyexpressed by the other professional on the same issue. The interpersonal perception method hasbeen used as the conceptual framework for the study.iiiiiA survey has been conducted among 28 physicians and 66 nurses. They volunteered to fillout a questionnaire called the Interprofessional Perception Scale, which has provided someinsight into the subjects' misperceptions.Only small degrees of misperceptions were found among the two professions. In fact, thehighest degree of misperception among 15 issues was still only 36%, and was found among thenurses regarding physicians' views on whether nurses expect too much of the physicians. It wasalso found that significant numbers of physicians and nurses perceived that they have difficultieswith the issues of professional territoriality, the under-utilization of their professional capabilities,and their lack of professional autonomy.Thus, despite the failure to find substantial interprofessional misperception, the findings ofthe study suggest that there are issues between the physicians and the nurses in long-term carefacilities that could be barriers to collaboration. There is a need for both professions to worktoward an improved form of collaborative team work. To this end, several strategies for changeare suggested as part of this study.TABLE OF CONTENTSPageABSTRACT^ iiTABLE OF CONTENTS^ ivLIST OF TABLES viiACKNOWLEDGMENTS^ viiiCHAPTER 1 Introduction 1The Purpose^ 1The Definitions 1The Problem 2The Significance of the Study^ 3The Data Source^ 4A Profile of the Study 4CHAPTER 2 A Review of the Literature^ 6Introduction^ 6Collaborative Team Work 7Benefits of Collaborative Team Work^ 10Barriers to Implementing CollaborativeTeam Work^15The Barrier Created by Interprofessional Misperceptionsamong Physicians and Nurses^ 23Make-or-Break Issues in Interprofessional Collaboration^25Issue No. 1 - Professional Competency^ 27Issue No. 2 - Professional Autonomy 30Issue No. 3 - Professional Capabilities 33Issue No. 4 - Professional Concern with Patient Welfare^34Issue No. 5 - Professional Territoriality^ 35Issue No. 6 - Professional Ethics 38Issue No. 7 - Interprofessional Role Expectations^40Issue No. 8 - Professional Status^ 43Issue No. 9 - Professional Ethnocentrism 45Issue No. 10 - Interprofessional Trust 47Issue No. 11 - Interprofessional Advice^ 48Issue No. 12 - Interprofessional Utilization of Capabilities^49Issue No. 13 - Interprofessional Cooperation 51Issue No. 14 - Professional Training 53Issue No. 15 - Interprofessional Relationships^54Demographic Correlates of Interprofessional Misperceptions andTeam Work^ 57Interprofessional Collaboration in Long-Term Care Facilities^61Summary 63ivCHAPTER 3 The Research Methodology^ 65Introduction^ 65The Development of the Research Proposal^ 65The Study Design 66The Instrument Used for the Survey 66The Research Procedures^ 69The Methods of Data Analysis 72Summary^ 74CHAPTER 4 The Findings 75Introduction^ 75Profiles of the Subjects in the Study^ 75Findings on Each of the Fifteen Issues Measured bythe Interprofessional Perception Scale 77Issue No. 1 - Professional Competency^ 79Issue No. 2 - Professional Autonomy 81Issue No. 3 - Professional Capabilities 83Issue No. 4 - Professional Concern with Patient Welfare^85Issue No. 5 - Professional Territoriality^ 87Issue No. 6 - Professional Ethics 88Issue No. 7 - Interprofessional Role Expectations^90Issue No. 8 - Professional Status^ 92Issue No. 9 - Professional Ethnocentrism^ 94Issue No. 10 - Interprofessional Trust 96Issue No. 11 - Interprofessional Advice 98Issue No. 12 - Interprofessional Utilization of Capabilities^100Issue No. 13 - Interprofessional Cooperation^ 101Issue No. 14 - Professional Training^ 103Issue No. 15 - Interprofessional Relationships 105Summary of the Degrees of Misperceptions Found among thePhysicians and the Nurses in Long-Term Care Facilities^107CHAPTER 5 Discussion of the Findings^ 112Introduction^ 112Misperceptions among the Physicians and the Nurses^112Discussions of the Findings for Each of the FifteenProfessional Issues^ 114Issue No. 1 - Professional Competency^ 114Issue No. 2 - Professional Autonomy 115Issue No. 3 - Professional Capabilities 116Issue No. 4 - Professional Concern with Patient Welfare^117Issue No. 5 - Professional Territoriality^ 118Issue No. 6 - Professional Ethics 119Issue No. 7 - Interprofessional Role Expectations^121Issue No. 8 - Professional Status^ 123Issue No. 9 - Professional Ethnocentrism^ 125Issue No. 10 - Interprofessional Trust 126vi126127128129130133138138138142144153158160164165166167168169170171Issue No. 11 - Interprofessional AdviceIssue No. 12 - Interprofessional Utilization of CapabilitiesIssue No. 13 - Interprofessional CooperationIssue No. 14 - Professional TrainingIssue No. 15 - Interprofessional RelationshipsSummary of the FindingsConclusionIntroductionSummary of the StudyLimitations of the StudyStrategies toward Improved Team CollaborationSuggestions for Further StudyConclusionInterprofessional Perception Scale for the PhysiciansInterprofessional Perception Scale for the NursesAgency Consent FormIntroductory Letter to the PhysiciansIntroductory Letter to the NursesPosterFollow-up Letter to the PhysiciansFollow-up Letter to the NursesCHAPTER 6REFERENCESAPPENDIX AAPPENDIX BAPPENDIX CAPPENDIX DAPPENDIX EAPPENDIX FAPPENDIX GAPPENDIX HLIST OF TABLESTABLE^ Page1^Demographic Data of all the Participating Physicians in the Studyon Interprofessional Misperceptions^ 762^Demographic Data of All the Participating Nurses in the Studyon Interprofessional Misperceptions^ 783^Response Rates of the Staff Nurses Across the ThreeProfessional Designations^ 794^List of the Degrees of Misperceptions Represented by PercentagesFound Among the Physicians and the Nurses in Long-Term Care Facilities^1075 List of Issues Around Which There is No Misperception FoundAmong Either the Physicians or the Nurses in Long-Term Care Facilities^1116 Demographic Data of the 29% Nurses Who Say that Physiciansin Long-Term Care Facilities Are Not Highly Ethical^ 1207 Demographic Data of the 44% Nurses Who Say that PhysiciansDo Expect Too Much of Nurses in Long-Term Care Facilities^1228 Demographic Data of the 9% Nurses Who Say that NursesDo Have a Higher Status than Physicians in Long-Term Care Facilities^1249 Demographic Data of the 18% Nurses Who Say that PhysiciansDo Not Have Good Relations With Nurses in Long-Term Care Facilities^132vi'viiiACKNOWLEDGMENTSMy thanks are extended to the Administrators and Directors of Care, who have given metheir consent to include their respective long-term care facility in the study. I also am verygrateful to the physicians and the nurses who volunteered to participate in the study.I particularly would like to thank Dr. Lawrence Green for directing the course of thisstudy, and Dr. Anna Marie Hughes and Ms. Ruth Milner for serving on my committee.To my family and friends who gave me encouragement and support throughout myMaster's Program, I extend my sincere thanks1CHAPTER 1IntroductionToday's challenges in health care consist of rapid technological changes, ethical and moraldilemmas, and cost constraints (Ornstein, 1990; Fagin, 1992). These challenges have made itnecessary for health professionals to function as members of a collaborative health care team.The necessity for collaborative team work definitely applies to the physicians and the nurses inlong-term care facilities, which is the group of professionals addressed by this study.Historically it appears to have been a rather difficult task for physicians and nurses truly towork collaboratively with each other. In fact, in the eyes of some, the concept of collaborativeteam work might be only an illusion (Nason, 1983). There appear to be many barriers betweenphysicians and nurses, which stand in the way of the collaborative team concept.One barrier is created by misperceptions between physicians and nurses. Banta and Fox(1972), Jacobson (1974), and Ducanis and Golin (1979) point out that misperceptions willseriously interfere with any collaborative effort between health professionals.The Purpose The purpose of this study is to investigate the degrees of misperceptions that physicians andnurses in long-term care facilities may have about each other.The Definitions For the purpose of this exploratory study the following definitions are used.2Collaborative Team Work Collaborative team work is "a joint communication and decision-making process betweenmedical staff and nurses with the goal of meeting the patient's wellness and illness needs asbest as possible, while respecting the unique qualities and abilities of both professions"(Ornstein, 1990, p. 10).Interprofessional Misperception Interprofessional misperception is the difference between one professional's perception onhow the other professional would view an issue, and the viewpoint actually expressed bythe other professional on the same issue.Physicians Physicians are the professionals who provide medical care to the patients in any of the 13long-term care facilities that have been included in the survey.NursesNurses are professionals who provide nursing care to the patients in any of the 13long-term care facilities that have been included in the survey. They work either as regularfull-time or part-time staff nurses, and they are registered nurses, registered psychiatricnurses, or licensed graduate nurses.The Problem Recent developments in long term care have made the issue of collaboration betweenphysicians and nurses in this sector of our health care system a more urgent matter then it hasbeen ever before (Ornstein, 1990; Samuelson, 1992). Ornstein (1990) points out that changes in3demographics have placed new demands on physicians and nurses in long term care. Largernumbers of elderly patients are admitted to long-term care facilities. Not only are the numberslarger, the patients that are admitted also present with health problems that require morecomplicated care then ever before. Faced with these new demands the physicians and the nursesin long term care are urged to take a closer look at how well they collaborate with each other(Samuelson, 1992). How one profession views another is a crucial factor contributing to thedegree to which interprofessional collaboration occurs. Examining the extent to which physiciansand nurses in long- term care facilities do not share perceptions with one another can provide animportant measure of potential conflict areas in the long term care setting.The Significance of the StudyThe poor collaborative status of today's health care teams is a serious matter. Especially ifthe significant benefits of collaborative team work are being considered, it becomes quiteapparent that the genuine implementation of collaborative teams is long overdue. Researchevidence has linked appropriate collaborative practice to improved patient outcome and increasedlevels of job satisfaction, as well as a decrease in overall health care costs (Beloff and Korper,1972; Ducanis and Golin, 1979; Anderson and Finn, 1983; Ritter, 1989; Ornstein, 1990; Fagin,1992). When these consequences are the benefits of collaborative team work between physiciansand nurses, no time should be wasted to analyze the divisive forces that somehow prevent thetwo professions to mutually commit to the collaborative team concept.As pointed out already the study focuses specifically on physicians and nurses in long-termcare facilities. Many of the challenges that today's health care system is facing are found right inthe domain of long term care. These challenges stress the need to specifically explore possiblebarriers to the current collaborative team work in long-term care facilities.4The results of this study show how the physicians and the nurses in long-term care facilitiesin Vancouver view one another. The research findings on interprofessional misperceptionsprovide helpful insight to today's health care managers in long term care. The managers can usethe information to further guide the interprofessional relationship between physicians and nursesin long-term care facilities toward a more collaborative experience.The findings can be used as a point of departure to develop educational experiences incollaborative skill building for physicians and nurses in long term care. Samuelson (1992) pointsout that at the moment such skill building is a rarity in long-term care facilities.The Data SourceThirteen long-term care facilities have been randomly selected from a universe of 22facilities in the city of Vancouver, British Columbia, which has given access to a data source ofone hundred and thirty eight physicians (n = 138) and one hundred and ten nurses (n = 110).The subjects have been invited to participate voluntarily in the survey by filling out aquestionnaire called the Interprofessional Perception Scale.A Profile of the StudyThis study is reported in six chapters. The first chapter presents the introduction to thestudy. Brief discussions of the purpose, the problem, the significance of the study, and the datasource are presented.In the second chapter a review can be found of the research literature on the theoreticalconcepts that define collaborative practice in health care. Misperceptions that physicians andnurses have of each other also are explored in this chapter by discussing the related researchdone on several interprofessional issues. Research on specific demographic correlates ofinterprofessional misperceptions and team work is included in the review. Finally, additional5research is reviewed on collaboration between physicians and nurses specifically in the long-termcare segment of health care.The research methodology of this study, including a description of the instrument used forthe survey, is described in chapter three. Chapter four presents an overview of the findings,which are further discussed in chapter five.Chapter six, finally, summarizes the study and concluding remarks are made about thefindings of the survey. The limitations of the study also are discussed in this chapter. In addition,strategies are included in this chapter that may be implemented in order to lessen the perceptualobstructions between physicians and nurses in long-term care facilities, which ultimately willenhance the concept of collaborative team work among the two professions. Suggestions forfurther study are made at the end of chapter six.CHAPTER 2A Review of the LiteratureIntroductionResearch and non-research literature was reviewed to determine what has been writtenregarding interprofessional collaboration between physicians and nurses. Special emphases in thereview was placed on literature that examined the benefits of collaboration between the twoprofessions, and also additional literature that outlined the barriers in the way of theircollaborative practice, especially the reciprocal misperception barrier. Misperceptions betweenphysicians and nurses are reviewed on a number of important interprofessional issues.The sources of literature that formed the basis for the study were found in medicine,nursing, management sciences, psychology, and sociology. In this chapter, first the review of theliterature will outline the theoretical concepts that define collaborative practice in health care.Second, literature findings will be discussed on the benefits of collaborative team work. Third,literature on the barriers to collaborative practice will be explored, including misperceptions thatphysicians and nurses have of each other. Fourth, a discussion will be provided of the relatedresearch done on several interprofessional issues identified as key to collaborative practice.Fifth, literature on specific demographic data of physicians and nurses will be reviewed,with a special emphasis on the impact of these demographics on the collaboration between thetwo professions. The final section in this chapter will review additional research on collaborationbetween physicians and nurses specifically in the long-term care segment of health care.67Collaborative Team Work Fagin (1992) points out that today's comprehensive system of health care delivery requiresknowledge and skills of physicians and nurses that neither profession can provide withoutcollaboration from the other. It appears that today's challenges in health care have made it anecessity for physicians and nurses to become members of a collaborative health care team. Thequestion arises, when does a team of physicians and nurses truly become a collaborative team,rather than just a group of health professionals who happen to work in the same building or withthe same patients?The literature provides many descriptions of what elements must be found in a team ofphysicians and nurses, before one can refer to the team as a collaborative team. In a report fromthe American Medical Association, a good collaborative team is described as patient-centered andas incorporating medical protocols through the cooperative efforts of physicians and nurses (ascited in Fagin, 1992).Ducanis and Golin (1979), who have studied the functioning of interprofessional teamsextensively in health care, also refer to the cooperative effort as a major characteristic ofcollaborative team work. They refer to the process of synergism on a collaborative team andexplain that the diverse skills and expertise of the different professionals on a team must becombined to provide solutions to specific patient care problems. In essence, collaborative teamwork is an intangible phenomena that allows a team to function synergistically as more than thesum of its parts.Ducanis and Golin (1979) also stress that team members will experience a real sense ofteam identity, but only if they participate collaboratively in the entire team process. Ornstein(1990) also describes collaborative team work as a process by referring to it as "a jointcommunication and decision-making process between medical staff and nurses with the goal of8meeting the patient's wellness and illness needs as best as possible, while respecting the uniquequalities and abilities of both professions" (p. 10).Ornstein's definition of collaborative team work includes the characteristics that arenecessary elements for the work relation between physicians and nurses to be truly collaborative.These characteristics must be fully understood by the physicians and the nurses, if they are tocontribute to the development of collaboration.Mutual respect is one such characteristic, which can have great impact on the developmentof a collaborative practice between physicians and nurses. Hughes and Mackenzie (1990) makethe point that physicians and nurses must accept and respect each other for their uniqueprofessional knowledge and expertise. If the one professional has no respect for the other,chances are very slim that an effort will be made to work collaboratively with each other.Many authors, who have written about interprofessional collaboration, have stressed theneed for parity among the members of a collaborative team (Ornstein, 1990; Fagin, 1992;Baldwin, 1993). The sense of equality between physicians and nurses is a major interprofessionalissue that will enhance the collaboration between the two professions. The traditional workrelationship between physicians and nurses, that has been physician dominated no longer fits thecollaborative model (Baggs and Schmitt, 1988). As noted earlier, Ornstein (1990) talked aboutthe joint participation in decision making that must be observed in members of a collaborativeteam. Baldwin (1993) also feels that an interdisciplinary team can only be described as acollaborative team if it operates on the basis of a partnership model. She points out that membersof a collaborative team develop a work relationship primarily based on the principle of linkingwith each other rather than ranking each other. Fagin (1992) makes a similar point by describingcollaboration as a professional relationship of interdependence. The members of a team dependon each other's unique skills and knowledge, if they want to provide comprehensive health care.9Ornstein (1990) also includes the need for joint communication and decision makingbetween physicians and nurses as a necessary element of collaborative team work. Fagin (1992)agrees that mutual communication must occur between physicians and nurses. Both authors pointout that poor communication between the doctors and the nurses will preclude the developmentof a collaborative practice and, in fact, will even result in potential peril to patient care. Hughesand Mackenzie (1990) also state that frequent open joint communication is necessary in acollaborative practice.There are many additional characteristics that have the potential to define the degree ofcollaboration attainable for physicians and nurses. Several of these have been made a focus ofthis study and match the issues addressed by the Interprofessional Perception Scale (Ducanis andGolin, 1979). They include:the belief in the other professional's competency- the acknowledgment of the other professional's autonomy- the understanding of the other professional's capabilities- the recognition of the other professional's concern with patient welfare- the sense of professional territoriality- the differences in each other's professional ethics- the role expectations of each other- the difference in professional status- the sense of professional ethnocentrism- the mutual trust in each other's professional judgement- the soliciting of each other's professional advice- the full utilization of each other's capabilities- the degree of interprofessional cooperation- the recognition of each other's professional training10the perceived quality of the interprofessional relation.Each of these interprofessional issues are separately discussed in greater detail insubsequent sections of this chapter.Literature will be reviewed first that has stressed the necessity for collaborative team workby pointing out all the benefits appropriate collaboration can bring to the patients, the healthprofessionals, and the health care system.Benefits of Collaborative Team Work The research literature summarized in this section elaborates on the reasons why physiciansand nurses must collaborate with each other in their delivery of health care. Many authors havestressed the importance of promoting collaborative team work between these two professions,because of the many important benefits it brings to all the interested parties in the health caresystem (Ducanis and Golin, 1979; Mechanic and Aiken, 1982; Keddy, Gillis, Jacobs, Burton andRogers, 1986; Baggs and Schmitt, 1988; Ornstein, 1990; Fagin, 1992). Fagin (1992) actuallymakes a much stronger statement by indicating that collaboration between physicians and nursesis no longer a choice.There have been numerous changes in our society, our economy, and our health caresystem, as well as within the professions of medicine and nursing, which have made it necessaryto shift from a physician dominated relationship to a collaborative practice between physiciansand nurses (Baggs and Schmitt, 1988; Ornstein, 1990).A very important survey, conducted in 1971 by the National Joint Practice Commission inthe United States, has provided a significant research basis for interprofessional collaborativepractice (Ornstein, 1990; Fagin, 1992). The commission's report describes benefits that arespecific to the patients, to the health professionals, and to the overall health care system reportedin this survey. These specific benefits and related research literature are discussed next.11Benefits for the Patients Ducanis and Golin (1979) state that appropriate collaboration between physicians andnurses avoids fragmentation of medical and nursing care, and prevents confusion andapprehension on the part of the patients. Ornstein (1990) makes it quite clear that for patients tocontinue to receive high quality of care, collaborative practice between physicians and nurses isessential. She indicates that in a collaborative work relation physicians and nurses develop moreeffective communication skills. Ornstein (1990) explains that one outcome of this improvedcommunication pattern between the two professions, is that less errors in patient care are beingcommitted. She further explains that the improved communication between the two professionsenhances the coordination and comprehensiveness of patient care resulting in greater patientsatisfaction. Other authors reach a similar conclusion and stress that patients receive betternursing care when the nurses participate in a collaborative practice with physicians (Beloff andKorper, 1972; Fagin, 1992).Professional associations seem to agree that patients are better served by physicians andnurses who collaborate with each other. In a recent document prepared by the Registered NursesAssociation of British Columbia the point is stressed that to serve the patient well,interprofessional team work has to involve ongoing collaboration (Registered Nurses Association,1992).Governments are equally convinced that collaborative practice between physicians andnurses will benefit the patients. The government of British Columbia recently has taken aninitiative to promote interprofessional collaboration between physicians and nurses with theultimate goal to serve patients better (Hutchison, 1993). The author reports that nurse midwifesand physicians in the province of British Columbia will work together providing pregnant womenwith a new approach to childbirth. Women who want to have midwife-assisted birth will have to12consult a physician during the first trimester of pregnancy, but for the remainder of theirpregnancy have the option to be cared for by a midwife.Recently, very concrete and far reaching benefits for patients have been reported in theliterature as an outcome of good collaborative practices by health care teams. Fagin (1992)reports that mortality rates for patients in intensive care units and other specialty areas aresignificantly lower than expected as a result of good collaborative team work. Fried, Leatt,Deber, and Wilson (1988) rightfully remark that little is understood to date how exactly thesemortality rates are improved by collaborative practice. The fact, however, remains that favorablechanges are noted in mortality rates in clinical areas where collaborative teams provide thepatient care.Benefits for the Physicians and the Nurses Authors have made the point that today's comprehensive health care, with its everincreasing sophistication in new technology, procedures, medications, and services, requires thebroad spectrum of knowledge and skills that practitioners no longer can provide on their own(Fried et al., 1988; Ornstein, 1990; Fagin, 1992). Just trying to keep up with the ever increasingbody of knowledge specific to one's own profession is quite a challenge for the physicians andthe nurses and requires much of their time and energy (Ornstein, 1990). Given the demands oneach profession, reciprocal information sharing is a great benefit of interprofessionalcollaboration.Based on her literature research Fagin (1992) concludes that with all the complexities andconstraints in today's health care system, the traditional approach of a physician dominated careteam does no longer function well for any of the team members. Ornstein (1990) argues that it isno longer realistic to look only at the group of physicians for prescribing and supervising all thepatient care activities. Stein, Watts and Howell (1990) observed the relationships between13physicians and nurses for more than two decades. They report on the changes affecting theserelationships over time and comment that physicians will have to depend on nurses' expertise, ifthe doctors want to remain the technical experts in patient care while also maintaining a humanattitude toward their patients.In her editorial, Oulton (1989) makes the point that alliances between physicians and nursesmust be forged in achieving common goals in patient care, and she encourages the professionalsto develop a creative approach toward the achievement of these common goals. Only through acollaborative team approach will physicians and nurses be able to continue to apply effectively alltheir unique professional expertise to the difficult challenges in patient care.An additional major benefit of collaborative practice comes to the physicians and the nursesin the form of increased job satisfaction. Ornstein (1990) and Fagin (1992) explain that bothprofessions enjoy greater respect and mutual trust, as well as autonomy, and more freedom toapply their knowledge, skills and judgment in patient care if they commit to a collaborativemodel of care delivery. Both authors have based their views on the findings of a surveyconducted by the National Joint Practice Commission in the United States in 1971. Thecommission has indicated that many nurses are very dissatisfied with their work, because they donot feel respected or trusted, they do not feel included in the decision-process of patient caremanagement, and they feel that there are no opportunities to apply fully all their expert nursingskills.Nurses, who experience higher degrees of job satisfaction, also will be at lower risks forburnout and related illnesses (Anderson and Finn, 1983; Ritter, 1989). Although many sourcescontribute to job satisfaction, if collaborative practice is one of them, and in turn, contributes tothe health of the health professionals, every effort must be made to create lasting conditions thatwill cultivate the collaborative teams.14Benefits for the Health Care System Several authors have referred to the tremendous rising costs in health care (Ritter, 1989;Ornstein, 1990; Fagin, 1992). The need for interprofessional collaboration has increasinglybecome an urgent matter for the survival of the health care system at the level of quality as weknow it today. It has been shown that the tremendous rising costs of health care can be reducedby utilizing nurses in a consultative relationship with physicians (Fagin, 1992). Quite clearly, fornurses to be utilized in a consultative role to the physicians, an open and ongoing communicationbetween the two professions is imperative.There is a decrease noted in total patient days in hospital when the care is provided by acollaborative team of physicians and nurses (Ritter, 1989; Fagin, 1992). Ritter (1989) alsoindicates a decrease in number of hours worked by the physicians and nurses. Improvedcommunication and joint decision making provide more efficient, coordinated and comprehensivepatient care (Ornstein, 1990). Such findings are indicative of greater staff efficiency andproductivity and ultimately lead to a decrease in health care costs.As noted earlier, nurses experience higher degrees of job satisfaction if they participate in acollaborative team (Ornstein, 1990). As these nurses experience higher degrees of jobsatisfaction, they are less likely to resign from their positions. The turnover rates, therefore, arenoted to be significantly less under collaborative work conditions as compared to health caresettings that operate with non - collaborative teams (Anderson and Finn, 1983; Ritter, 1989).Lower turnover rates translate into less need for new staff, and therefore, lead to lower costs fororientation programs. Any reduction in costs is a welcome benefit to a health care system that iscoping with tremendous cost constraints.With all these exciting benefits to patients, to health care professionals, and to the healthcare system, it is disappointing to see so little reported in the literature on how well physicians15and nurses actually are working in a collaborative practice. The next section in this literaturereview will discuss the reasons why much of the discussion given to the concept of collaborativeteam work is only lip-service.Barriers to Implementing Collaborative Team Work Many health professionals are quick to commit verbally to collaborative team work, andyet, these same professionals are very slow to follow through with this commitment in actualpractice. Nason (1983) explains that the collaborative team concept is only an illusion held by themore powerless care givers on the team. Physicians, on the other hand, have been reported tohave limited interest in the administrative functioning of a team (Hanlon and Gladstein, 1984).Many reasons have been cited in the literature for this lip-service to collaborative teamwork. The reasons are characterized in the literature as barriers to collaboration, and they arereviewed in the following sections of this chapter.The Barrier Created by Historical Developments As far back as the early 19th century, when physicians and nurses were at the bedsides intheir patients' homes, the two professions have not collaborated well with each other (Ornstein,1990; Fagin, 1992). A period in which many physicians and nurses have been reportedly able towork well as a team has been under circumstances such as during World War II. During thiswar, collaborative team work received a major impetus, and physicians and nurses experiencedgood colleagueship, while facing their common problems for which they found shared solutions(Ducanis and Golin, 1979; Fagin, 1992). Fagin (1992) states, however, that as soon as the warwas over both professions somehow were unable to continue their collaborative practice.The implications of the collaborative team concept have not always been fully understood,and the initial enthusiasm for the concept has been followed by disillusionment (Ducanis and16Golin, 1979). The authors explain that the concept of collaborative practice was seen even asobsolete by some health professionals in the late 1950s.The Barrier Created by Clinical Uncertainty in Health Care Horder (1992) notes that the more stressful the challenge in patient care is, the moredifficult it appears to be for professionals to collaborate. This observation is rather paradoxical.Consider, for instance, the stress of World War II. As noted earlier, under these tryingcircumstances of war, physicians and nurses have been reported as having worked very well witheach other (Ducanis and Golin, 1979; Fagin, 1992).One actually expects that professionals would be more motivated to work collaboratively ifthe task on hand is very difficult. Fried et al. (1988) argue this same point and say that whenthere is an increase of clinical uncertainty in a patient's case, the chance for successfully treatingthe patient is largely dependent on how well the involved health professionals collaborate witheach other.Horder (1992) admits to the paradoxical nature of his observation, but still supports it byreferring to a number of systematic studies which suggest that only 20% of physicians and nursesare working in partial or full collaboration. Horder (1992) maintains that the uncertainties inhealth care, as well as the insecurities and the anxieties, are the exact reasons why there are lowsuccess-rates with the interprofessional collaborative team concept. The author perceives that theunpleasant feeling of uncertainty is creating a barrier to collaboration. He argues that healthprofessionals want to avoid collaboration when they feel uncertain and anxious. However, Friedet al. (1988) in their indepth study conducted on units treating renal disease and cancer clinics,present a counter argument. They conclude that the clinical uncertainties in renal and cancerpatients has lead to the deliberate choice of physicians and nurses to work collaboratively.17The Barrier Created by Dominance in the Work Place Many work relations between physicians and nurses are dominated by physicians (Baggsand Schmitt, 1988; Ornstein, 1990). This condition of dominance in the work place byphysicians is seen as a major barrier to interprofessional collaboration. It is now believed that itis highly inadvisable for a patient care team to follow blindly what ever has been stipulated byone of the professionals on the team. Fagin (1992) strongly warns that a single-discipline view ofhealth care in the future will be destructive to the patients, the health professionals, and thehealth care system. This warning is of real significance especially when seen together with areport prepared by Kurtz (1980). The author has examined the views of 800 physicians to assesstheir preferences in interprofessional interactions. From the report it appears that physiciansgenerally prefer not to be interactive. Physicians prefer to avoid group involvement. With suchpreferences for individual action on the part of the physicians, the development of collaborationwith nurses has a very slim chance of success.Baldwin (1993), associate professor in the Counseling and Educational PsychologyDepartment at the University of Nevada, examines the element of dominance in the work settingfrom a psychological view point. She explains that dominance in the work-place finds its originin the North- American society's orientation toward a dominator model of interaction. Ornstein(1990) classifies this form of interaction as oppressed group behavior. She identifies the nurses asthe members of the oppressed group, and the physicians as the oppressors. Baldwin (1993) addsthat until very recently, scholarly research and developmental theories generated within thedominator model has sent women the message that they are somehow not equal in anymeaningful way to men. This message definitely has reinforced the feelings of oppression amongnurses, who are predominantly female. Already, in 1967, the oppression and the dominancemodel of interaction between physicians and nurses have been recognized and have been calledelements of the doctor-nurse game, and a recent review of the rules of this game shows that little18has changed in the interplay between the physicians and nurses (Stein et al., 1990). The authorsindicate that still much tension appears to exist between the two professions. Based on Baldwin'sreview (1993) of the history of the dominator model, it appears that these tensions partially arethe result of struggles with models of dominance and hierarchy. Baldwin (1993) urges thatinstead, the professionals should work towards models of partnership and cooperation in order toachieve collaboration.The Barrier Created by Poor Communication Patterns Poor communication patterns between the physicians and the nurses form serious barriersin the way of collaborative practice. Both professionals are at fault in this instance. Nursesfrequently express their dissatisfactions in very indirect and covert behavior (Fagin, 1992).Unfortunately, this poor communication habit of nurses is only reinforced by physicians. Manyphysicians are reported to disapprove of any open expression of dissatisfaction among nurses,and this disapproval, in turn, results in an inability for the physicians to see clearly what isdistressing to the nurses (Fagin, 1992). Indeed, the physicians are reported generally to bepuzzled and confused by nurses' behavior (Stein et al., 1990). The same authors report thatphysicians even feel betrayed and are angered by the nurses' behavior.Without an open, ongoing communication between the two professions, they will continuenot to be able to understand each others' point of view. Physicians and nurses will continue to beignorant of each others' roles, and they will have a very slim chance to find remedies for theirproblems. Nor will they ever be able to collaborate well with each other when these bad habits ofcommunication are maintained.19The Barrier Created by Limited Available Time Another reason for seeing little evidence of successful collaborative team work, is theenormous amount of time it takes to develop such a work method. Baggs and Schmitt (1988)explain that there is a greater demand on the physicians' and the nurses' time, becausecollaborative practice requires the professionals to participate in many joint committee meetings.Ornstein (1990) feels that as long as physicians' meeting time is not compensated for, it isunlikely that physicians are willing to spend the extra time in meetings in order to develop acollaborative relationship with nurses. She also explains the dilemma of time constraints thatnurses are facing, who already are trying to cope with very high patient workloads.The Barrier Created by Limited Financial Resources The impact of collaborative practice on health care costs also is indicated as a barrier.Anderson and Finn (1983) point out that implicit to collaborative team work is the introductionof primary nursing models at a high cost. As noted earlier, however, patient care eventually isdelivered more efficiently, and is less costly, if it is provided by a team of physicians and nurseswho collaborate well with each other (Ornstein, 1990). This barrier, therefore, seems to be anissue mainly during the initial stages of preparing the nurses to work as primary nurses and incollaborative practice with physicians.The Barrier Created by the Lack of Institutional Support A look at the above barriers partially explains why physicians and nurses have beenstruggling with each other ever since they have cared for the same patients at the same time.Nason (1983) draws a similar conclusion and points out that patient care teams have seldomlyrun smoothly. Fried et al. (1988) suggest that the lack of guidance by management thought andpractices partially explains the long record of poor team performance. Considering the20tremendous complexity of today's health care system, it is easily understood why there is a needfor expert management advice to guide all parties through the difficult challenges. It does takesomeone with expert management skills and administrative knowledge to integrate patient needswith the institution's need for fiscal solvency, while at the same time also having to consider theconflicting interests of different employee groups (Nason, 1983; Hanlon and Gladstein, 1984).The balancing of all these different needs is not an easy task, but can be achieved partially byguiding the professionals toward good collaborative practice. Fried et al. (1988), however, pointout that health services managers have not been serious enough about this guidance and the needto inject group management practices into the teams of physicians and nurses. Ducanis and Golin(1979) make a similar point. They conclude that physicians and nurses have not been made awareof the factors that have an impact upon team collaboration. Epton, Payne and Pearson (1984)elaborate on some of these factors. They say that team members must be informed about theprocess of team management and team building. In particular, team members should be toldabout the procedures for resolving conflicts and ways on how to obtain agreement oncontroversial issues. This educational approach, indeed, has proven to be very effective in thoseinstances where it has been used. In an interview Joyce Clifford, Vice-President for Nursing andNurse-in-Chief at Beth Israel Hospital in Boston, Massachusetts, tells how she, and the othermembers of the senior management team at the hospital, have provided directions to thephysicians and the nurses in resolving potential conflict situations (Bocchino, 1991). They havestressed the importance to avoid the classic we/they syndrome in attempts to resolve controversialissues and to remain always focussed on patient centered care. The management at Beth IsraelHospital has placed emphasis on conflict resolution, not conflict avoidance. To this end, theadministration has seen to it that the nurses at Beth Israel are represented on the MedicalExecutive Committee and all its subcommittees with equal participation and voting powers as thephysicians (Bocchino, 1991). Bocchino (1991) reports that this interprofessional collaboration at21Beth Israel Hospital has been a success for over 15 years. Koerner and Armstrong (1983) reporton an other successful implementation of collaborative practice. At the Hartford Hospital inHartford, Connecticut, the administration has recognized the need for collaboration betweenphysicians and nurses and they have implemented a Joint Practice Committee to enhance thequality of the interface between the two professions. The administration at Hartford Hospital hassupported the collaborative team concept and has seen to it that equal numbers of physicians andnurses are on this joint committee.It seems from this review of the literature, that the administrative support to thecollaborative team concept seen at Beth Israel Hospital and at Hartford Hospital still is perceivedto be more the exception than the rule in today's health care system. Repeatedly theadministrators are encouraged to increase the guidance of the physicians and the nurses in theirattempts to collaborate well with each other and to provide these professionals with the necessaryeducational resources. Yet, Nason (1983) points out that many of today's health care teams stilldo not have the advantage of team training. Administrators themselves also will have to becomefully aware on how the internal workings of their health organizations can become a constraint tothe development of collaborative teams (Epton et al., 1984).Administrators can create an additional barrier to collaborative practice if they are not trulycommitted to the collaborative team concept (Nason, 1983; Epton et al., 1984; Hanlon andGladstein, 1984). Their commitment will show only through insightful leadership and often verytime consuming and hard work. Hanlon and Gladstein (1984) make it clear that managers mustbe committed to the goals of a collaborative team. Nason (1983) stresses the importance foradministrators to commit themselves to the difficult task of analyzing the devise forces on theteams. Nason (1983) and Epton et al. (1984) point out how important it is for administrators toknow exactly how team members relate to each other. It is vitally important that administratorsbecome aware of the exact degree of collaboration that exists among team members, because a22lack of collaboration reflects both system and patient care problems (Nason, 1983). Epton et al.(1984) stress that, most importantly, administrators should spend time appropriately controlling,co-ordinating and motivating the members of the teams to work together. Without suchleadership on the part of the administrator, the health organization will not see the developmentof collaborative teams. Nason (1983) thinks that institutional support for collaborative teams willdepend on how much those in power will come to rely themselves on the collaborative process asan administrative style. As long as collaborative practice is not being recognized as a means toachieving their own administrative goals, administrators might be slow in genuinely supportingthe collaborative team concept.In summary, the lack of guidance in team management by administrators of physicians andnurses potentially can be a barrier in the way of developing well functioning collaborative teams.An equally significant administrative barrier is the lack of involvement and genuine interest incollaborative teams on the part of health care administrators. A third administrative barrier is alack of awareness of barriers to interprofessional collaboration.The Barrier Created by Resistance to Change The above barriers have all been barriers specifically identified or suggested as standing inthe way of collaborative team work. There is also a more general form of barrier described inthe literature, which is the mere resistance to change itself. Keddy et al. (1986) make the pointthat the present work relationship between physicians and nurses has existed for more than acentury. The authors explain that physicians and nurses are threatened by the introduction of thenew work method of collaborative practice. Both professions react to this threat by resisting anydevelopment towards collaborative practice. Keddy et al. (1986) further clarify that bothprofessions may not have been prepared for this change in their work method. They explain thatphysicians and nurses have not been educated nor socialized to work collaboratively with each23other. This may contribute to another major barrier, that of misperceptions of one another byphysicians and nurses.The Barrier Created by Interprofessional Misperceptions Among Physicians and Nurses In addition to the forementioned barriers there is one additional barrier to collaborativepractice cited in the literature, which has been made the focus of this study. Interprofessionalmisperception has been identified as a major barrier in the way of collaborative work betweenphysicians and nurses (Banta and Fox, 1972; Jacobson, 1974; Ducanis and Golin, 1979). Theseauthors point out that misperceptions will seriously interfere with any collaborative effortbetween health professionals. Interprofessional misperception has been defined as the differencebetween one professional's perception on how the other professional would view an issue, andthe view point actually expressed by the other professional on the same issue.The Interpersonal Perception Method The interpersonal perception method developed by Laing, Phillipson, and Lee (described inDucanis and Golin, 1979) is used as the conceptual framework for this study on interprofessionalmisperceptions between physicians and nurses in long term care facilities.The interpersonal perception method asserts that each member in a dyadic relationshipdevelops different levels of perspectives. At one level, the professional develops a directperspective on an issue. At a different level, the same professional also develops a perspective onhow an other professional would respond to the same issue. The interpersonal perception methodis adaptable to a variety of investigations, including group perceptions.Based on the interpersonal perception method, Ducanis and Golin (1979) suggest thatphysicians and nurses enter their work relationship with certain preconceptions about each other.These preconceptions can consist of expectations that one has of one's own professional role in24the work relationship with others, and also can consist of expectations one has of the role andresponsibilities of the other profession. What is of interest, is to note that these preconceptionsappear not always to reflect reality. In essence, these preconceptions could be misperceptions.Jenny (1990) provides an account of a physician who required hospitalization following a cardiacarrest, and who had preconceptions about nurses which turned out to be definite misperceptions.The doctor thought nurses were a sort of executive secretary, who took orders and gave the rightpill. Through his experience as a patient, the physician realized that nurses were doing muchmore than following orders and giving pills. The same physician who referred to nurses asexecutive secretaries perceived them now as his lifesavers.Using the framework of the interpersonal perception method two scenarios of perceptionscan be described, which have become the focus of this study.Scenario 1 - Members of one profession perceive themselves in a certain way (level I), andthey perceive that members of another profession either agree with them or not agree withthem (level II).Scenario 2 - Members of one profession perceive the members of another profession in acertain way (level I), and they perceive that the members of the other profession eitheragree with them or do not agree with them (level II).Scenario 1 indicates how professionals see their own profession and whether they think themembers of an other profession will agree with them or not. Scenario 2 shows how professionalsview the members of another profession, and whether they think these members will agree withthis view or not.To determine whether or not these preconceptions are misperceptions, a comparison needsto be made between the level II perception of scenario 1 and the level I perception of scenario 2.25Similarly, a comparison needs to be made between level II perception of scenario 2 and the levelI perception of scenario 1. In essence, a comparison is made between a perceived view point onan issue and an actually existing view point on the same issue in order to determine whether theperceived viewpoint is a misperception.The focus of this study has been interprofessional misperceptions rather thanintraprofessional misperceptions, because the potential misperceptions are usually more seriousbetween members of different professions than between members of the same profession(Ducanis and Golin, 1979). The focus of the study has been further delineated by lookingspecifically at the physicians and the nurses, because historically these two professions have beenat odds with each other longer than any other profession in health care (Ornstein, 1990; Fagin,1992).Fried et al. (1988) stress the importance for health professionals of sharing theirperceptions of each other. Only through open and honest sharing of these perceptions willphysicians and nurses be able to move a step closer to collaborative practice. They will be in aposition to identify any existing misperceptions there may be amongst the members of the team.Ducanis and Golin (1979) have developed an instrument that measures the existing degreesof misperception among health professionals. This instrument asks the professionals to share theirperceptions on a number of interprofessional issues. These interprofessional issues are consideredthe "make-or-break" issues in interprofessional collaboration, and are discussed in the nextsections of this chapter.Make-or-Break Issues in Interprofessional Collaboration Of the many issues described in the literature that have major influence on collaborativeteam building, there are make-or-break issues in professional collaboration. These issues are26considered make-or-break issues, because they seem to have as much potential to contribute tothe formation of a well functioning team as they seem to have the potential to stand in the way ofany collaborative team effort.Ducanis and Golin (1979) apply the interpersonal perception method to misperceptionsamong physicians and nurses by focussing on 15 interprofessional issues that are supported in theliterature. They include:the belief in the other professional's competencythe acknowledgment of the other professional's autonomythe understanding of the other professional's capabilitiesthe recognition of the other professional's concern with patient welfarethe sense of professional territorialitythe differences in each other's professional ethicsthe role expectations of each otherthe difference in professional statusthe sense of professional ethnocentrismthe mutual trust in each other's professional judgementthe soliciting of each other's professional advicethe full utilization of each other's capabilitiesthe degree of interprofessional cooperationthe recognition of each other's professional trainingthe perceived quality of the interprofessional relation.In the next sections each of the 15 issues will be separately reviewed to assess priorresearch on each. Their potential to be either a contributor or a hindrance in interprofessionalcollaboration will become quite apparent through each of the separate discussions. This dualpotential stresses the importance for all health care professionals to understand fully these issues27and use them to their advantage. Hughes and Mackenzie (1990) suggest that knowledge of thenecessary elements of collaboration can assist nurses and physicians toward an enhancedcollaborative relationship. Through complete understanding of these make-or-break issues is therean increased chance for successful interprofessional collaboration.Issue No. 1 - Professional Competency It is easy to see how the issue of professional competency can have the potential to be amake-or-break issue in interprofessional collaboration. Afterall, one could hardly expect aprofessional to work collaboratively with another professional who is perceived to beincompetent. If on the other hand the one professional believes the other professional to becompetent, chances are high that the two will want to work together collaboratively in theprovision of patient care.How does one come to the conclusion that the other professional on the team is competentor not? What is it about the other professional that makes him or her perceived to be competent?Prescott and Bowen (1985) have deliberated about these questions. As part of a larger studyexamining organizational factors in hospitals, these authors have studied physician-nurserelationships. They have interviewed 187 physicians and 264 staff nurses and have been able toverify that the competency of physicians is often assumed, the nurses, on the other hand, oftenhave to prove their competency. Fagin (1992) indicates that this fundamental difference inacquiring credibility as a competent health professional definitely can stand in the way ofbuilding a collaborative relationship between the two professionals. The literature provides anumber of additional insights on how people appear to make up their minds about an otherperson's level of competency.The more experience and exposure a person has to a certain clinical area, the more theperson is thought of as competent. Jenny (1990) contends that nurses who have chosen to remain28in the same clinical area for longer than five years are often the only ones with the finiteknowledge of typical patient responses seen in that area, and are often very skillful in handlingthe very specialized technology available to treat these patients. Of course, one should becautioned and realize that the mere longevity of a person's exposure to one clinical area does notguarantee that person's competency. In fact, bad habits and stagnation in acquiring knowledgemay very well have lead to the development of less than competent skills in the professional.Ducanis and Golin (1979) reported on a different method used by some people to assess another person's level of competency. They allude to the basic assumption made by many healthprofessionals that those who are higher in the hierarchy of a health organization possess all of theknowledge and skills of those lower in the system, in addition to their own uniquely acquiredknowledge and skills. The authors are quick to add, however, that such an assumption no longercan be defended given the tremendous specialization that has been observed in each of theseparate disciplines on a health care team. No longer can a "higher" professional know all thespecialized knowledge of a "lower" professional. Despite this reality some health professionalsstill live by this assumption, and perceive other professionals as competent solely because theyare "higher" in the organization.Educational status of the professional often determines how "high" the person is in theorganization. The more education the person has the more competent he or she is perceived tobe. For instance, traditionally physicians have always outnumbered the nurses in terms of yearsof education, and have enjoyed a higher place in the hierarchy. However, changes are occurringin the educational status of nurses (Nurse-Physician, 1989). More nurses are prepared at theuniversity level, both the undergraduate and graduate levels. With this change in educationalstatus the nurses are being perceived as more competent by many other health professionals,including the physicians. The order of who is perceived as higher or lower in the organization29based on education is constantly changing as health professionals require more education in theirrespective fields.Unfortunately, there are professionals who see this change in educational status andcompetency as a threat to their own position in the organization. These professionals believe thattheir own skills and knowledge will become obsolete as the other professionals becomeincreasingly more competent. Ducanis and Golin (1979) point out that such situations are oftenfraught with acrimony and rancor and may lead to interprofessional strife and rivalry. Fagin andDiers (1983) add that such situations can produce anxiety. They feel that the anxiety is the endresult of a chain of reactions, which starts with the nurses. Because of their 24-hour position atthe bed side, nurses see all that happens with the patients. The nurses see the cures, but also theneglect. As the nurses increase their competency and knowledge, they will develop a frameworkwithin which they can scrutinize better all the work produced by the physicians. Fagin and Diers(1983) speculate that some physicians may feel rather anxious about this heightened form ofscrutiny.A 1988 study brought out another alarming point concerning professional competency(cited in Nurse-Physician, 1989). Based on interview results the study reports, that some nursesperceive they are a scapegoat for medical incompetency. Such a perception on the part of nursesis indeed very alarming and requires further investigation, which goes beyond the current scopeof this study. It is, however, important to note that a nurse who perceives herself or himself tobe a scapegoat of medical incompetency is very unlikely to engage in collaborative team workwith physicians.Hopefully not too many professionals would feel threatened by an other professional'scompetency. It also is hoped, that each professions' monitoring of its members' competencieswill lessen the circumstances where one professional may be seen as a scapegoat for another'sincompetency. It is hoped that we would see more and more professionals agree with Samuelson30(1992). He made the important point that if each professional would be allowed and encouragedto function more efficiently within his or her area of greatest competency, an environment ofmutual respect could be fostered for health care teams rather than an atmosphere of rivalry.Issue No. 2 - Professional Autonomy Nason (1983) points out that physicians and nurses have a need to be autonomous andbecome a self-regulating profession. To obtain professional autonomy is seen as a confirmationof one's unique expertise and professional knowledge. Ducanis and Golin (1979) explain thatsociety's willingness to confer autonomy on a health professional serves as a recognition of theprofessional's unique contribution to health care. The authors point out that such recognition, inturn, is seen as a source of professional power, which explains why professionals appear to beeager to have autonomy. Jenny (1990) agrees with this point and feels that the route to nursingpower lies in autonomous nursing acts.It is easily seen how the issue of professional autonomy becomes a make-or-brake issue incollaborative practice, when one considers how autonomy is equated to professional power. Oneprofession can easily misperceive the viewpoints of an other profession on professionalautonomy. Ornstein (1990) illustrates this point by citing how physicians have reacted to therecommendations nurses have made to make nurses the gatekeepers to community-based primaryhealth care services. She explains that physicians have perceived these recommendations as athreat to the doctors' clinical autonomy. Such a perception of threat hardly makes a physicianwant to contribute to the concept of collaboration with a nurse. Yet, the success ofcommunity-based primary health care services relies on the collaboration between the nurse andthe physician.The fact remains, however, that physicians see their professional autonomy increasinglychanging. Fagin (1992) points out that more physicians are becoming salaried employees. No31longer are the physicians entirely autonomous under these new work conditions. They now areaccountable for their actions to an employer. The autonomous characteristic of being aself-regulating profession is changed for the physicians, now that an employer partially providesregulations on how the physicians will perform their duties. Ducanis and Golin (1979) point outthat some physicians might perceive such changes as evidence that some of their professionalautonomy is being eroded. The authors explain how the bureaucratically prescribed functions ofphysicians may be in direct conflict with the orientations to the professional role as formulated bythe physicians themselves.As for the nurses, they have been very interested in the issue of their own professionalautonomy for quite some time (Stein et al., 1990). The nurses strongly feel they need to increasetheir autonomy for reasons, which Stein elaborates on, discussed in an earlier article written in1967 (as cited by Fagin, 1992). In this 1967 article Stein describes the interaction betweenphysicians and nurses as a game. Even in today's health care settings part of the doctor-nursegame still consists of physicians managing nurses' initiatives and recommendations on careinterventions without giving the nurses autonomy over the final decisions. Ornstein (1990) makesa similar observation and states that the responsibility of care is left to the nurses, but without theauthority to act in the absence of the physicians. Under these circumstances it is easy to see hownurses perceive their autonomy to be in need of more substance. The nurses are gaining groundin this respect, because they increasingly are receiving recognition for their professionalautonomy. In a recent interview British Columbia's current Minister of Health expressed interestin exploring the future role of nurses (Bruce Wells, 1992). Based on the report of the province'sRoyal Commission on Health Care and Costs, the Minister believes that nurses will acquire aneven stronger role than they already have as advocates for patients. It seems that, particularly inthe areas of community care, health promotion, and the prevention of illness, the nurses can lookforward to an increase in their clinical and professional autonomy.32Both professions see their professional autonomy also change by the rise of consumerism(Ducanis and Golin, 1979). The consumer movement strongly influences the current autonomy ofphysicians and nurses. Today, the public is much more knowledgeable and aware of and aredemanding services that can be rendered by a team of physicians and nurses. No longer do theprofessionals have free reign over what services they will provide. To this end, the professionalsalso face more governmental interventions especially tied to cost containment. The change toprofessional and clinical autonomy, as driven by consumerism, is a change for the better. Therehas been a longstanding lack of real team accountability for the care the different members on theteam provide. Butterill, O'Hanlon, and Book (1992) have identified this poorly definedaccountability of a care team as a common problem faced by the public. The authors have cometo this conclusion after reviewing the literature on organizational structure, power,communication, and boundaries within the organization. The increasingly more knowledgeablepublic now demands more accountability and no longer blindly confers complete clinicalautonomy to the physicians and the nurses.These shifts, however, in professional autonomy should be perceived as positivemovements toward a more efficient and effective health care system that is provided by acollaborative team of physicians and nurses. If both professions can acknowledge each other'sprofessional autonomy purely as a reflection of each one's unique professional expertise andknowledge, rather than only a reflection of professional power, then the issue of professionalautonomy has the potential to contribute to the collaborative team concept. It is encouraging,therefore, to see that some of the physicians of tomorrow already seem to have formulated apositive viewpoint of nurses in this respect. Anvaripour et al. (1991) report on the results of aworkshop for second-year medical students on collegiality and find that medical students dorecognize nurses as autonomous professionals.33Issue No. 3 - Professional Capabilities Another important factor contributing to poor collaboration between physicians and nursesis the lack of understanding the capabilities of the other professional (Ducanis and Golin, 1979;Mechanic and Aiken, 1982). One profession appears to have certain perceptions about an otherprofessions' capabilities to handle the problems in patient care. A recent reaction from physiciansto the legalization of midwifery for home births in the province of British Columbia serves as agood illustration of a profession's perception about the capabilities of an other profession(Hutchison, 1993). The legalization has been met with resistance from the province's MedicalAssociation. The physicians argue that home births have great potential for risks and thatmidwives should not be legalized for home births (Hutchison, 1993). Such a viewpoint is a clearillustration of the physicians' lack of understanding the capabilities of midwives. All evidencepoints to the fact that home births under supervision of midwives are extremely safe for low-riskbirthing women. The midwives are specialists who have been very well trained and who have aproven track record as capable care-givers for pregnant women (Rooks, 1990).If the other professional is perceived as not capable of solving, or significantly contributingto solving problems, chances for the development of interprofessional collaborations are ratherslim. It is important, therefore, to create a proper understanding of each other's capabilities andto eliminate any misperceptions about such an important issue.It is suggested that both professions should be educated about each other's capabilities.Horder (1992) notes that it is a widespread assumption that education about the work of otherprofessions can contribute to better collaboration between these professions. Even though theimpact of education on team collaboration is only an assumption, Horder (1992) does stress thatignorance definitely is a barrier to collaboration. It appears, therefore, to be important thatefforts are made by physicians and nurses to learn about each other's capabilities. It takes more34than education, however, to create the mutual understanding for each other's capabilities. Nason(1983) explains that it takes experience and empathy for each other's capabilities, as well aslimitations, for a team of professionals to appreciate how each profession deals with the problemsin patient care. Hughes and Mackenzie (1990) make a similar point. They add that physiciansand nurses must accept and respect each other for their unique expertise.From this review on professional capabilities, it appears that for several decades theliterature has stressed that collaboration between physicians and nurses requires knowledge,empathy, acceptance, and respect for each discipline's scope of unique capabilities.Issue No. 4 - Professional Concern with Patient Welfare While at times it may appear that interprofessional collaboration is promoted for the sakeof the professionals on the team or the health care organizations, the main reason for developingcollaborative practice is to serve the patients. Clifford, Vice-President at Beth Israel Hospital inBoston explains in her interview, that throughout the entire process of fully integrating thecollaborative team concept at her hospital, the focus has been kept on the essential reasons forthe institution's being, which are patients, their families and how to provide excellent care tothem (Bocchino, 1991). Ducanis and Golin (1979) also stress, that the patient is the focus of theteam's efforts and the reason for the team's existence. Furthermore, Fried et al. (1988) argue,based on their literature review and study results, that the patient actively should be included as amember of the collaborative team. With all their self-confessed altruistic intent, physicians andnurses certainly will not argue with this point. On the other hand, Nason (1983) notes that thesesame professionals are known to pursue professional priorities that appear to have no relevanceto patient care.Members of both professions frequently perceive the members of the other profession to bepreoccupied with self- serving priorities rather than the welfare of the patients. These perceived35self-serving priorities can become a source of tension between the physicians and nursesimpeding the collaborative functioning of the team (Nason, 1983). There is a reluctance to spendtime on collaborative effort with another professional, when this professional is perceived to bemore concerned with the enhancement of self-serving goals rather than the welfare of thepatients. To illustrate, some physicians have been reported to be concerned about the priority thatnurses persistently have set for themselves in recent years, to see the baccalaureate degree as theentry level to nursing (Nurse-physician relationships, 1989). The physicians are concerned thatnurses will become less interested in direct nursing care, as the nurses enter their profession withuniversity degrees. The physicians ask the question, who will do the basic patient care? Thisperception on the part of the physicians sharply differs from the actual reasons that have beengiven by nursing leaders for their attempts to make the baccalaureate degree a requirement toenter the practice of nursing. In fact, nurses feel they need to be prepared at the university levelsprecisely in order to serve the patients better in today's complex health care system. The twoprofessions appear at odds with each other on the issue, which does not add to the developmentof the collaborative team concept.A better understanding of rationale for actions taken by a profession will prevent possiblemisperceptions on the true intent of that profession to continue to have the welfare of the patientfirst and foremost in mind.Issue No. 5 - Professional TerritorialityOf all the issues discussed in this literature review, professional territoriality is one of themost sensitive issues causing great amounts of tension between physicians and nurses. Fagin(1992) argues that this issue looms large as a barrier in the way of collaborative practice. Forany collaboration to occur the two professions first must work out their perceptions of eachother's sense of professional territoriality and encroachment. The sensitivity around the issue is36well described by Ducanis and Golin (1979). The authors explain that as soon as one professionclaims the right to solve a problem, which formerly has been solved by an other profession, thelatter profession will perceive that claim as an accusation of its incompetency or a threat to theirunique scope of practice. The latter profession will react, in turn, by accusing the otherprofession of professional encroachment.Both the medical and the nursing profession have been noted to engage in the habit ofaccusing each other of professional encroachment. Fagin and Diers (1983) explain that dominantgroups always are very reluctant to yield any professional ground. Both the physicians and thenurses are dominant players in the health care system. Historically the physicians have been theupper and controlling class in the health care system. As for the nurses, their dominance is foundpurely in their great numbers. They are the largest professional group in the health care system(Fagin and Diers, 1983). It is no surprise, therefore, to find both professions at odds with eachother over issues relating directly to their sense of professional territoriality.The physicians' and nurses' concern over their professional territory also has beenheightened by the actions of other health professionals. Beloff and Korper (1972) explain thatwith the ever growing number of new health professionals, who are ready and able to serve thepatients, the physicians and the nurses can spend less actual time with patients. Not only are thetwo professions of medicine and nursing, therefore, in competition with each other, they also arecompeting for patient time with social workers, dieticians, neighborhood health aides, and othermembers of the care team. Ducanis and Golin (1979) come to similar conclusions and note thateach profession has a tendency to become increasingly more protective of its domain.Fagin (1992) reports that the American Medical Association appears to have been obsessedwith the competition and the threats from nurses. Rooks (1990) states that the Americanphysicians have attacked and nearly obliterated midwifery. Nurse anesthetists also have been keptfrom doing their work by anesthesiologists groups, who have used such unfair means to attack37the nurses that antitrust action appeared to have been necessary against the physicians (Maineaims antitrust blow at MDs and saves the day for CRNAs, 1985). In Canada similar strongreactions are seen amongst the physicians, whenever nurses appear to be inching in on thephysicians territory. Ornstein (1990) reports on the uneasy feelings physicians in Ontario haveabout nurses' involvement in community-based primary health care services. The Ontariophysicians feel their professional territory threatened and very reluctantly want to share their turf.In the province of British Columbia the situation around professional territoriality is not muchdifferent. As noted earlier, the province's Medical Association is quoted to be against homebirths under the supervision of midwifes (Hutchison, 1993). From these illustrations, it becomesclear that professional territoriality truly is a very sensitive issue.Fortunately, many authors have tried to put the issue of professional territoriality in theright perspective by suggesting positive and effective approaches to maintain one's uniqueness asa profession, but without becoming territorial. (Hughes and Mackenzie, 1990; Fagin, 1992;Samuelson, 1992).Increasingly more physicians and nurses are reported to be saying that their physicalterritories are overlapping, but that their clinical territory can be uniquely maintained(Nurse-Physician, 1989). Physicians and nurses each have their own perspectives on patient carefrom their own professional knowledge base, but collectively both professions can add to theoverall quality of patient care. Physicians have been reported to say that there is nothing wrongin itself with nurses taking over tasks, which have been performed previously by the physicians,but this take- over can be done in conjunction with the physicians rather than independently ofthe doctors (Nurse-physician, 1989).Hughes and Mackenzie (1990) point out as well that physicians and nurses are in a positionto complement each other's roles through recognition and appreciation of each other'suniqueness. Fagin (1992) stresses that physicians and nurses should not have to be in competition38for patients' time. She explains that each profession certainly can have its own territory. Nursescan devote their expertise and skills to patient services which require highly interpersonalinteractions, whereas physicians can engage in services for which substantial scientific andtechnological expertise is needed.Team collaboration is most likely to occur when physicians and nurses accept each other'sinput in the overall care to the patients without perceiving that input as a threat to their ownprofessional territory (Samuelson, 1992).Issue No. 6 - Professional Ethics Medical and nursing professional associations have developed codes of ethics regulating thebehaviors of their respective members. These associations have given much careful thought to thedevelopment of their respective codes of ethics in order to provide assurance to their ownmembership and the general public, that each member in the association behaves in a mannerappropriate for either a physician or a nurse. Ducanis and Golin (1979) explain that a code ofethics is necessary for the physicians and the nurses, because each of these professions enjoys agreat degree of freedom and autonomy. They argue that the greater the freedom of a profession,the more chance there is for improper conduct by a member. The associations, therefore, musthave codes of ethics and strictly enforce them.A code of ethics is based on the norms and values that a profession has adopted through asocialization process (Ducanis and Golin, 1979). Dr. Marsha Fowler, a nurse and professor inthe school of nursing and graduate school of theology at Azusa Pacific University in California,points out that the value systems of physicians and nurses differ from each other (Ethics ForNurses, 1991). Given again that these different value systems form the basis for the codes ofethics, the ethical standards for physicians and nurses are different as well. Because of thisdifference, the issue of professional ethics is included in this discussion of make- or-break issuesin collaborative practice. The differences are not always well understood and may lead to39misperceptions about each other's code of ethics, which in turn, will stand in the way of anycollaborative effort. Huntington and Shores (1983) agree with this observation and point out thatconflict always seems to arise from differences in value systems and moral distress.Gramelspacher, Howell, and Young (1986) have conducted structured interviews with 26 nursesand 24 physicians and have found that physicians and nurses often disagree about ethicaldecisions. Especially if the differences between the two professions are perceived to be too farapart, chances for developing any form of collaborative team work are slim.Dr. Fowler provides an illustration of an important difference in the value systems betweenphysicians and nurses (Ethics For Nurses, 1991). She tells of the way physicians and nurses oftendiffer in what they seek as the end result for the dying patient. Physicians tend to use allavailable medical technology to preserve life for as long as possible. Nurses, on the other hand,are more inclined to allow the patient to complete his death rather than complete his life. Bothprofessionals are intensely involved in the process of the dying patient, but the physicians and thenurses come from different value systems in their approach to the dying patient. Under thesecircumstances, true interprofessional collaboration will be much harder to achieve.Dr. Fowler's illustration is only one of the many ethical dilemmas that physicians andnurses face in today's health care system. The many uncertainties in health care have brought ona multitude of moral and ethical dilemmas for the physicians and the nurses (Ornstein, 1990).The uncertainty and the constant changes in medical technology have made it necessary for thephysicians and the nurses to respond to new ethical dilemmas. The various professionalassociations have guided their members through the thorny ethical dilemmas by setting strictstandards of professional ethics. The focus, however, has been only on members of their ownrespective associations. Physicians and nurses increasingly need to approach collectively theethical dilemmas in health care. Before any collaboration can take place between the physicians40and the nurses, both professions must create a mutual understanding of their respective valuesystems and mutually solve ethical issues by maintaining an open dialogue on the related topics.Issue No. 7 - Interprofessional Role Expectations Most discussions on barriers to collaborative team work seem to include details on theissue of interprofessional role expectations. The issue certainly has caused much tension betweenphysicians and nurses. Butterill et al. (1992) confirm this notion and describe the problem aroundrole expectations as a definite contentious issue.It appears that a considerable amount of confusion exists among the physicians and thenurses on how each of them should contribute to the overall care. Fagin (1992) explains thereason for all the confusion. She points out that medicine and nursing overlap in many areas oftheir service to patients, which has contributed greatly to the confusion and the lack of effectivecollaboration between the two professions.In this confusion physicians and nurses have developed different perceptions andexpectations about each other's roles on the team, which are often misperceptions (Ducanis andGolin, 1979; Fried et al., 1988; Samuelson, 1992). Fried et al. (1988) further point out a relatedand very alarming detail. Physicians and nurses apparently are not sharing their perceptions.There is no ongoing discussion about what they think each other's role and functions should be.Without this sharing the confusion will go on and misperceptions can continue to develop, whichin turn, will stand in the way of any collaboration between the two professions. Ducanis andGolin (1979) also stress that health professionals must learn what they can expect of the othermembers on the team. Only through ongoing communication can physicians and nurses becomemore familiar with each other's roles.The constant change in the roles of physicians and nurses, needless to say, has not madethings any easier. Physicians have seen their role change from unchallenged master to41bureaucratic functionary (Ducanis and Golin, 1979). The physicians are constantly reminded thatthey no longer can assume the role of the charismatic dominating leader of the team, instead theyare to become a team player like any of the other members on the team.The role of the nurses is changing constantly as well. The role of the nurses, in fact, haschanged dramatically from past years (Nurse-Physician, 1989). There are still a few individualswho continue to stereotype nurses as temperature takers with small brains and big hearts (Keddyet al., 1986). Others even might still perceive the role of nurses to be that of the handmaidens tophysicians (Nurse-Physician, 1989). Fortunately, these misperceptions are on their way out. It isvery encouraging to see Dr. John Anderson, in his function as president of the British ColumbiaMedical Association, being quoted to say that nurses no longer are the handmaidens to physicians(Nurse-Physician, 1989). In a discussion paper by the Registered Nurses Association of BritishColumbia (1990) Dr. Halfdan Mahler, in his capacity as the director-general of the World HealthOrganization, is quoted to be saying that nurses will become more the resources of people ratherthan resources to physicians. Dr. Mahler also feels that nurses increasingly will take on greaterresponsibility for the decision-making in our health care system.Many role changes for the physicians and the nurses have been the result of a direct shiftof responsibility and actual work from the physicians to the nurses (Jenny, 1990). She maintains,however, that this steady shift of responsibilities often has been conducted in an unplannedmanner and without appreciation or proper compensation to the nurses. Jenny (1990) clearlyconveys the sense of frustration among nurses about this particular aspect of their role change inhealth care. The physicians are not too happy either. The real issue here seems to be whether theshift results in a purposeful delegation by the physicians or an assumpton of duties by nurseswithout physician delegation. They perceive these shifts of responsibilities and actual work as acase of boundary violations and a threat to their professional territory (Butterill et al., 1992).42The physicians definitely have voiced their concerns and confusions about what the role ofnursing actually is (Ornstein, 1990). Eventhough the physicians express their confusion, thereappears to be a strange reluctance to take it a step further, however, and engage the nurses into adiscussion about what is making everybody unhappy. Fagin (1992) describes this strangesituation as an informal conspiracy, which keeps the frustrations from being discussed out in theopen. She explains that physicians and administrators fear that such open discussions would onlyshake the boat even more. This fear, however, could not be farther removed from the truth. Inorder to calm matters between physicians and nurses, an open dialogue must take place. Onlythrough such communication can the two professions be brought together in a collaborative team.Fagin (1992) stresses that without open ongoing communication the relationships betweenphysicians and nurses will remain dishonest and even demeaning. No professional will ever getto see clearly what the role of the other professional is, if they do not talk with each other.Effective team collaboration is enhanced further when the parties involved accept thedifferent role changes, and clarify each others' new roles (Samuelson, 1992). The record to dateshows that this acceptance and clarification may not be an easy task. Samuelson (1992) warns,however, that the team members should not become discouraged in their attempts to developbetter collaboration, just because of futile attempts that have been made in the past. These pastfailures resulted from role conflicts and role ambiguities. Samuelson (1992), therefore, repeatedlystresses the importance of professional role clarity, which will permit the professionals to acceptothers and their input non-defensively.Ducanis and Golin (1979) also warn the physicians and the nurses not to become overlyrigid in their role expectations. They explain that a certain amount of role flexibility is necessaryfor effective team collaboration to occur. With such flexibility, opportunities will be created forthe physicians and the nurses to engage in role negotiations that can be important to the smoothfunctioning of their collaborative teams. Fried et al. (1988) argue a similar point. They stress43that physicians and nurses must recognize that individuals may serve in different roles on theteam depending on their level of time commitment.It is clear, for collaborative team building to be successful, each player on the team mustunderstand the different roles of everyone. Only with such full understanding can the professionalformulate appropriate role expectations and avoid falling in the trap of misperceiving what theother professional is doing.Issue No. 8 - Professional Status The issue of professional status has definite potential to become a thorny barrier in the wayof collaboration between the physicians and the nurses (Horder, 1992). The reason for this highpotential is simple. The difference in professional status between physicians and nurses is real.As already has been discussed, historically nurses always have assumed a position of lower statusto the physicians (Ducanis and Golin, 1979; Ornstein, 1990).There are a number of factors that contribute to this difference in professional statusbetween the physicians and the nurses. Fagin (1992) indicates that the difference partially isbased on class differences. She points out that most nurses come from the middle class or theworking class, whereas physicians tend to come from the upper middle and the upper classes. Inan earlier article Fagin and Diers (1983) describe nursing even as a metaphor for class struggle.The authors believe that nurses represent the classic underdogs in the world of health care, whoare struggling to be heard, approved, and recognized.Fagin (1992) indicates an additional factor that contributes to the difference in status of thetwo professions. She points out that the majority of the nurses are salaried employees, andtherefore, fit in a different professional status than the physicians. This factor, however,gradually will have less impact on the issue of professional status as the physicians' employment44arrangement is changing. Fagin (1992) points out that increasingly more physicians becomesalaried employees as well and, therefore, to some extent status differences with the nurses arelessened. In the eyes of some physicians this changing trend in their employment arrangement, isseen to have caused a deterioration in the physicians' professional status. Stein et al. (1990)indicate that the public esteem for physicians actually has deteriorated in recent years. Theauthors further explain that physicians are no longer seen as omnipotent, instead the publicrecognizes that physicians can be fallible.At the same time that the physicians are upset to see their professional status change, thenurses are upset that their professional status has remained the same. Ornstein (1990) explainsthat nurses have taken on additional tasks and responsibilities, but their professional status hasnot changed accordingly. The public esteem of the nurses has not increased. Nurses still areviewed by some members of the public as physician's hand-maidens (Ornstein, 1990).The traditional hierarchical authority of health care organizations also has contributed to thedifference in the two professions' status (Ornstein, 1990). The impact of this factor has been feltin particular by the nurses. Ornstein (1990) maintains that health care organizations have found iteconomically advantageous to keep nurses at the lower end of the hierarchy. Lower wages can bepaid to those who are at the lower end of the totem pole.A major factor that contributes to the status difference is the fact that the nursingprofession is predominantly practiced by women. Porter (1991) explains that historically nurseshave been subordinated to physicians along the lines of the sexual division of labour. With therise in the women movement, however, and the concurrent change in women's status, nurses areno longer interested in being placed in the health care hierarchy at a lower level than physicians(Stein et al., 1990).Given that the difference in status between the two professions is well established, Fried etal. (1988) wonder to what extend there can be equal participation in decision making. They45question whether the goal of achieving parity on the team is realistic. Nason (1983) alsoquestions whether effective negotiation is achievable for the physicians and the nurses, given thatit requires equal power among the participants. In essence, these authors question whether thecollaborative team concept has any chance at all to ever be successful. The nurses certainlybelieve that all certainly is achievable. The nurses think that they actually are taking their placesas full and equal members on the team with definitely something to contribute (Nurse-Physician,1989).Indeed, the issue of professional status does not have to be a barrier, provided that theprofessionals handle the issue wisely. The physicians and the nurses must be sensitive to thedifferences in status (Ducanis and Golin, 1979). It is very important for the physicians and thenurses to acknowledge the difference between their professional status as a reality. As Fagin(1992) points out it is foolish, for instance, to ignore the power of social status on professionalinteractions and its impact on the parity implied in a collaborative team concept. A professional,however, should refrain from pulling rank simply because of his or her status. At the same time,one must remember that the status of a professional is deserving of courteous respect. Ornstein(1990) explains that interprofessional collaboration involves both physicians and nurses respectingeach other. Under these circumstances the potential is there for professionals of different status towork well in good collaboration.Issue No. 9 - Professional Ethnocentrism Professional ethnocentrism is cited as a primary barrier to collaborative team work(Ducanis and Golin, 1979). In an environment where team collaboration is genuinely practiced, aprofessional can not perceive his or her own profession to be the most important one on theteam. Such a view is very detrimental to the collaborative team concept. Neither can a professiontruly feel committed to collaborate with another profession, when the latter one is perceived to be46more important. It is fundamental to the survival of the collaborative team that one acknowledgesthat all its members are equally important.The reality, however, is that such an acknowledgment does not always appear to exist.Medical students have given witness to the fact that physicians often appear condescending tonurses (Anvaripour et al., 1991). Such an attitude is extremely destructive to any collaborativeeffort. Samuelson (1992) agrees with this notion. He maintains that there is no place forarrogance or professional chauvinism on collaborative teams.Professional chauvinism, however, does appear on the scene, in particular, when oneprofession sees its prerogatives eroded by another profession. Under these circumstances theprofession will try to gain back its prerogatives by exerting control over the other profession'spractice (Ducanis and Golin, 1979). The authors further explain that professions will try tolegally define the boundaries of their own profession and also of the other profession. Such anattempt is seen as a preventative measure to assure that the profession will retain exclusive rightsto as many professional prerogatives as possible. Huntington and Shores (1983) provide anillustration of one such attempt made by physicians. In the state of Washington nurses have triedto include the term 'diagnosis' in the state nurse practice act. The physicians, however, haveasserted that the term, and all its implied judgments and action, belongs to them, and them only.These type of attempts to retain exclusive rights become difficult barriers to collaborativeteam work. In particular, when the focus is on the conflicting prerogatives of the differentprofessions, the professionals can build formidable barriers to effective collaboration (Hanlon andGladstein, 1984)Whenever conflicting prerogatives emerge, effective leadership is required to prevent theteam from falling apart. There always seems to be one person on the team, who will emerge asthe team leader. If this professional, however, has taken on the leadership role solely based onhis or her feeling of professional ethnocentrism, the team obviously is being lead by the wrong47person. To take on the leadership role only because one feels more important than the othermembers on the team often leads to a dictatorial leadership and a reluctance to share power,rather than a balanced leadership which will guide the team toward achieving its common goal(Baldwin, 1993).Good leadership will encourage physicians and nurses to refrain from seeing onlythemselves as the most vital member on the team with all the know-how. Instead, bothprofessionals will be encouraged to respect each discipline's scope of knowledge and uniquenessof functions. They must acknowledge that the uniqueness of both professions make each of thema vital member of the team.Issue No. 10 - Interprofessional Trust Interprofessional trust is essential for collaboration to be successful (Ornstein, 1990). It isthe key to a positive relationship between physicians and nurses (Nurse-Physician, 1989; Fagin,1992). Afterall, one can hardly expect a professional to collaborate with an other professional,whose professional judgment is perceived to be rather shaky and can not be trusted. Cautionmust be taken, however, not to come too quickly to the conclusion that the other professional cannot be trusted. There is a high chance this conclusion is a misperception of the true facts. Thereshould be concrete evidence, before a professional concludes that an other professional is nottrust worthy. It takes time to collect enough evidence on which professionals can build theirmutual trust. Fagin (1992) agrees and reports that it has been shown that the longer twoprofessionals work together, the better the opportunity is to build trust.Ornstein (1990) also reports that physicians and nurses develop more trust as they workcollaboratively. These observations of Ornstein (1990) and Fagin (1992) bring out an interestingdetail about interprofessional trust. Their observations beg the question, what develops first, trustor collaboration. It is beyond the current scope of this study to delve deeper into this question,48but suffice it to say that obviously interprofessional collaboration and interprofessional trust gohand in hand.As a final comment, it bears repeating that trust is also linked to competency, as discussedearlier under issue number 3 - professional capabilities.Issue No. 11 - Interprofessional Advice A fundamental element of collaboration between professionals is the ability to depend oneach other for advice. The issue of interprofessional advice, however, does seem to have thepotential to cause tension among the members of the team.Samuelson (1990) indicates one form of tension brought on by the issue of interprofessionaladvice. He argues that the act of asking an other professional for advice may be perceived asevidence of one's professional weakness. No professional wants to appear weak. To thoseprofessionals who think that asking for advice reflects a weakness, it must be pointed out that therapid expansion of knowledge in health care necessitates the division of tasks and functions alongdifferent lines of expertise (Ducanis and Golin, 1979). No longer can one professional beexpected to know everything, and consequently, the professional will have to depend on othersfor advice and this dependency should not be perceived as a form of weakness. Such a perceptionclearly is a misperception.It seems that nurses have talked much about the dependency aspect of interprofessionaladvice (Nurse-Physician, 1989). This is, because nurses constantly ask physicians for advice. Thenurses stress, however, that this dependency on physicians for advice does not mean that nursesare subservient to the doctors.As much as the nurses depend on the physicians, the doctors depend on the nurses foradvice as well. This advice, however, is cloaked often in suggestions to the physicians, which thedoctors either may accept or may not accept (Jenny, 1990). If they do accept the suggestions, the49physicians often also take credit for them, which creates a lot of tension among the nurses. Thenurses feel that credit should go where credit is due. Jenny (1990) further explains that as soonas the nurses' suggestions appear to challenge medical authority, they face automatic rejection.This reaction from the physicians adds to the tension among the team members, and certainlydistracts from the collaborative aspect of the team.Porter (1992) points out that ideally team interactions around interprofessional advicebetween physicians and nurses are to be perceived as complimentary rather than contradictory. Itshould be made clear that someone's advice is just that - advice. It is not a command. Porter(1992) maintains that nurses appear to have captured well the complimentary nature of theinterprofessional advice exchange. He explains that nurses increasingly feel no longer constrainedfrom frequently making overt suggestions to the physicians about patient care issues. In fact, thenurses increasingly feel comfortable to argue in support of their given advice.If interprofessional advice can not be exchanged, not only is there really no collaborationbetween the professionals, but patient care may suffer from lack of input from both professions.The dynamics behind the issue of interprofessional advice should be well understood. A goodunderstanding will help a professional to overcome the perceived problems with interprofessionaladvice. As the problems are resolved, the professional will be able to enjoy a much better senseof interprofessional collaboration.Issue No. 12 - Interprofessional Utilization of Capabilities The issue of professional capabilities already has been discussed in an earlier section of thisreview under the heading of issue number 3 - professional capabilities. What is stressed in thisearlier section is the difficulties that may arise when professionals misperceive each other'scapabilities. Many frustrations are caused by this lack of understanding. The frustrations,50however, become even more pronounced, when a profession's capabilities are known, but are notproperly used.Cartwright (1991) has conducted a survey among the members of a team that care for theterminally ill patient. The author finds that the most frequent criticism made by the nurses ofphysicians is that they do not ask for nursing help early enough in the care of the terminally illpatient. This under-utilization of nurses happens despite the fact that the physicians in the surveyare convinced that the nurses' contribution is very helpful to the program of terminal careservices. The sooner nursing gets involved with the care of the terminally ill patient, the morenursing can contribute to the decision making around any diagnostic and preventative measure. Itappears that in this instance, the utilization of nursing expertise mostly is limited to providing thetask oriented direct care to the terminally ill patient. The capabilities of these nurses clearly arebeing under- utilized.The issue of under-utilization, however, is changing. Ornstein (1990) points out thatphysicians increasingly are accepting of delegating to nurses tasks which have been at one timesolely the physicians' responsibility. This development contributes well to the collaborative teamconcept. Caution must be taken, however, to use the full gamut of nurses' capabilities and tohave nurses involved when decisions are being made about what functions are delegated to thenurses or incorporated into nursing practice. Again, strictly limiting the nurses to tasks of directcare leaves a whole arsenal of diagnostic and preventative capabilities under-utilized.As much as under-utilization is a concern, the "spread-to- thin" phenomena using aprofessional's capabilities appears to be a problem as well. Jenny (1990) warns that nurses arebeing asked to stretch their capabilities too far. She argues that increasingly the nurses are askedto do more with less resources. Such conditions are very detrimental to the nurses' self-esteemand create moral outrage (Pike, 1991). The author describes moral outrage as an emotionalresponse seen in nurses, who are not able to carry out moral choices in patient care due to51constraints. Based on her observations of physicians and nurses on a patient care unit dedicatedto the study and development of interprofessional collaboration, the author reports a decline inincidents of moral outrage among the nurses on the unit as a favorable outcome of theircollaboration with physicians. There has to be a balance between what one can do and what oneis asked to do. Professionals do feel better if they fully can use their capabilities and are properlyprovided with the necessary resources. Samuelson (1992) explains that professionals' self-esteemis enhanced further, when their contributions and capabilities are genuinely recognized by theircolleagues. Pike (1991) attributes the decline in moral outrage to mutual trust and respectbetween nurses and physicians, and an appreciation that the two professions are dependent on theutilization of each other's professional capabilities.It is important for physicians and nurses to properly utilize each other's capabilities. Thisreview shows that the issue of interprofessional utilization of capabilities must be handled withcare. Misperceptions appear to develop easily among the physicians and the nurses on how mucheach of them is capable of contributing to the overall care. Administrators play a key role inproper utilization and appropriate resource allocation as well as ensuring physicians and nursesrecognition and appreciation of one another's capabilities.Issue No. 13 - Interprofessional Cooperation Samuelson (1992) stresses that meaningful collaboration depends heavily upon interpersonaldynamics. These dynamics must reflect interprofessional cooperation. If there is nointerprofessional cooperation, then collaboration between physicians and nurses definitely isunachievable. Samuelson (1992) further points out that it takes practice to work cooperatively ingroups. It requires skill to cooperate with another profession, especially if one is new at the issueof interprofessional cooperation.52However, even if one has learned to cooperate, it still does not guarantee interprofessionalcollaboration. Hughes and Mackenzie (1990) state that physicians and nurses must have anon-going commitment to cooperate with each other. The two professions genuinely must want tocollaborate. Ornstein (1990) maintains that even if physicians and nurses are coerced tocooperate, or forced to do so by law, there still may be no collaboration. Her point is that thetwo professions can never be coerced to collaborate. As seen from the discussion at thebeginning of this chapter on what constitutes collaborative team work, coercing physicians andnurses to collaborate is extremely ineffective. Feelings of mutual trust and respect, as well ascollegiality, are at the core of collaboration. One can not force these feelings upon theprofessionals. There has to be a real desire to collaborate, and in order to achieve this goal, theprofessionals must effectively cooperate with each other, rather than just going through themotions. Professionals who are perceived to be going only through the motions will not likely beapproached for any collaborative effort. The higher the degree of genuine interprofessionalcooperation the more chance there is to see physicians and nurses work well collaboratively.Interprofessional cooperation is a desirable goal in health care, because of its by-products.Efficiency and appropriate resource allocation are the by-products of cooperation (RegisteredNurses Association of British Columbia, 1992). The Registered Nurses Association of BritishColumbia endorses the idea of interprofessional cooperation, and points out that when physiciansand nurses work in cooperation, the resulting plan of care can be implemented by the mostappropriate member of the team. The appropriateness is determined by the skills required for thecare to be given, as well as the degree of efficiency with which the care can be given. Throughgood cooperation physicians and nurses collectively can decide which professional is mostappropriate to provide the service.53In summary, it is clear that a real commitment to the issue of interprofessional cooperationwill enhance the chances of successful collaboration between physicians and nurses, and in turn,will lead to all the different benefits that interprofessional collaboration brings.Issue No. 14 - Professional Training As much as professional training has the potential to add to a professions' ability to providehigh quality of care, it also has great potential to be a barrier between different professions(Horder, 1992). Ducanis and Golin (1979) point out that professional education involves adoptinga certain professional lingo, developing certain assumptions, and learning to work within aunique conceptual framework. While all this training enhances intraprofessional communication,it tends to create barriers between professions.The issue of professional training has been the cause of many interprofessionalmisperceptions. The professional training issue closely relates to the issue of professionalcompetency. The related misperceptions around competency already has been discussed earlier inthis chapter. Nurses are reported to believe that physicians feel threatened by the increasededucation levels in the nursing profession (Nurse-Physician, 1989). For the most part this tendsto be a misperception. While some physicians may feel threatened indeed by the increase inuniversity prepared nurses, most are reported to say that it is not an issue of feeling threatened atall, they perceive it to be more a matter of concern that university prepared nurses may becomeless interested in providing bedside care. These concerned physicians beg the question - who willcontinue to provide quality bedside care? The physicians' concern, in turn, is based also on amisperception. Many degree nurses prefer to stay right at the bedside. In time, given thatuniversity preparation is the entry level for nursing, all nurses at the bedside will be universityprepared.54Physicians also are concerned that nurses make judgments about medical practice for whichthey do not have the background training (Nurse-Physician, 1989). As discussed earlier in thischapter this concern more often than not is also based on a misperception. Some nurses are verywell trained to make judgments about medical practice (Jenny, 1990). The author supports herargument by pointing to nurses who have chosen to remain in the same clinical area for anumber of years. These nurses are often the only ones with the finite knowledge of typicalpatient responses seen in that clinical area, and are often very well trained to handle the veryspecialized technology available to treat these patients. Some of these nurses, in fact, haveprepared themselves as clinical specialists with masters and doctorate degrees. Ornstein (1990)hopes that these academic credentials will add credibility to nursing in the eyes of medicine.Baldwin et al. (1992) say that nurses will see their relationships with physicians improve as thenurses increase their education.One way to deal with the misperceptions around professional training is to promoteinterprofessional training (Glendon and Ulrich, 1992; Horder, 1992). Glendon and Ulrich (1992)argue that medical and nursing students need to be taught together on how to interact skillfullywith each other. Opportunities for these interactions will also allow physicians and nurses toappreciate the similarities and uniquenesses of each profession. Currently, the University ofBritish Columbia offers an interdisciplinary ethics course that provides such learning, but suchcourses are rare (A. M. Hughes, personal communication, August 20, 1993). Throughinterprofessional training, interprofessional collaboration will have a better chance to succeed.Issue No. 15 - Interprofessional Relationships The issue of interprofessional relationships is an important determinant of collaborativeteam effectiveness (Ducanis and Golin, 1979). Most physicians and nurses perceive theirrelationships with each other as positive, however, when asked to substantiate their view point55the professionals are hard pressed for examples of existing collaborative behaviors (Fagin, 1992).In fact, a review of the literature provides details of some serious difficulties with therelationships between physicians and nurses that have caused a major barrier to the developmentof collaborative team work.A quick look at the difference in basic terminology used by either profession to describetheir relationship shows already that the physicians and the nurses are far apart on the issue(Huntington and Shores, 1983). While nurses talk of collegial relationships with physicians, thephysicians continue to talk of supervisory relationships with nurses. With such a difference inperception on what form the relationship should take, it is no surprise to see that the relationshipsbetween the two professions are sometimes adversarial and often guarded (Nurse-Physician,1989).Fagin (1992) continues to describe the relationships between the two professions to be ahierarchical one, where the nurse is subordinate to the physician. She even maintains that somerelationships between physicians and nurses are actually dishonest and demeaning. Notsurprisingly, the author is concerned about the current status of the interprofessionalrelationships. She strongly advocates that the physicians and the nurses relate moreinterdependently with each other, where both professionals have complimentary roles.It is interesting, however, to see that some nurses are not keen to see the status quochanged at all. Ornstein (1990) points out that many nurses feel threatened by the idea of anincreased interdependence with physicians. She explains that these nurses equate such a change inthe relationship with an unwanted increase in their responsibility and accountability. It seems thatthese nurses are not ready, or lack the knowledge to adjust to a relationship with physicians thatis characterized by interdependence.Ornstein (1990) reports that physicians are not too keen either to move toward an increasedform of interdependence in their relationships with nurses. In fact, the author explains that the56physicians also feel threatened. To remedy these uneasy feelings among the physicians, Ornstein(1990) suggests that the nurses should develop skills in leadership, as well as skills in bargainingand negotiating. She argues that with these skills nurses can approach the physicians withoutbeing perceived as threatening the doctors with their suggestions to change their workrelationships. This argument, of course, seems to be equally valid for the physicians. If bothprofessions have improved their negotiating skills then perhaps the physicians and the nurses canmove toward a more collaborative relationship.The nurses have a real interest to see their relationship with the physicians change, becausewithout a more collaborative relationship the nurses see one important part of their job almostmade impossible. Mechanic and Aiken (1982) explain that without collaboration the nurses areoften left in the dark about the physicians intent of care. The nurses will not have full knowledgeabout what the physicians intend to do with their patients. Nurses, therefore, will not be in aposition to provide insightful emotional support to the patients, who are trying to cope with themany uncertainties brought on by their illnesses. In addition, without nursing input, physiciansmay be unaware of the patients' or the families' inability to cope with these uncertainties.There is hope, however, that the interprofessional relationships will improve. A documentprepared by the Registered Nurses Association of British Columbia and endorsed by the BritishColumbia Medical Association stresses that "medical and nursing team work is enhanced by arelationship that respects the uniqueness and interdependency of the respective services of eachdiscipline" (Registered Nurses Association of British Columbia, 1992, p. 7). These areencouraging words, which hopefully will be followed by confirming actions on the part of thephysicians and the nurses.The fifteen issues that have been reviewed in this chapter have all been included in asurvey conducted among physicians and nurses in long term care facilities in the city of57Vancouver, British Columbia. With the survey an attempt has been made to assess whatperceptions the two professions have developed on each of these fifteen important issues incollaborative practice. The results of this survey can be found in chapter three and are furtherdiscussed in chapter four of this study.Demographics that have been collected on the subjects in this study have been chosenspecifically because of their potential to influence physicians and nurses in their development ofdifferent perceptions and attitudes about collaborative practice. The following section provides aliterature review describing the potential influences.Demographic Correlates of Interprofessional Misperception and Team WorkThe subjects have been asked to share personal information on a number of pertinent data.The demographics include age, gender, education, ethnic background, and work experience.They are discussed separately in the following sections.AgeIt seems that the age of a professional might have an impact on that persons outlook oncollaborative practice. Ducanis and Golin (1979) argue that professionals develop attitudes towardcertain role behaviors already early on in life. Through real-life experiences with physicians andnurses people develop a set of role expectations that they perceive to be true of physicians andnurses. Ducanis and Golin (1979) explain that these attitudes and perceptions are shaped furtherthroughout life through the process of socialization. The older person, of course, is exposed to alonger period of socialization than the younger person. The older professional, therefore, hasmore real-life experiences from which to develop an attitude toward collaborative team work.58The exact effect of a longer socialization process on a professional's attitude towardcollaboration is extremely difficult to assess. There are so many additional factors that contributeto the formation of one's feelings about interprofessional collaboration that it is impossible tosingle out the effect of just one factor. However, the type of socialization process withinprofessional education can often be identifed by age. Nonetheless, it was thought to be interestingto see whether more positive or more negative attitudes toward interprofessional collaborationwould be found in one particular age group among the subjects in the survey.GenderKeddy et al. (1986) point out that the attempts on developing collaborative relationshipsbetween physicians and nurses have been characterized by an enduring pattern of physiciandominance and nurse deference, paralleling the male-female societal relationships. Baldwin(1993) points out that these intergender relationships have been woven into the fabric of ourhistory for aeons. She argues that dominance is a style of interaction based on ranking of onegender, and she explains that within the dominator model women are sent the message that theyare somehow not equal in any meaningful way to men. With this perception ingrained in people'sminds, together with the fact that nursing predominantly is practiced by women, it appears to bean almost insurmountable challenge to develop a truly collaborative practice between physiciansand nurses.Baldwin (1993) believes that this dominator bias is trapping both men and women in anarrow configuration of humanity. Men perceive they constantly must try to develop their senseof professional success by being dominant. Based on this perception the men will not likely signup for any form of interprofessional relationship that takes away their sense of dominance.Women, on the other hand, perceive they constantly must way their professional goals with theirresponsibilities as housewifes and mothers. This perception is changing, however, as more men59get involved with the maintenance role of house and family. The male-female societalrelationship is changing, which may hold promise for the collaborative team concept.Fagin (1992) also believes that the issue of gender difference between physicians andnurses and its impact on the collaborative team concept is starting to become an issue of the past.Ornstein (1990) agrees and states that the women's movement is forcing the nurses to reexaminetheir relationships with the physicians. No longer are nurses prepared to play the role ofphysicians' handmaidens (Keddy et al., 1986).The gender demographic has been included in the survey to see if any impact is evidencedon the perceptions among physicians and nurses about their collaborative relationships.Education Data on the subjects' educational background has been included, because professionals withhigher education are said to be often better prepared for collaborative team work than those withless education (Ornstein, 1990). The author explains that the higher educated professionals areperceived to be more capable as team members than the lower educated professionals, becausethey have a better understanding for committee work, they have better problem-solving skills,and they also are better at making decisions.It was thought to be interesting to see whether or not more positive attitudes towardcollaborative team work would be seen among those subjects in the survey with highereducational levels than those with less education.Ethnic Background Multiculteralism is at the heart of Canadian society and that fact holds true for the healthcare system as well. Physicians and nurses come from a variety of ethnic backgrounds. They60bring with them different values and norms, as well as different levels of command overCanada's two official languages.Horder (1992) has pointed out that the use of different languages can form a definitebarrier to the development of collaborative teams. The author specifically makes reference to thedifferences in professional lingo, but the point is equally well taken when it comes to thedifferences in command over the English or the French language. If one professional can notunderstand an other professional because their mother-tongues are different, it will be very hardfor the two to work collaboratively. Fundamental to any form of collaboration is goodcommunication, which is hard to achieve if the members on the team do not speak the sameconversational language.Ethnic background, therefore, was thought to be a very crucial piece of demographic datathat needed to be included in the survey. Of course, it is not assumed that a difference in ethnicbackground automatically indicates a difference in command over the English language. Todetermine such a difference other tests should be conducted. The intent for this study is toindicate only the possibility that language and culture differences might be at the root of theproblems faced by collaborative teams.Work Experience The length of work experience appears to have an impact on professionals' perceptionsabout collaborative team work.Vance (1992) comments that professionals in their first year of practice need to learn theorganizational savvy. As new corners to the team, they have to learn the norms and the patternsof their work team. In fact, they may have to adjust their own perceptions on how teamcollaboration ought to work to how things are actually working, which might have quite abearing on their continued attitude towards the collaborative team concept.61Fagin (1992) also makes a point about a professional's length of work experience and theperson's inclination to trust the other team members. She points out that the longer professionalswork together the better the opportunity is for them to build a mutual trust, which will enhancethe collaboration on the team.With these points kept in mind, it was thought to be of interest to include data on thesubjects' years of work experience and see whether or not more positive perceptions about teamcollaboration are found among those professionals in the survey with considerable amounts ofmore work experience.This study specifically has been focussed on long-term care facilities. The recentdevelopments in this sector of the health care system together with the unique circumstancesunder which physicians and nurses in long-term care facilities have to work have prompted acloser look at collaborative team work in long-term care facilities.Interprofessional Collaboration in Long-Term Care Facilities There are a number of unique circumstances and elements in the organizational setting oflong-term care facilities that have a major impact on the development of collaboration betweenphysicians and nurses.One very significant element is the frequency of face-to- face contact between the twoprofessions. On average, physicians spend less than two hours per month in long-term carefacilities (Mechanic and Aiken, 1982; Fagin, 1992). Consequently, physicians are most often notthere in person to collaborate with the 'nurses on patient care issues. Fagin (1992) points out thatthe care in long-term care facilities is predominantly provided by nurses. It appears that thenurses have no choice. Ornstein (1990) points out that the physicians simply are not easilyaccessible to the nurses for consultation. It appears to be difficult for the nurses in long-term care62facilities to have timely access to physicians. The physicians' time is scheduled with their patientsin hospitals and in their offices, which often are located far away from the long-term carefacilities. Ducanis and Golin (1979) point out that physical location is an important aspect of howprofessionals will function as a team. They argue that it is more likely that collaboration will takeplace if the team members are housed in the same building. If both professions are present to seethe problems first hand, chances are increased that physicians and nurses will collaborate in theirefforts to solve the problems in a timely mannerIncreasingly the inaccessibility to physicians is becoming a dilemma for the nurses, whofind themselves having to care for a geriatric patient population that is getting older and sickerand requiring considerably more complicated care then ever before (Ornstein, 1990; Samuelson,1992). Ornstein (1990) explains the dilemma of the nurses. She points out that the nurses are leftwith the responsibility of providing complicated care without the presence of a physician, and yetthe nurses have no authority to act in the absence of a physician. Samuelson (1992) is concernedabout this dilemma faced by the nurses and points out that the challenges of long term care havebecome increasingly more complex in nature for one profession to resolve. He argues, therefore,that team collaboration has to be more strongly promoted in long term care facilities thancurrently is the case. He points out, in fact, that very little is known about the levels ofinterprofessional collaboration in long term care facilities. One thing Samuelson (1992) doesknow is that, especially in long term care, attempts to build collaborative skills among thephysicians and the nurses is a rarity.However, opportunities do exist for the professionals in long term care to develop a goodcollaborative relationship. The collaborative team concept does not necessarily exclude groupsthat rarely or never meet face-to-face (Ducanis and Golin, 1979). As long as the professionalscommunicate there is a chance to collaborate. For the moment, the physicians and the nurses inlong-term care facilities primarily have to use the telephone for their communication needs. This63method of communicating is fraught with problems, but the fact remains, the professionals are ina position to communicate.To further increase their chances of developing collaborative teams, the physicians and thenurses in long term care facilities have to learn to work within the unique circumstances of theirwork environment. Physicians have to rely more on nurses and nurses have to become moreautonomous in daily decision making (Nurse-Physician, 1989).It would be in the best of interest to the elderly patients to see both professions adapt totheir new work relation as soon as possible. Mechanic and Aiken (1982) point out that nursesneed to increase their efforts in becoming clinically skilled enough to make the autonomousdecisions. The authors point out that with skilled nursing care in long term care facilities, theelderly patients will require less admissions to costly emergency-rooms and in-patient services ofacute care hospitals. As for the physicians, Fagin (1992) points out that they should start viewingtheir role as collaborative and consultative with nurses, rather than seeing their role as that ofdirect care-givers. It is encouraging to see that in those instances where physicians and nurseshave adapted to their new roles in long-term care facilities, improvements have been noted in thecare of the elderly patients (Fagin, 1992).SummaryThis chapter has reviewed the literature regarding the need for, benefits of and barriers tocollaborative team work. It also has reviewed 15 issues used as a basis by Ducanis and Golin(1979) for their instrument, which is the main data collection instrument for this study. As can beseen from this discussion, much appears to be gained from appropriate collaborative team workin long-term care facilities. As Samuelson (1992) has pointed out, however, not much is knownabout how well the physicians and the nurses in long-term care facilities are under way with theircollaborative efforts. This study has tried to shed some light on the issue.64The remainder of this report is devoted to a description of the design and methods used toconduct a survey among the physicians and the nurses in 13 long-term care facilities inVancouver, British Columbia, and to present and discuss the findings. The professionals weresurveyed for their misperceptions on the make-and-break issues of interprofessional collaboration.Even though the various degrees of misperceptions form only a very small part of the totaldynamics that surrounds the collaborative team concept, the findings of the survey still may serveas an indicator of how well the concept is perceived by physicians and nurses in long term carefacilities.65CHAPTER 3The Research MethodologyIntroductionThis chapter discusses the research methodology chosen for this study of interprofessionalmisperceptions among physicians and nurses in long-term care facilities. Where applicable,rationale is given for the particular choices.For clarity the chapter has been divided into six different sections. The first sectionprovides details concerning the development of the research proposal. The design specificallychosen for the study is outlined in the second section, and the instrument used for the survey isdescribed in the third section of the chapter. The next section provides details on each of theprocedures followed in conducting the survey. This section includes a description of theprocedures used for selecting the long-term care facilities, and the respective samples of thephysicians and the nurses, as well as a description of the methods used for distributing thequestionnaire. Ethical considerations are incorporated.In the fifth section of this chapter the methods used for the data analysis are presented. Asummary is provided in the final section of this chapter.The Development of the Research Proposal In order to assess the feasibility of exploring interprofessional misperceptions amongphysicians and nurses in long-term care facilities, and to assess the potential for any practicalapplication in the long term care setting, the nature and the purpose of the research wasdiscussed with various individuals, including physicians and nurses in long term care. The topic66of the research was met with great enthusiasm by the different individuals and definitely seen asa very timely issue. This response was very encouraging and led to the development of aresearch proposal.The research proposal was submitted to the members of the Thesis Screening Panel of theDepartment of Health Care and Epidemiology at the University of British Columbia. Themembers' permission and support for the research was obtained, as well as the approval of theuniversity's Behavioral Sciences Screening Committee for Research and Other Studies InvolvingHuman Subjects.The Study Design A descriptive study design was selected for this research. The purpose of the study was toinvestigate the degrees of misperception that physicians and nurses in long-term care facilitiesmay have about each other. The intent was not to engage in any hypotheses testing.The conceptual framework for this research was based on the interpersonal perceptionmethod described by Ducanis and Golin (1979).The Instrument Used for the Survey An adapted form of a previously validated instrument was used for the data collection inthis study (see Appendix A for the instrument used for the physicians and see Appendix B for theinstrument used for the nurses). Ducanis and Golin (1979) developed this instrument in the late1970s, and called it the Interprofessional Perception Scale.The scale was specifically designed to examine how professionals viewed themselves,viewed members of other professions, and perceived how the members of these other professionsviewed them (Ducanis and Golin, 1979). The scale, therefore, yielded a great deal of data67concerning the way in which one group of professionals viewed relationships with another groupof professionals.The Interprofessional Perception Scale was used for the present research because of itsdiagnostic and descriptive capabilities related to existing degrees of perceptions among physiciansand nurses in long-term care facilities. By comparing these perceptions conclusions could bemade with respect to any degrees of misperception among the two professions.Ducanis and Golin (1979) included a total of 15 issues on the scale. The 15 items wereconcerned with interprofessional issues:- the belief in each other's professional competency- the acknowledgment of each other's professional autonomy- the understanding of the other professional's capabilitiesthe recognition of the other professional's concern with patient welfarethe sense of professional territorialitythe differences in each other's professional ethicsthe role expectations of each otherthe difference in professional statusthe sense of professional ethnocentrismthe mutual trust in each other's professional judgementthe soliciting of each other's professional advicethe full utilization of each other's capabilitiesthe degree of interprofessional cooperationthe recognition of each other's professional trainingthe perceived quality of the interprofessional relation.68All these 15 issues, selected for the scale, have been described in the literature as havinggreat impact on interprofessional relationships. The literature base and the exact potential forthese issues to contribute to interprofessional collaboration have been discussed in detail inchapter two of this study.Ducanis and Golin (1979) designed the scale to elicit a response from their subjects at threedifferent levels. First the subjects were asked to give an opinion of the other profession (level I)with respect to these 15 issues. Then the subjects were asked to tell how the other professionalswould respond to the same issues (level II). Finally the subjects were asked to assess how theother professionals would say that the subjects had answered the questions on each of the issues(level III). With this method a direct view was obtained on how one profession perceived another(level I), whether one profession thought the other would agree or disagree with that directperception (level II), and whether the other profession would understand or misunderstand thatperception (level III).For the purpose of this study, it was sufficient to collect data only on level I and IIresponses. The Interprofessional Perception Scale, therefore, was adapted to include only thosetwo levels. The scale was further adapted by using more specific labeling to clearly denote eitherthe physicians or the staff nurses in long-term care facilities, rather than using the more genericlabels of 'your own profession' and 'the other profession'.Ducanis and Golin (1979) maintained that content validity of the instrument was establishedby the direct nature of the questions on the scale. They also reported that the instrument'sreliability was established through a test- retest procedure over a specific period of time. Thereliabilities were measured by percent of exact agreement. An 80 percent mean across severalprofessions, who were included in the test-retest procedure, was obtained for level I responses.The percent of exact agreement ranged from 74 percent to 86 percent for level I responses. The69level II responses showed a mean of 79 percent exact agreement, with a range of 74 percent to81 percent.An additional adaptation was made to the instrument by adding specific details to therespondent data in order to obtain a more complete and pertinent profile of the subjects in thestudy. The original instrument included information on the subjects' age, gender, years ofexperience, and education. The specific details added to the instrument included information onthe subjects' ethnic background, and the detail on years of experience was expanded byspecifically asking for the number of years the subjects had cared for patients in long-term carefacilities. The nurses' professional designation as well as the nurses' ratings of their jobsatisfaction were added to the nurses' version. The detail concerning the area of practice wasadded to the physicians' version. These specific demographic data were included in the packagebased on findings in the literature, which stressed the potential of these demographics tosignificantly influence physicians and nurses in their development of perceptions of each other.The pertinent literature on these demographic data is discussed in Chapter Two.The Research Procedures The Procedure for Selecting the Long-Term Care Facilities No evidence was found in the literature of any exploratory or descriptive study previouslydone on misperceptions among physicians and nurses in long-term care facilities. There was,therefore, no specific guidance available on how many long-term care facilities, or how manysubjects of each of the two disciplines, ideally should be included in the sampling in order forthis exploratory study to be truly reflective of physicians and nurses in long-term care facilities.However, a study done by Katzman (1989) on physicians' and nurses' perception of nursingauthority reflected much of the intent of this study in that both focus on perceptions of physiciansand nurses. Katzman's study, therefore, provided some guidance in determining how many70physicians and nurses were ideally to be included in the sampling. Katzman used responses of 53physicians and 110 nurses.From a preliminary study it was estimated, that by including 13 long-term care facilitiesaccess could be obtained to approximately 75 physicians and 120 staff nurses. Even with theexpected difficulties associated with possible low response rates to a voluntary questionnaire,these target numbers for each of the two disciplines were seen as appropriate for the purpose ofthis study. Accordingly 13 long-term care facilities were randomly selected from a universe of 22facilities in the city of Vancouver, British Columbia.Meetings were arranged with officials of each of the 13 facilities. These meetings wereheld to inform the officials of the purpose of the study, as well as the scope of involvementrequired on the part of the facility, its nursing staff, and its physicians. Most of the officials werefunctioning either as the Director of Care or the Administrator of the facility. Once the officialshad expressed their interest to see their facility included in the study, they were asked to sign anAgency Consent form. A copy of this consent form is found in Appendix C. The AgencyConsents were sent along with the request for ethical review to the University of BritishColumbia Behavioral Sciences Screening Committee for Research and Other Studies InvolvingHuman Subjects.The Procedure and Ethical Considerations for Selecting the Sample of Physicians and theSample of NursesNone of the 13 long-term care facilities had a standing committee for ethical reviews orresearch. All the ethical considerations for the seclection of the subjects, therefore, werediscussed with the Administrator, or the Director of Care, or in some instances with bothofficials. The confidential nature of the survey was stressed with the officials, and it wasexplained that the voluntary return of a completed questionnaire would imply the subject'sconsent to participate.71After carefully reviewing all the ethical considerations, the officials allowed for the studyto proceed and they assisted with the selection of the samples by providing lists of eligiblemedical and nursing subjects. Only physicians who had patients at one or more of the 13long-term care facilities were considered as eligible to participate in the study. The nurses wereonly eligible to participate if they worked as regular full-time or part-time staff nurses in thesesame facilities.The lists for the physicians had to include their name as well as the address of their office.The address was needed to assure that physicians, who were associated with more than one of thethirteen facilities, only were approached once for their participation in the study. The list ofeligible staff nurses included their name and professional designation of either registered nurse,registered psychiatric nurse, or licensed graduate nurse. The exact number of nurses in each ofthese professional designations was needed in order to compare the actual response rates for eachof these categories of nurses.A package was distributed to all the eligible physicians and nurses. The physicians receivedtheir packages in the mail at their respective offices. The packages for the nurses were eitherdistributed together with the nurses' pay cheque, hand-delivered to the nurses by the agency'sofficial, or placed in the nurses' respective mailbox.The package included a copy of the questionnaire, called the Interprofessional PerceptionScale, together with detailed instructions on how to fill in this questionnaireThe package also included an introductory letter, which stressed that the return of thecompleted questionnaire would imply the subjects' consent. The letter further explained themerits of the study, the confidential and voluntary nature of the questionnaire, information aboutthe author of the study, as well as instructions on how to return the completed questionnaire. Thephysicians were asked to return the questionnaire to the author in an addressed and stampedenvelope, which was also enclosed in the physicians' package. The nurses were asked to return72the questionnaire to an envelope, which was located in the staff room of each of their respectivefacilities. Because of the difference in instructions on how to return the questionnaire, theintroductory letters differed slightly for each of the two professions (see Appendix D for theintroductory letter to the physicians and Appendix E for the introductory letter to the nurses).Throughout the duration of the data collection, colorful posters were put on display in eachof the consenting facilities. The posters conveyed information similar to the content of theintroductory letters and were encouraging the subjects to participate in the survey (see AppendixF).In order to maximize the response rates, each of the questionnaires were coded allowingfor a second distribution two weeks later to subjects who did not respond the first time. Thecontent of the package for the second distribution was exactly the same as the package send outthe first time, with the exception of the introductory letters. The introductory letters enclosedwith the package for the second distribution served as a thank-you for those subjects, who hadresponded, and a reminder for those who had not yet completed the questionnaire (see AppendixG for the letter to the physicians and Appendix H for the letter to the nurses). Enclosed with thesecond package was also a replacement questionnaire in the event the first copy inadvertently hadbeen misplaced. The subjects, who received the second package, were prompted to disregard thereminder and the second copy of the questionnaire, if they already had returned the first copy.Of the 138 questionnaires distributed to the physicians, 28 questionnaires (20%) werereturned as completed. A total of 66 completed questionnaires (60%) were returned of the 110distributed to the nurses.The Methods of Data Analysis The data obtained were to be analyzed for any existing degrees of interprofessionalmisperception among the physicians and the nurses in long-term care facilities. For the purpose73of the study, interprofessional misperception had been defined as the difference between oneprofessional's perception on how the other professional would view an issue, and the view pointactually expressed by the other professional on the same issue. What was being measured,therefore, was the degree of agreement between the two professions on a particular view point.The literature shows that the easiest and most frequently used index of agreement is theoverall proportion of agreement (Fleiss, 1981; Sackett et al., 1985). It was decided that the sameindex of agreement would be used for the present research. Accordingly proportions werecomputed for the different degrees of perceptions found to be present among the physicians andthe nurses on each of the 15 issues on the Interprofessional Perception Scale.From these computations on proportions, it was determined what perception per issue wasfound in the majority of the physicians and the nurses, respectively. After these particularperceptions were identified, a comparison was made with the proportion of members of the otherprofession, who actually had expressed similar viewpoints on the same issues. Through thesecomparisons different degrees of misperception came to light.In order to determine the severity of the misperceptions each of the professions actuallyhad about the other one, different ranges of values were used for the computed differencesbetween the applicable proportions. Once again, what had been measured, was the degree ofagreement between the two professions on a particular view point. Fleiss (1981) indicated thatfor the purpose of indicating degrees of agreement, in most cases the values of 75 percent and 40percent have been used to divide the full range from 0 percent to 100 percent ranges of valuesfor degrees of agreement. The same values have been used for the present study. Values below40 percent were taken to represent excellent agreement, or very little misperception, valuesgreater than 75 percent were taken to represent poor agreement, or a high degree ofmisperception, while values between 40 percent and 75 percent were taken to represent fair to74good agreement, or a fair amount of misperception. The computed misperceptions were tabulatedand ranked in order of severity, from the most severe misperception to the least severe one.Finally, profiles of the subjects were compiled. Separate profiles were created for eachgroup of subjects according to their true or false responses reflecting either their direct views onan issue or their perceptions of the views held by the members of the other profession on thesame issue. Through this method conclusions could be made as to whether there was a differencein profiles of subjects who had very little misperception on a given issue as compared to subjectswho had a high degree of misperception on a given issue about the members of the otherprofession.SummaryTwenty eight physicians and 66 nurses participated in this descriptive and exploratorysurvey, which examined the degrees of interprofessional misperception among physicians andstaff nurses in long-term care facilities on 15 interprofessional issues. The data was collected viaa questionnaire adapted from the Interprofessional Perception Scale (Ducanis and Golin, 1979).Pertinent demographic data was obtained as well. Proportions of perceptions were computed andcompared between the two professions to determine the existing degrees of misperceptions acrossthe 15 issues. Through this method of data analyses it was possible to develop a view of the totalpattern of interprofessional misperceptions between the physicians and the nurses in long-termcare facilities.75CHAPTER 4The FindingsIntroductionThe data collection resulted in descriptive information about the different misperceptionsthe physicians and the nurses had of each other. The information has been tabulated to provide aclear presentation of all the findings. This chapter has been divided into three sections.The first section presents the profiles of the subjects in the study. The second sectionpresents the findings on each of the 15 issues measured by the Interprofessional Perception Scale.This is followed by a percentage calculation of misperceptions held by the physicians and acalculation of misperceptions found among the nurses. The last section in the chapter presents alist of the degrees of misperceptions as represented by percentages found among the physiciansand the nurses in long-term care facilities. The misperceptions are ranked in order of theirpercentage, from the highest percentage of misperception to the lowest percentage. A second listis presented in this section indicating the issues around which neither the physicians nor thenurses appear to have misperceptions of the views held by the members of the other profession.Profiles of the Subjects in the StudyTable 1 provides a profile of all the physicians, who participated in the study. Thephysicians are mostly male family practitioners, who are over 40 years old and are Caucasian. Italso shows that most of the physicians have worked for more than 15 years in long-term carefacilities. Of note is the predominance of male respondents in this group of physicians. Verysignificant is the finding that all the physicians, who participated in the survey, are family76practitioners. None of the respondents claimed to have expertise in gerontology. The lack ofethnic diversity also is noteworthy.Table 1^Demographic Data of all the Participating Physicians in the Study onInterprofessional MisperceptionsN = 28 =100%GENDER: FEMALE^ N = 5 = 18%MALE N = 23 = 82%AGE (*):^20-30^ N = 0 = 0%31-40 N = 8 = 29%41-50 Isi = 1 = 36%Over 50^ N = 10 = 36%NUMBER OF YEARS THE PHYSICIANS HAVE CARED FOR PATIENTS IN LONG-TERMCARE FACILITIES (*):1-5 YEARS N = 2 = 7%6-10 YEARS N = 6 = 21%11-15 YEARS N = 4 = 14%OVER 15 YEARS N = 16 = 57%AREA OF PRACTICE:FAMILY PRACTICE N = 28 = 100%OTHER:N = 0 =- 0%ETHNIC BACKGROUND (*):CAUCASIAN N = 26 = 93%ORIENTAL N = 1 = 4%NATIVE INDIAN N = 0 = 0%EAST INDIAN N = 0 = 0%OTHER N = 1 = 4%(*) The percentages are rounded off, so they do not always add up to 100%.77Table 2 provides a profile of the nurses in the study. Most of the nurses, who participatedin the survey are female registered nurses, who are in their 40s and are diploma trained. All ofthe nurses rate their job satisfaction as good to excellent. Of note is the even percentage ofCaucasian and Oriental nurses in the survey. All the nurses are employed in long-term carefacilities and all items are worded with respect to their perceptions and experiences in long-termcare facilities. The words "long-term care facilities", therefore, will be omitted in the reportingof some of the findings in the interest of space and readibility.Table 3 provides an overview of the staff nurses from 13 long-term care facilities, all ofwhom were invited to participate in the survey. The nurses are divided into three separate groupsas per their professional designation. The data has been tabulated to compare response rates andnon- response rates of the nurses across the three different professional designations. Registerednurses have the lowest response rate, although it is still over 50% and they constitute 59% of allrespondents.Findings on Each of the Fifteen Issues Measured by the Interprofessional Perception ScaleIn this section the findings are presented on each of the 15 issues measured by theInterprofessional Perception Scale. The presentation of the findings on each issue follows aconsistent format. The findings on each issue are presented in two parts. Part A looks at the issueas it reflects on the nursing profession. Part B shifts the focus of the issue to the medicalprofession. Under each part, first the views of the physicians are presented followed by the viewsof the nurses. The expressed views, in turn, are followed by a percentage calculation ofmisperception held by the physicians and a percentage calculation of misperception found amongthe nurses. In order to determine the severity of the misperceptions each of the professions78Table 2^Demographic Data of all the Participating Nurses in the Study on InterprofessionalMisperceptionsN = 66 = 100%GENDER:^FEMALE N = 65 = 98%MALE N = 1 = 2%AGE:^20-30 N = 2 = 3%31-40 N = 15 = 23%41-50 N = 30 = 45%Over 50 N = 19 = 29%NUMBER OF YEARS THE NURSES HAVE CARED FOR PATIENTS IN LONG-TERMCARE FACILITIES (*): 1-5 YEARS N = 16 = 24%6-10 YEARS N = 14 = 21%11-15 YEARS N = 20 = 30%OVER 15 YEARS N = 16 = 24%EDUCATIONAL PREPARATION:DIPLOMA N = 51 = 77%SPECIALTY CERTIFICATION N = 6 = 9%BACCALAUREATE N = 9 = 14%MASTERS N = 0 = 0%PROFESSIONAL DESIGNATION:RN N = 39 = 59%RPN N = 6 = 9%LGN N = 21 = 32%ETHNIC BACKGROUND: CAUCASIAN N = 31 = 47%ORIENTAL N = 31 = 47%NATIVE INDIAN N = 0 = 0%EAST INDIAN N = 2 = 3%OTHER N = 2 = 3%NURSES' JOB SATISFACTION: POOR N = 0 = 0%GOOD N = 49 = 74%EXCELLENT N = 17 = 26%(*) The percentages are rounded off, so they do not add up to 100%.79Table 3^Response Rates of the Staff Nurses Across the Three Professional DesignationsREGISTEREDNURSESREGISTEREDPSYCHIATRICNURSESLICENSEDGRADUATENURSESTOTALSNUMBER OF STAFF NURSESINVITED TO PARTICIPATEIN THE SURVEY 73 6 31 110NUMBER OF STAFF NURSESRESPONDING TO THE SURVEY 40 6 22 68RESPONSE RATES 55% 100% 71% 62%Note: One registered nurse and one licensed graduate nurse did respond, but their questionnaireswere incomplete.actually has about the other one, different ranges of values are used following Fleiss (1981)guidelines. Values below 40% are taken to represent very little misperception, values greaterthan 75% are taken to represent a high degree of misperception, while values between 40% and75% are taken to represent a fair amount of misperception. In order to present a range withgroupings, the terms "very little" and "little misperception" are both used.Issue No. 1 - Professional Competency Part A - Are Nurses in Long-Term Care Facilities Competent?^93 %^physicians said that nurses are competent.7%^physicians said that nurses are not competent.100%^physicians perceived that nurses would think of themselves as competent.80^0%^physicians perceived that nurses would not think of themselves as competent.95%^nurses said that they are competent.5%^nurses said that they are not competent.83%^nurses perceived that physicians would say that nurses are competent.17%^nurses perceived that physicians would say that nurses are not competent.All physicians perceived that nurses would think of themselves as competent. In fact, 95 %of the nurses thought of themselves as competent. It appears, therefore, that there is very littlemisperception (100% - 95% = 5%) on the part of the physicians about the nurses' view on theirown competency.A majority (83%) of the nurses perceived that physicians would say that nurses arecompetent. In fact, 93 % of the physicians said that the nurses are competent. It appears,therefore, that there is very little misperception on the part of the nurses (93% - 83% = 10%)about the physicians' view on nurses' competency.Part B - Are Physicians in Long-Term Care Facilities Competent? 96%^physicians said that they are competent.4%^physicians said that they are not competent.93 %^physicians perceived that nurses would say that physicians are competent.7%^physicians perceived that nurses would say that physicians are not competent.86%^nurses said that physicians are competent.14%^nurses said that physicians are not competent.100%^nurses perceived that physicians would think of themselves as competent.0%^nurses perceived that physicians would not think of themselves as competent.A majority (93%) of the physicians perceived that nurses would say that physicians arecompetent. In fact, 86% of the nurses said that physicians are competent. It appears, therefore,81that the physicians have very little misperception (93% - 86% = 7%) about the nurses' view ofphysicians' competency.All nurses perceived that physicians would think of themselves as competent. In fact, 96%of the physicians said that they are competent. It appears, therefore, that there is very littlemisperception on the part of the nurses (100% - 96% = 4%) of the physicians' view ofthemselves as competent.Issue No. 2 - Professional Autonomy Part A - Do Nurses in Long-Term Care Facilities Have Very Little Autonomy? 36%^physicians said nurses do have very little autonomy.64%^physicians said nurses do not have very little autonomy.61 %^physicians perceived that nurses would say that nurses do have very little autonomy.39%^physicians perceived that nurses would say that nurses do not have very littleautonomy.39%^nurses said that they do have very little autonomy.61 %^nurses said that they do not have very little autonomy.45%^nurses perceived that physicians would say that nurses do have very little autonomy.55%^nurses perceived that physicians would say that nurses do not have very littleautonomy.A majority (61 %) of the physicians perceived that nurses would say that nurses do havevery little autonomy. In fact, 39% of the nurses said that they do have very little autonomy. Itappears, therefore, that there is little misperception (61% - 39% = 22%) on the part of thephysicians about the nurses' view of themselves as having very little autonomy.A majority (55%) of the nurses perceived that physicians would say that nurses do not havevery little autonomy. In fact, 64% of the physicians said that nurses do not have very little82autonomy. It appears, therefore, that there is very little misperception (64% - 55% = 9%) on thepart of the nurses about the physicians' view that nurses do not have very little autonomy.Part B - Do Physicians in Long-Term Care Facilities Have Very Little Autonomy?25%^physicians said that they do have very little autonomy.75%^physicians said that they do not have very little autonomy.18%^physicians perceived that nurses would say that physicians do have very littleautonomy.82%^physicians perceived that nurses would say that physicians do not have very littleautonomy.17%^nurses said physicians do have very little autonomy.83%^nurses said physicians do not have very little autonomy.33 %^nurses perceived that physicians would say that physicians do have very littleautonomy.67%^nurses perceived that physicians would say that physicians do not have very littleautonomy.A majority (82%) of the physicians perceived that nurses would say that physicians do nothave very little autonomy. In fact, 83 % of the nurses said physicians do not have very littleautonomy. It appears, therefore, that there is very little misperception (83% - 82% = 1%) on thepart of the physicians about the nurses' view that physicians do not have very little autonomy.A majority (67%) of the nurses perceived that physicians would say that physicians do nothave very little autonomy. In fact, 75% of the physicians said that they do not have very littleautonomy. It appears, therefore, that there is very little misperception (75% - 67% = 8%) on thepart of the nurses about the physicians' view that physicians do not have very little autonomy.83Issue No. 3 - Professional CapabilitiesPart A - Do Nurses Understand the Capabilities of Physicians in Long-Term CareFacilities?82%^physicians said nurses do understand the capabilities of physicians.18%^physicians said nurses do not understand the capabilities of physicians.96%^physicians perceived that nurses would say that nurses do understand the capabilities ofphysicians.4%^physicians perceived that nurses would say that nurses do not understand thecapabilities of physicians.97%^nurses said that they do understand the capabilities of physicians.3%^nurses said that they do not understand the capabilities of physicians.85%^nurses perceived that physicians would say that nurses do understand the capabilities ofphysicians.15%^nurses perceived that physicians would say that nurses do not understand thecapabilities of physicians.A majority (96%) of the physicians perceived that nurses would say that nurses dounderstand the capabilities of physicians. In fact, 97% of the nurses said that they do understandthe capabilities of physicians. It appears, therefore, that there is very little misperception on thepart of the physicians (97% - 96% = 1 %) about the nurses' view that they do understand thecapabilities of physicians.A majority (85%) of the nurses perceived that physicians would say that nurses dounderstand the capabilities of physicians. In fact, 82% of the physicians said that nurses dounderstand the capabilities of physicians. It appears, therefore, that there is very littlemisperception on the part of the nurses (85% - 82% = 3 %) about the physicians' view thatnurses do understand the capabilities of physicians.Part B - Do Physicians Understand the Capabilities of Nurses in Long-Term CareFacilities?89%^physicians said they do understand the capabilities of nurses.11 %^physicians said they do not understand the capabilities of nurses.43 %^physicians perceived that nurses would say that physicians do understand thecapabilities of nurses.57%^physicians perceived that nurses would say that physicians do not understand thecapabilities of nurses.64%^nurses said physicians do understand the capabilities of nurses.36%^nurses said physicians do not understand the capabilities of nurses.89%^nurses perceived that physicians would say that physicians do understand thecapabilities of nurses.11 %^nurses perceived that physicians would say that physicians do not understand thecapabilities of nurses.A majority (57%) of the physicians perceived that nurses would say that physicians do notunderstand the capabilities of nurses. In fact, 36% of the nurses said that physicians do notunderstand the capabilities of nurses. It appears, therefore, that there is little misperception onthe part of the physicians (57% - 36% = 21%) about the nurses' view that physicians do notunderstand the capabilities of nurses.A majority (89%) of the nurses perceived that physicians would say that physicians dounderstand the capabilities of nurses. In fact, 89% of the physicians, indeed, said that they dounderstand the capabilities of nurses. It appears, therefore, that there is no misperception on thepart of the nurses (89% - 89% = 0%) about the physicians' view that physicians do understandthe capabilities of nurses.8485Issue No. 4 - Professional Concern with Patient WelfarePart A - Are Nurses in Long-Term Care Facilities Highly Concerned with the Welfareof the Patient?^96%^physicians said nurses are highly concerned with the welfare of the patient.4%^physicians said nurses are not highly concerned with the welfare of the patient.100%^physicians perceived that nurses would say that nurses are highly concerned with thewelfare of the patient.0%^physicians perceived that nurses would say that nurses are not highly concerned withthe welfare of the patient.95%^nurses said that they are highly concerned with the welfare of the patient.5%^nurses said that they are not highly concerned with the welfare of the patient.98%^nurses perceived that physicians would say that nurses are highly concerned with thewelfare of the patient.2%^nurses perceived that physicians would say that nurses are not highly concerned withthe welfare of the patient.All physicians (100%) perceived that nurses would say that nurses are highly concernedwith the welfare of the patient. In fact, 95% of the nurses said that they are highly concernedwith the welfare of the patient. It appears, therefore, that there is very little misperception on thepart of the physicians (100% - 95% = 5%) about the nurses' view that nurses are highlyconcerned with the welfare of the patient.A majority (98%) of the nurses perceived that physicians would say that nurses are highlyconcerned with the welfare of the patient. In fact, 96% of the physicians said that nurses arehighly concerned with the welfare of the patient. It appears, therefore, that there is very littlemisperception on the part of the nurses (98% - 96% = 2%) about the physicians' view thatnurses are highly concerned with the welfare of the patient.86Part B - Are Physicians in Long-Term Care Facilities Highly Concerned with theWelfare of the Patient?^100%^physicians said they are highly concerned with the welfare of the patient.0%^physicians said they are not highly concerned with the welfare of the patient.82%^physicians perceived that nurses would say that physicians are highly concerned withthe welfare of the patient.18%^physicians perceived that nurses would say that physicians are not highly concernedwith the welfare of the patient.70%^nurses said physicians are highly concerned with the welfare of the patient.30%^nurses said physicians are not highly concerned with the welfare of the patient.97%^nurses perceived that physicians would say that physicians are highly concerned withthe welfare of the patient.3%^nurses perceived that physicians would say that physicians are not highly concernedwith the welfare of the patient.A majority (82%) of the physicians perceived that nurses would say that physicians arehighly concerned with the welfare of the patient. In fact, 70% of the nurses said that physiciansare highly concerned with the welfare of the patient. It appears, therefore, that there is very littlemisperception (82% - 70% = 12%) on the part of the physicians about the nurses' view thatphysicians are highly concerned with the welfare of the patient.A majority (97%) of the nurses perceived that physicians would say that physicians are nothighly concerned with the welfare of the patient. In fact, 100% of the physicians said that theyare highly concerned with the welfare of the patient. It appears, therefore, that there is very littlemisperception on the part of the nurses (100% - 97% = 3%) about the physicians' view that theyare highly concerned with the welfare of the patient.87Issue No. 5 - Professional TerritorialityPart A - Do Nurses Sometimes Encroach on Physicians' Professional Territory inLong-Term Care Facilities?39%^physicians said nurses do sometimes encroach on physicians' professional territory.61 %^physicians said nurses do not encroach on physicians' professional territory.25%^physicians perceived that nurses would say that nurses do sometimes encroach onphysicians' professional territory.75%^physicians perceived that nurses would say that nurses do not encroach on physicians'professional territory.30%^nurses said that they do sometimes encroach on physicians' professional territory.70%^nurses said that they do not encroach on physicians' professional territory.53%^nurses perceived that physicians would say that nurses do sometimes encroach onphysicians' professional territory.47%^nurses perceived that physicians would say that nurses do not encroach on physicians'professional territory.A majority (75%) of the physicians perceived that nurses would say that nurses do notencroach on physicians' professional territory. In fact, 70% of the nurses said that nurses do notencroach on physicians' professional territory. It appears, therefore, that there is very littlemisperception (75% - 70% = 5%) on the part of the physicians about the nurses' view thatnurses do not encroach on physicians' professional territory.A majority (53%) of the nurses perceived that physicians would say that nurses dosometimes encroach on physicians' professional territory. In fact, 39% of the physicians said thatnurses do sometimes encroach on physicians' professional territory. It appears, therefore, thatthere is little misperception (53% - 39% = 14%) on the part of the nurses about the physicians'view that nurses do sometimes encroach on physicians' professional territory.88Part B - Do Physicians Sometimes Encroach on Nurses' Professional Territory inLong-Term Care Facilities?36%^physicians said they do sometimes encroach on nurses' professional territory64%^physicians said they do not encroach on nurses' professional territory.68%^physicians perceived that nurses would say that physicians do sometimes encroach onnurses' professional territory.32%^physicians perceived that nurses would say that physicians do not encroach on nurses'professional territory.61 %^nurses said physicians do sometimes encroach on nurses' professional territory.39%^nurses said physicians do not encroach on nurses' professional territory.27%^nurses perceived that physicians would say that physicians do sometimes encroach onnurses' professional territory.73 %^nurses perceived that physicians would say that physicians do not encroach on nurses'professional territory.A majority (68%) of the physicians perceived that nurses would say that physicians dosometimes encroach on nurses' professional territory. In fact, 61 % of the nurses said thatphysicians do sometimes encroach on nurses' professional territory. It appears, therefore, thatthere is very little misperception (68% - 61% = 7%) on the part of the physicians about thenurses' view that physicians do sometimes encroach on nurses' professional territory.A majority (73%) of the nurses perceived that physicians would say that physicians do notencroach on nurses' professional territory. In fact, 64% of the physicians said that they do notencroach on nurses' professional territory. It appears, therefore, that there is very littlemisperception on the part of the nurses (73% - 64% = 9%) about the physicians' view thatphysicians do not encroach on nurses' professional territory.Issue No. 6 - Professional EthicsPart A - Are Nurses in Long-Term Care Facilities Highly Ethical?93%^physicians said nurses are highly ethical.89^7%^physicians said nurses are not highly ethical.100%^physicians perceived that nurses would say that nurses are highly ethical.0%^physicians perceived that nurses would say that nurses are not highly ethical.89%^nurses said that they are highly ethical.11 %^nurses said that they are not highly ethical.85%^nurses perceived that physicians would say that nurses are highly ethical.15%^nurses perceived that physicians would say that nurses are not highly ethical.All the physicians (100%) perceived that nurses would say that nurses are highly ethical. Infact, 89% of the nurses said that nurses are highly ethical. It appears, therefore, that there islittle misperception on the part of the physicians (100% - 89% = 11 %) about the nurses' viewthat nurses are highly ethical.A majority (85%) of the nurses perceived that physicians would say that nurses are highlyethical. In fact, 93% of the physicians said that nurses are highly ethical. It appears, therefore,that there is very little misperception on the part of the nurses (93% - 85% = 8%) about thephysicians' view that nurses are highly ethical.Part B - Are Physicians in Long-Term Care Facilities Highly Ethical? 93 %^physicians said they are highly ethical.7%^physicians said they are not highly ethical.93%^physicians perceived that nurses would say that physicians are highly ethical.7%^physicians perceived that nurses would say that physicians are not highly ethical.71%^nurses said physicians are highly ethical.29%^nurses said physicians are not highly ethical.95%^nurses perceived that physicians would say that physicians are highly ethical.5%^nurses perceived that physicians would say that physicians are not highly ethical.90A majority (93%) of the physicians perceived that nurses would say that physicians arehighly ethical. In fact, 71 % of the nurses said that physicians are highly ethical. It appears,therefore, that there is little misperception on the part of the physicians (93% - 71% = 22%)about the nurses' view that physicians are highly ethical.A majority (95%) of the nurses perceived that physicians would say that physicians arehighly ethical. In fact, 93% of the physicians said that they are highly ethical. It appears,therefore, that there is very little misperception (95% - 93% = 2%) on the part of the nursesabout the physicians' view that physicians are highly ethical.Issue No. 7 - Interprofessional Role ExpectationsPart A - Do Nurses Expect Too Much of Physicians in Long-Term Care Facilities?^25%^physicians said nurses do expect too much of physicians.75%^physicians said nurses do not expect too much of physicians.4%^physicians perceived that nurses would say that nurses do expect too much ofphysicians.96%^physicians perceived that nurses would say that nurses do not expect too much ofphysicians.24%^nurses said that they do expect too much of physicians.76%^nurses said that they do not expect too much of physicians.61 %^nurses perceived that physicians would say that nurses do expect too much ofphysicians.39%^nurses perceived that physicians would say that nurses do not expect too much ofphysicians.A majority (96%) of the physicians perceived that nurses would say that nurses do notexpect too much of physicians. In fact, 76% of the nurses said that they do not expect too muchof physicians. It appears, therefore, that there is little misperception (96% - 76% - 20%) on thepart of physicians about the nurses' view that nurses do not expect too much of physicians.91A majority (61 %) of the nurses perceived that physicians would say that nurses do expecttoo much of physicians. In fact, 25% of the physicians said that nurses do expect too much ofphysicians. It appears, therefore, that there is little misperception (61% - 25% = 36%) on thepart of the nurses about the physicians' view that nurses do expect too much of physicians arehighly ethical.Part B - Do Physicians Expect Too Much of Nurses in Long-Term Care Facilities?21 %^physicians said they do expect too much of nurses.79%^physicians said they do not expect too much of nurses.50%^physicians perceived that nurses would say that physicians do expect too much ofnurses.50%^physicians perceived that nurses would say that physicians do not expect too much ofnurses.44%^nurses said physicians do expect too much of nurses.56%^nurses said physicians do not expect too much of nurses.30%^nurses perceived that physicians would say that physicians do expect too much ofnurses.70%^nurses perceived that physicians would say that physicians do not expect too much ofnurses.Half of the physicians (50%) perceived that nurses would say that physicians do not expecttoo much of nurses. In fact, 56% of the nurses said that physicians do not expect too much ofnurses. It appears, therefore, that there is very little misperception (56% - 50% = 6%) on thepart of physicians about the nurses' view that physicians do not expect too much of nurses.A majority (70%) of the nurses perceived that physicians would say that physicians do notexpect too much of nurses. In fact, 79% of the physicians said that they do not expect too muchof nurses. It appears, therefore, that there is very little misperception (79% - 70% = 9%) on thepart of the nurses about the physicians' view that physicians do not expect too much of nurses.92Issue No. 8 - Professional StatusPart A - Do Nurses Have a Higher Status Than Physicians in Long-Term CareFacilities?^0%^physicians said nurses do have a higher status than physicians.100%^physicians said nurses do not have a higher status than physicians.0%^physicians perceived that nurses would say that nurses do have a higher status thanphysicians.100%^physicians perceived that nurses would say that nurses do not have a higher status thanphysicians.9%^nurses said that they do have a higher status than physicians.91%^nurses said that they do not have a higher status than physicians.17%^nurses perceived that physicians would say that nurses do have a higher status thanphysicians.83 %^nurses perceived that physicians would say that nurses do not have a higher status thanphysicians.All the physicians (100%) perceived that nurses would say that nurses do not have a higherstatus than physicians. In fact, 91 % of the nurses said that they do not have a higher status thanphysicians. It appears, therefore, that there is very little misperception (100% - 91% = 9%) onthe part of the physicians about the nurses' view that nurses do not have a higher status thanphysicians.A majority (83%) of the nurses perceived that physicians would say that nurses do not havea higher status than physicians. In fact, 100% of the physicians said that nurses do not have ahigher status than physicians. It appears, therefore, that there is little misperception on the part ofthe nurses (100% - 83% = 17%) about the physicians' view that nurses do not have a higherstatus than physicians.93Part B - Do Physicians Have a Higher Status Than Nurses in Long-Term CareFacilities?86%^physicians said they do have a higher status than nurses.14%^physicians said they do not have a higher status than nurses.82%^physicians perceived that nurses would say that physicians do have a higher status thannurses.18%^physicians perceived that nurses would say that physicians do not have a higher statusthan nurses.79%^nurses said physicians do have a higher status than nurses.21 %^nurses said physicians do not have a higher status than nurses.86%^nurses perceived that physicians would say that physicians do have a higher status thannurses.14%^nurses perceived that physicians would say that physicians do not have a higher statusthan nurses.A majority (82%) of the physicians perceived that nurses would say that physicians do havea higher status than nurses. In fact, 79% of the nurses said that physicians do have a higherstatus than nurses. It appears, therefore, that there is very little (82% - 79% = 3%)misperception on the part of the physicians about the nurses' view that physicians do have ahigher status than nurses .A majority (86%) of the nurses perceived that physicians would say that physicians do havea higher status than nurses. In fact, 86% of the physicians, indeed, said that they do have ahigher status than nurses. It appears, therefore, that there is no misperception on the part of thenurses (86% - 86% = 0%) about the physicians' view that they do have a higher status thannurses.94Issue No. 9 - Professional EthnocentrismPart A - Are Nurses in Long-Term Care Facilities Very Defensive about TheirProfessional Prerogatives?43%^physicians said nurses are very defensive about their professional prerogatives.57%^physicians said nurses are not very defensive about their professional prerogatives.29%^physicians perceived that nurses would say that nurses are very defensive about theirprofessional prerogatives.71 %^physicians perceived that nurses would say that nurses are not very defensive abouttheir professional prerogatives.53 %^nurses said that they are very defensive about their professional prerogatives.47%^nurses said that they are not very defensive about their professional prerogatives.71 %^nurses perceived that physicians would say that nurses are very defensive about theirprofessional prerogatives.29%^nurses perceived that physicians would say that nurses are not very defensive abouttheir professional prerogatives.A majority (71 %) of the physicians perceived that nurses would say that nurses are notvery defensive about their professional prerogatives. In fact, 47% of the nurses said that they arenot very defensive about their professional prerogatives. It appears, therefore, that there is littlemisperception (71 % - 47% = 24%) on the part of the physicians about the nurses' view thatnurses are not very defensive about their professional prerogatives.A majority (71 %) of the nurses perceived that physicians would say that nurses are verydefensive about their professional prerogatives. In fact, 43 % of the physicians said that nursesare very defensive about their professional prerogatives. It appears, therefore, that there is littlemisperception on the part of the nurses (71 % - 43% = 28%) about the physicians' view thatnurses are very defensive about their professional prerogatives.95Part B - Are Physicians in Long-Term Care Facilities Very Defensive about TheirProfessional Prerogatives? 43 %^physicians said they are very defensive about their professional prerogatives.57%^physicians said they are not very defensive about their professional prerogatives.68%^physicians perceived that nurses would say that physicians are very defensive abouttheir professional prerogatives.32%^physicians perceived that nurses would say that physicians are not very defensive abouttheir professional prerogatives.77%^nurses said physicians are very defensive about their professional prerogatives.23%^nurses said physicians are not very defensive about their professional prerogatives.48%^nurses perceived that physicians would say that physicians are very defensive abouttheir professional prerogatives.52%^nurses perceived that physicians would say that physicians are not very defensive abouttheir professional prerogatives.A majority (68%) of the physicians perceived that nurses would say that physicians arevery defensive about their professional prerogatives. In fact, 77% of the nurses said thatphysicians are very defensive about their professional prerogatives. It appears, therefore, thatthere is very little misperception (77% - 68% = 9%) on the part of the physicians about thenurses' view that physicians are very defensive about their professional prerogatives.A majority (52%) of the nurses perceived that physicians would say that physicians are notvery defensive about their professional prerogatives. In fact, 57% of the physicians said that theyare not very defensive about their professional prerogatives. It appears, therefore, that there isvery little misperception (57% - 52% = 5%) on the part of the nurses about the physicians' viewthat physicians are not very defensive about their professional prerogatives.96Issue No. 10 - Interprofessional TrustPart A - Do Nurses Trust Physicians' Professional Judgment in Long-Term CareFacilities?89%^physicians said nurses do trust physicians' professional judgment.11 %^physicians said nurses do not trust physicians' professional judgment.89%^physicians perceived that nurses would say that nurses do trust physicians' professionaljudgment.11 %^physicians perceived that nurses would say that nurses do not trust physicians'professional judgment.73 %^nurses said that they do trust physicians' professional judgment.27%^nurses said that they do not trust physicians' professional judgment.80%^nurses perceived that physicians would say that nurses do trust physicians' professionaljudgment.20%^nurses perceived that physicians would say that nurses do not trust physicians'professional judgment.A majority (89%) of the physicians perceived that nurses would say that nurses do trustphysicians' professional judgment. In fact, 73% of the nurses said that they do trust physicians'professional judgment. It appears, therefore, that there is little misperception on the part of thephysicians (89% - 73% = 16%) about the nurses' view that nurses do trust physicians'professional judgment.A majority (80%) of the nurses perceived that physicians would say that nurses do trustphysicians' professional judgment. In fact, 89% of the physicians said that nurses do trustphysicians' professional judgment. It appears, therefore, that there is very little misperception onthe part of the nurses (89% - 80% = 9%) about the physicians' view that nurses do trustphysicians' professional judgment.97Part B - Do Physicians Trust Nurses' Professional Judgment in Long-Term CareFacilities?86%^physicians said they do trust nurses' professional judgment.14%^physicians said they do not trust nurses' professional judgment.71 %^physicians perceived that nurses would say that physicians do trust nurses' professionaljudgment.29%^physicians perceived that nurses would say that physicians do not trust nurses'professional judgment.86%^nurses said physicians do trust nurses' professional judgment.14%^nurses said physicians do not trust nurses' professional judgment.91 %^nurses perceived that physicians would say that physicians do trust nurses' professionaljudgment.9%^nurses perceived that physicians would say that physicians do not trust nurses'professional judgment.A majority (71 %) of the physicians perceived that nurses would say that physicians do trustnurses' professional judgment. In fact, 86% of the nurses said that physicians do trust nurses'professional judgment. It appears, therefore, that there is little misperception on the part of thephysicians (86% - 71% = 15%) about the nurses' view that physicians do trust nurses'professional judgment.A majority (91%) of the nurses perceived that physicians would say that physicians do trustnurses' professional judgment. In fact, 86% of the physicians said that they do trust nurses'professional judgment. It appears, therefore, that there is very little misperception on the part ofthe nurses (91 % - 86% = 5%) about the physicians' view that physicians do trust nurses'professional judgment.98Issue No. 11 - Interprofessional AdvicePart A - Do Nurses Seldomly Ask Physicians for Professional Advice in Long-TermCare Facilities?25%^physicians said nurses do seldomly ask physicians for professional advice.75%^physicians said nurses do ask physicians for professional advice.32%^physicians perceived that nurses would say that nurses do seldomly ask physicians forprofessional advice.68%^physicians perceived that nurses would say that nurses do ask physicians forprofessional advice.5%^nurses said that they do seldomly ask physicians for professional advice.95%^nurses said that they do ask physicians for professional advice.20%^nurses perceived that physicians would say that nurses do seldomly ask physicians forprofessional advice.80%^nurses perceived that physicians would say that nurses do ask physicians forprofessional advice.A majority (68%) of the physicians perceived that nurses would say that nurses do askphysicians for professional advice. In fact, 95% of the nurses said that they do ask physicians forprofessional advice. It appears, therefore, that there is little misperception (95% - 68% = 27%)on the part of the physicians about the nurses' view that the nurses do ask physicians forprofessional advice.A majority (80%) of the nurses perceived that physicians would say that nurses do askphysicians for professional advice. In fact, 75% of the physicians said that nurses do askphysicians for professional advice. It appears, therefore, that there is very little misperception onthe part of the nurses (80% - 75% = 5%) about the physicians' view that nurses do askphysicians for professional advice.99Part B - Do Physicians Seldomly Ask Nurses for Professional Advice in Long-TermCare Facilities?29%^physicians said they do seldomly ask nurses for professional advice.71 %^physicians said they do ask nurses for professional advice.61 %^physicians perceived that nurses would say that physicians do seldomly ask nurses forprofessional advice.39%^physicians perceived that nurses would say that physicians do ask nurses forprofessional advice.65%^nurses said physicians do seldomly ask nurses for professional advice.35%^nurses said physicians do ask nurses for professional advice.48%^nurses perceived that physicians would say that physicians do seldomly ask nurses forprofessional advice.52%^nurses perceived that physicians would say that physicians do ask nurses forprofessional advice.A majority (61 %) of the physicians perceived that nurses would say that physicians doseldomly ask nurses for professional advice. In fact, 65% of the nurses said that physicians doseldomly ask nurses for professional advice. It appears, therefore, that there is very littlemisperception (65% - 61 % = 4%) on the part of the physicians about the nurses' view that thephysicians do seldomly ask nurses for professional advice.A majority (52%) of the nurses perceived that physicians would say that physicians do asknurses for professional advice. In fact, 71 % of the physicians said that physicians do ask nursesfor professional advice. It appears, therefore, that there is little misperception on the part of thenurses (71 % - 52% = 19%) about the physicians' view that physicians do ask nurses forprofessional advice.100Issue No. 12 - Interprofessional Utilization of CapabilitiesPart A - Do Nurses Fully Utilize the Capabilities of Physicians in Long-Term CareFacilities?64%^physicians said nurses do fully utilize the capabilities of physicians.36%^physicians said nurses do not fully utilize the capabilities of physicians.68%^physicians perceived that nurses would say that nurses do fully utilize the capabilities ofphysicians.32%^physicians perceived that nurses would say that nurses do not fully utilize thecapabilities of physicians.85%^nurses said that they do fully utilize the capabilities of physicians.15%^nurses said that they do not fully utilize the capabilities of physicians.80%^nurses perceived that physicians would say that nurses do fully utilize the capabilities ofphysicians.20%^nurses perceived that physicians would say that nurses do not fully utilize thecapabilities of physicians.A majority (68%) of the physicians perceived that nurses would say that nurses do fullyutilize the capabilities of physicians. In fact, 85% of the nurses said that they do fully utilize thecapabilities of physicians. It appears, therefore, that there is little misperception on the part ofthe physicians (85% - 68% = 17%) about the nurses' view that nurses do fully utilize thecapabilities of physicians.A majority (80%) of the nurses perceived that physicians would say that nurses do fullyutilize the capabilities of physicians. In fact, 64% of the physicians said that nurses do fullyutilize the capabilities of physicians. It appears, therefore, that there is little misperception on thepart of the nurses (80% - 64% = 16%) about the physicians' view that nurses do fully utilize thecapabilities of physicians.101Part B - Do Physicians Fully Utilize the Capabilities of Nurses in Long-Term CareFacilities? 50%^physicians said they do fully utilize the capabilities of nurses.50%^physicians said they do not fully utilize the capabilities of nurses.36%^physicians perceived that nurses would say that physicians do fully utilize thecapabilities of nurses.64%^physicians perceived that nurses would say that physicians do not fully utilize thecapabilities of nurses.55%^nurses said physicians do fully utilize the capabilities of nurses.45%^nurses said physicians do not fully utilize the capabilities of nurses.80%^nurses perceived that physicians would say that physicians do fully utilize thecapabilities of nurses.20%^nurses perceived that physicians would say that physicians do not fully utilize thecapabilities of nurses.A majority (64%) of the physicians perceived that nurses would say that physicians do notfully utilize the capabilities of nurses. In fact, 45% of the nurses said that physicians do not fullyutilize the capabilities of nurses. It appears, therefore, that there is little misperception on thepart of the physicians (64% - 45% = 19%) about the nurses' view that physicians do not fullyutilize the capabilities of nurses.A majority (80%) of the nurses perceived that physicians would say that physicians do fullyutilize the capabilities of nurses. In fact, 50% of the physicians said that they do fully utilize thecapabilities of nurses. It appears, therefore, that there is little misperception on the part of thenurses (80% - 50% = 30%) about the physicians' view that physicians do fully utilize thecapabilities of nurses.Issue No. 13 - Interprofessional Cooperation Part A - Do Nurses Not Cooperate Well with Physicians in Long-Term Care facilities?14%^physicians said nurses do not cooperate well with physicians.10286%^physicians said nurses do cooperate well with physicians.11 %^physicians perceived that nurses would say that nurses do not cooperate well withphysicians.89%^physicians perceived that nurses would say that nurses do cooperate well withphysicians.5%^nurses said that they do not cooperate well with physicians.95%^nurses said that they do cooperate well with physicians.20%^nurses perceived that physicians would say that nurses do not cooperate well withphysicians.80%^nurses perceived that physicians would say that nurses do cooperate well withphysicians.A majority (89%) of the physicians perceived that nurses would say that nurses docooperate well with physicians. In fact, 95% of the nurses said that they do cooperate well withphysicians. It appears, therefore, that there is very little misperception on the part of thephysicians (95% - 89% = 6%) about the nurses' view that nurses do cooperate well withphysicians.A majority (80%) of the nurses perceived that physicians would say that nurses docooperate well with physicians. In fact, 86% of the physicians said that nurses do cooperate wellwith physicians. It appears, therefore, that there is very little misperception on the part of thenurses (86% - 80% = 6%) about the physicians' view that nurses do cooperate well withphysicians.Part B - Do Physicians Not Cooperate Well with Nurses in Long-Term Care Facilities?14%^physicians said they do not cooperate well with nurses.86%^physicians said they do cooperate well with nurses.29%^physicians perceived that nurses would say that physicians do not cooperate well withnurses.10371 %^physicians perceived that nurses would say that physicians do cooperate well withnurses.35%^nurses said physicians do not cooperate well with nurses.65%^nurses said physicians do cooperate well with nurses.12%^nurses perceived that physicians would say that physicians do not cooperate well withnurses.88%^nurses perceived that physicians would say that physicians do cooperate well withnurses.A majority (71 %) of the physicians perceived that nurses would say that physicians docooperate well with nurses. In fact, 65% of the nurses said that physicians do cooperate wellwith nurses. It appears, therefore, that there is very little misperception on the part of thephysicians (71% - 65% = 6%) about the nurses' view that physicians do cooperate well withnurses.A majority (88%) of the nurses perceived that physicians would say that physicians docooperate well with nurses. In fact, 86% of the physicians said that they do cooperate well withnurses. It appears, therefore, that there is very little misperception (88% - 86% = 2%) on thepart of the nurses about the physicians' view that physicians do cooperate well with nurses.Issue No. 14 - Professional TrainingPart A - Are Nurses in Long-Term Care Facilities Well Trained? 75%^physicians said nurses are well trained.25%^physicians said nurses are not well trained.96%^physicians perceived that nurses would say that nurses are well trained.4%^physicians perceived that nurses would say that nurses are not well trained.94%^nurses said that they are well trained.6%^nurses said that they are not well trained.77%^nurses perceived that physicians would say that nurses are well trained.10423 %^nurses perceived that physicians would say that nurses are not well trained.A majority (96%) of the physicians perceived that nurses would say that nurses are welltrained. In fact, 94% of the nurses said that they are well trained. It appears, therefore, that thereis very little misperception on the part of the physicians (96% - 94% = 2%) about the nurses'view that nurses are well trained.A majority (77%) of the nurses perceived that physicians would say that nurses are welltrained. In fact, 75% of the physicians said that nurses are well trained. It appears, therefore,that there is very little misperception on the part of the nurses (77% - 75% = 2%) about thephysicians' view that nurses are well trained.Part B - Are Physicians in Long-Term Care Facilities Well Trained?96%^physicians said they are well trained.4%^physicians said they are not well trained.89%^physicians perceived that nurses would say that physicians are well trained.11 %^physicians perceived that nurses would say that physicians are not well trained.80%^nurses said physicians are well trained.20%^nurses said physicians are not well trained.98%^nurses perceived that physicians would say that physicians are well trained.2%^nurses perceived that physicians would say that physicians are not well trained.A majority (89%) of the physicians perceived that nurses would say that physicians arewell trained. In fact, 80% of the nurses said that physicians are well trained. It appears,therefore, that there is very little misperception (89% - 80% = 9%) on the part of the physiciansabout the nurses' view that physicians are well trained.A majority (98%) of the nurses perceived that physicians would say that physicians arewell trained. In fact, 96% of the physicians said that they are well trained. It appears, therefore,105that there is very little misperception on the part of the nurses (98% - 96% = 2%) about thephysicians' view that physicians are well trained.Issue No. 15 - Interprofessional RelationshipsPart A - Do Nurses Have Good Relations with Physicians in Long-Term CareFacilities?89%^physicians said nurses do have good relations with physicians.11 %^physicians said nurses do not have good relations with physicians.86%^physicians perceived that nurses would say that nurses do have good relations withphysicians.14%^physicians perceived that nurses would say that nurses do not have good relations withphysicians.89%^nurses said that they do have good relations with physicians.11 %^nurses said that they do not have good relations with physicians.92%^nurses perceived that physicians would say that nurses do have good relations withphysicians.8%^nurses perceived that physicians would say that nurses do not have good relations withphysicians.A majority (86%) of the physicians perceived that nurses would say that nurses do havegood relations with physicians. In fact, 89% of the nurses said that they do have good relationswith physicians. It appears, therefore, that there is very little misperception on the part of thephysicians (89% - 86% = 3%) about the nurses' view that nurses do have good relations withphysicians.A majority (92%) of the nurses perceived that physicians would say that nurses do havegood relations with physicians. In fact, 89% of the physicians said that nurses do have goodrelations with physicians. It appears, therefore, that there is very little misperception on the partof the nurses (92% - 89% = 3%) about the physicians' view that nurses do have good relationswith physicians.106Part B - Do Physicians Have Good Relations with Nurses in Long-Term CareFacilities?^96%^physicians said they do have good relations with nurses.4%^physicians said they do not have good relations with nurses.82%^physicians perceived that nurses would say that physicians do have good relations withnurses.18%^physicians perceived that nurses would say that physicians do not have good relationswith nurses.82%^nurses said physicians do have good relations with nurses.18%^nurses said physicians do not have good relations with nurses.95%^nurses perceived that physicians would say that physicians do have good relations withnurses.5%^nurses perceived that physicians would say that physicians do not have good relationswith nurses.A majority (82%) of the physicians perceived that nurses would say that physicians do havegood relations with nurses. In fact, 82% of the nurses, indeed, said that physicians do have goodrelations with nurses. It appears, therefore, that there is no misperception (82% -82% = 0%) onthe part of the physicians about the nurses' view that physicians do have good relations withnurses.A majority (95%) of the nurses perceived that physicians would say that physicians do havegood relations with nurses. In fact, 96% of the physicians said that they do have good relationswith nurses. It appears, therefore, that there is almost no misperception (96% - 95% = 1 %) onthe part of the nurses about the physicians' view that physicians do have good relations withnurses.107Summary of the Degrees of Misperceptions Found among the Physicians and the Nurses inLong-Term Care FacilitiesIn table 4 the degrees of misperceptions as represented by percentages among physiciansand nurses have been summarized. They are misperceptions held by the members of oneprofession on how the members of the other profession view the 15 professional issues that havebeen included in the survey.The misperceptions have been ranked in order of percentage, from the highest percentageof misperception to the least percentage. In other words, the misperceptions of one profession atthe bottom of the list are not far from the actual opinions expressed by the members of the otherprofession.Table 4 List of the Degrees of Misperceptions Represented by Percentages Found Among thePhysicians and the Nurses in Long-Term Care FacilitiesDEGREE OFMISPERCEPTION^ISSUE36%^nurses' misperception of physicians' views on whether nurses expect toomuch of physicians.30%^nurses' misperception of physicians' views on whether physicians fullyutilize the capabilities of nurses.28%^nurses' misperception of physicians' views on whether nurses are verydefensive about their professional prerogatives.27%^physicians' misperception of nurses' views on whether nurses askphysicians for professional advice.24%^physicians' misperception of nurses' views on whether nurses are verydefensive about theirprofessional prerogatives.22%^physicians' misperception of nurses' views on whether nurses have verylittle autonomy.22%^physicians' misperception of nurses' views on whether physicians arehighly ethical.10821%^physicians' misperception of nurses' views on whether physiciansunderstand the capabilities of nurses.20%^physicians' misperception of nurses' views on whether nurses expect toomuch of physicians.19%^nurses' misperception of physicians' views on whether physicians asknurses for professional advice.19%^physicians' misperception of nurses' views on whether physicians fullyutilize the capabilities of nurses.17%^nurses' misperception of physicians' views on whether nurses have a higherstatus than physicians.17%^physicians' misperception of nurses' views on whether nurses fully utilizethe capabilities of physicians.16%^physicians' misperception of nurses' views on whether nurses trustphysicians' professional judgment.16%^nurses' misperception of physicians' views on whether nurses utilize thecapabilities of physicians.15%^physicians' misperception of nurses' views on whether physicians trustnurses' professional judgment.14%^nurses' misperception of physicians' views on whether nurses sometimesencroach on physicians' professional territory.12%^physicians' misperception of nurses' views on whether physicians arehighly concerned with the welfare of the patient.11%^physicians' misperception of nurses' views on whether nurses are highlyethical.10%^nurses' misperception of physicians' views on whether nurses arecompetent.9%^nurses' misperception of physicians' views on whether nurses have verylittle autonomy.9%^nurses' misperception of physicians' views on whether physicians encroachon nurses' professional territory.9%^nurses' misperception of physicians' views on whether physicians expecttoo much of nurses.9%^physicians' misperception of nurses' views on whether nurses have a higherstatus than physicians.1099%^physicians' misperception of nurses' views on whether physicians are verydefensive about their professional prerogatives.9%^nurses' misperception of physicians' views on whether nurses trustphysicians' professional judgment.9%^physicians' misperception of nurses' views on whether physicians are welltrained.8%^nurses' misperception of physicians' views on whether physicians have verylittle autonomy.8%^nurses' misperception of physicians' views on whether nurses are highlyethical.7%^physicians' misperception of nurses' views on whether physicians arecompetent.7%^physicians' misperception of nurses' views on whether physicianssometimes encroach on nurses' professional territory.6%^physicians' misperception of nurses' views on whether physicians expecttoo much of nurses.6%^physicians' misperception of nurses' views on whether nurses cooperatewell with physicians.6%^nurses' misperception of physicians' views on whether nurses cooperatewell with physicians.6%^physicians' misperception of nurses' views on whether physicians cooperatewell with nurses.5%^physicians' misperception of nurses' views on whether nurses arecompetent.5%^physicians' misperception of nurses' views on whether nurses are highlyconcerned with the welfare of the patient.5%^physicians' misperception of nurses' views on whether nurses encroach onphysicians' professional territory.5%^nurses' misperception of physicians' views on whether physicians are verydefensive about their professional prerogatives.5%^nurses' misperception of physicians' views on whether physicians trustnurses' professional judgment.5%^nurses' misperception of physicians' views on whether nurses askphysicians for professional advice.1104%^nurses' misperception of physicians' views on whether physicians arecompetent.4%^physicians' misperception of nurses' views on whether physicians seldomask nurses for professional advice.3%^nurses' misperception of physicians' views on whether nurses understandthe capabilities of physicians.3%^nurses' misperception of physicians' views on whether physicians arehighly concerned with the welfare of the patient.3%^physicians' misperception of nurses' views on whether physicians have ahigher status than nurses.3%^physicians' misperception of nurses' views on whether nurses have goodrelations with physicians.3%^nurses' misperception of physicians' views on whether nurses have goodrelations with physicians.2%^nurses' misperception of physicians' views on whether nurses are highlyconcerned with the welfare of the patient.2%^nurses' misperception of physicians' views on whether physicians arehighly ethical.2%^nurses' misperception of physicians' views on whether physicians cooperatewell with nurses.2%^physicians' misperception of nurses' views on whether nurses are welltrained.2%^nurses' misperception of physicians' views on whether nurses are welltrained.2%^nurses' misperception of physicians' views on whether physicians are welltrained.1%^physicians' misperception of nurses' views on whether physicians have verylittle autonomy.1%^physicians' misperception of nurses' views on whether nurses understandthe capabilities of physicians.1%^nurses' misperception of physicians' views on whether physicians havegood relations with nurses.111In table 5 a list is provided indicating the issues around which either the physicians or thenurses appear not to have a misperception of the views held by the members of the otherprofession.Table 5 List of Issues Around Which There is no Misperception Found Among Either thePhysicians or the Nurses in Long-Term Care FacilitiesDEGREE OFMISPERCEPTION^ISSUE0%^nurses' misperception of physicians' views on whether physiciansunderstand the capabilities of nurses.0%^nurses' misperception of physicians' views on whether physicians have ahigher status than nurses.0%^physicians' misperception of nurses' views on whether physicians havegood relations with nurses.112CHAPTER 5Discussion of the FindingsIntroductionThe survey among the physicians and the nurses of 13 long- term care facilities inVancouver, British Columbia, has measured the misperceptions among these professionals on 15professional issues. A total of thirty one physicians responded to the voluntary survey. Threeresponses of the physicians were incomplete and could not be included in the study, leaving asample of twenty eight physicians (n = 28). Sixty-eight nurses responded, of which 2 nursesprovided incomplete responses, leaving a sample of sixty-six (n = 66) nurses. All theinformation obtained through the survey has been tabulated in the previous chapter and is furtherdiscussed in this chapter.The chapter has been divided into three sections. The first section provides a generaloverview of the misperceptions found among the physicians and the nurses. Finer details of themisperceptions are discussed in the second section of the chapter. In this section the subjects'direct perceptions as well as related misperceptions each are discussed under the headings of the15 separate professional issues, which have been measured by the Interprofessional PerceptionScale (Ducanis and Golin, 1979). The third section of the chapter provides a summary of thefindings.Misperceptions Among the Physicians and the NursesBased upon the predetermined range of values from Fleiss (1981), where values below40% are taken to represent very little misperception, it appears that there are very littlemisperceptions among the physicians and the nurses in long- term care facilities. In fact, on a113number of responses the majority of the physicians and the nurses appear to have nomisperceptions of the other profession at all.On the issue of how well physicians relate with nurses, the majority of the physiciansperceived that nurses will agree that physicians have good relations with nurses. An equalmajority of nurses indeed confirmed that they find the physicians to relate well with nurses.Similarly, there appears to be no misperception on the part of a majority of the nurses ontwo additional issues. A majority of nurses perceives that physicians will say that physicians dohave a higher status than nurses, which is confirmed by an equal majority of physicians. Amajority of nurses also perceive that physicians will say that physicians do understand thecapabilities of nurses. Indeed, a similar percentage of physicians shares this notion.Even though equal majorities of physicians and nurses seem to confirm each others'perceptions on these certain issues, the two professions still appear to be apart on these otherissues based on the expressed direct views by the members of each of the professions. Thespecific details on these direct perceptions are discussed in the next section. The fact remains,however, that the majority of the one profession sees eye to eye with the exact same majority ofthe other profession on these three important professional issues in collaborative team work.The one issue around which there appears to be the highest degree of misperceptionconcerns the nurses' expectations of physicians. A majority of 61 % nurses perceives thatphysicians will say that nurses do expect too much of physicians. However, a much smallerpercentage of physicians expresses a similar view. In fact, only 25% of the physicians do saythat nurses expect too much of the physicians. The nurses, therefore, have a 36% degree ofmisperception of the physicians on the issue, which, according to Fleiss (1981), is considered tobe still a very little degree of misperception.Despite the fact that all the degrees of misperceptions among the subjects in the surveyhave been found to be very little or even non-existent, it should be pointed out that such findings114do not automatically mean that all is smooth between the physicians and the nurses. There areseveral illustrations of this point described in the next section of this chapter.The participant responses are discussed further under the headings of the 15 separateprofessional issues underlying the Interprofessional Perception Scale in the next section. Areas ofconcern are identified and discussed in conjunction with both misperceptions and the relateddirect perceptions expressed by the members of each of the professions.Discussions of the Findings for Each of the 15 Professional Issues Issue No. 1 - Professional CompetencyLarge majorities of physicians (93%) and nurses (95%) say that nurses in long-term carefacilities are competent. The physicians appear to have only a very small misperception (5%)about the nurses' own views of their competency. Of interest, however, is the perception held by17% of the nurses who perceive that physicians will say that nurses are not competent. This(17% - 7% = 10%) misperception on the part of the nurses is a small misperception held by aminority of nurses, but still is noteworthy. It will benefit these nurses to know that 93% of thephysicians with whom they work in long-term care facilities think that nurses are competent. Inother words, the actual number of physicians, who believe that nurses are competent is higherthan is expected by the group of nurses. Perhaps this misperception reflects a degree of lowself-esteem or a lack of self- confidence or a feeling of not being respected and valued. A largemajority of physicians (96%) think that physicians are competent. This opinion, however, isshared by only 86% of the nurses. Interestingly, all nurses (100%) do perceive that physicianswill think of themselves as competent. This perception turns out to be only a small misperception(100% - 96% = 4%).It will be of interest to the physicians to know that all nurses in long-term care facilitiesbelieve that physicians think of themselves as competent, but that not every nurse actually agrees115with this perception. Nor does 4% of the physicians' own membership believe that physicians arecompetent in long-term care facilities.The administration of the long-term care facilities should take note that also 5% of thenurses has described themselves as not competent. These findings of self-confessed incompetencyamong the physicians and the nurses may reflect their high sense of self-criticism, or mayindicate their need for educational opportunities to enhance their professional skills andknowledge.Issue No. 2 - Professional AutonomyApproximately one third of the physicians (36%) and the nurses (39%) appear to believethat nurses in long-term care facilities have very little autonomy. The fact that approximately onethird of both groups have close agreement on this issue is, of itself, a concern. Their respectivemisperceptions on the issue are further apart. The physicians have a 22% misperception of thenurses' views on the issue of nurses' professional autonomy, and the nurses have a 9%misperception of the physicians' views on this issue.These figures compare to much lower percentages expressed on the autonomy issue forphysicians. A fourth or 25% of the physicians and 17% of the nurses say that physicians inlong-term care facilities have very little autonomy. The physicians have a very smallmisperception (1 %) of the nurses' views, and the nurses have an 8% degree of misperception ofphysicians' views on the issue of physician's professional autonomy.It seems that physicians are perceived to enjoy higher levels of professional autonomy inlong-term care facilities than nurses. Judging further from the direct views on the issue, theperception seems to be acknowledged almost equally by both professions.Despite the fact that physicians appear to have higher levels of autonomy, still 25% of thephysicians say that they have very little autonomy. It appears, therefore, that considerable116numbers of members in both professions believe that they have very little professional autonomyin long-term care facilities. It has been stressed in the literature that professionals have a need tobe autonomous (Nason, 1983; Stein, et al., 1990). The findings of this survey show thatsignificant numbers of physicians and nurses do not see their needs for professional autonomymet.Issue No. 3 - Professional CapabilitiesThe majority of physicians (82%) and nurses (97%) believe that nurses understand thecapabilities of physicians in long-term care facilities. The physicians only have a 1%misperception of nurses on this issue, and the nurses only have a 3% misperception.Of concern is the belief of 18% of the physicians who say that nurses do not understandthe capabilities of physicians. Eventhough only 3% of the nurses admits to this lack ofunderstanding, the fact remains that 18% of the physicians still believes that nurses, with whomthey work in the facility, do not understand their capabilities.A majority of 89% of the physicians say that they do understand the capabilities of nursesin long-term care facilities, whereas only 64% of the nurses believe this understanding to be true.The two professions appear to be considerably more apart on this issue (89% - 64% = 25%) ascompared to the issue of the nurses' (97% - 82% = 15%) understanding of the physicians'capabilities. The perception appears to exist that in long-term care facilities nurses understandphysicians better than physicians understand nurses with respect to each others' professionalcapabilities. The review of the literature on professional capabilities has illustrated the physicians'lack of understanding the capabilities of nurses in other clinical areas such as obstetrics(Hutchison, 1993). Whether the physicians truly have a lack of understanding the nurses'capabilities also in long-term care facilities needs to be further explored. The administration ofthe long-term care facilities should take note that 36% of the nurses and 18% of the physicians117feel that their respective capabilities are not understood by the members of the other profession.A feeling of not being understood is frustrating and will not enhance the collaborative effortbetween the two professions.There is also a considerable difference in the degrees of misperception on the part of bothprofessions. The physicians have a 21 % degree of misperception of nurses on the issue of thephysicians' understanding of nurses' capabilities. The nurses drastically differ, in this respect,with a 0% degree of misperception. The nurses appear to match their perceptions aboutphysicians' views on the issue of the physicians understanding of nurses' capabilities.This finding illustrates very well that nurses are still facing a problem in their collaborativeefforts with physicians, despite the fact that the nurses do not have a misperception of thephysicians' views. A large group of nurses (36%) still believes that physicians do not understandthe nurses' capabilities.Issue No. 4 - Professional Concern With Patient WelfareA majority of the nurses (95%) say that they are highly concerned with the welfare of thepatient. Most physicians (96%) believe that this conviction of the nurses in long- term carefacilities is true. As for the physicians, all of them (100%) say that they are highly concernedwith the welfare of the patient. Almost one third of the nurses (30%), however, believe thatphysicians in long-term care facilities are not highly concerned with the welfare of the patient. Inaddition, the majority of nurses (97%) perceive that physicians will say that they are highlyconcerned with the welfare of the patient.The misperceptions on the issue of the physicians' concern for the welfare of the patientare 12% on the part of the physicians and 3% on the part of the nurses. Once again, low degreesof misperceptions do not automatically mean that all is smooth between the physicians and thenurses. There appears to be a definite problem around the nurses' perceived lack of physicians'118concern for the welfare of the patient. The administration of long-term care facilities should takenote of this critical view of the physicians among nurses, and try to resolve the issue throughopen discussions with the two professional groups.Issue No. 5 - Professional TerritorialityThe issue of professional territoriality appears to be a concern of both professions. A ratherlarge minority of physicians (39%) feels that nurses sometimes encroach on physicians'professional territory. At the same time a small majority of nurses (61 %) also feels thatphysicians do encroach on the nurses' professional territory. In addition, 36% of the physicianssay that they encroach on nurses' territory, and 30% of the nurses say they encroach onphysicians' territory. It appears also that a fair number of physicians (39%) and a majority ofnurses (61 %) feel that their professional territory is violated by the members of the otherprofession. It also appears that significant numbers of physicians (36%) and nurses (70%) admitto their encroachment on the territory of the other profession.On the issue of nurses encroaching on the physicians' territory, the physicians have a 5%misperception of the nurses' point of view and the nurses have a 14% misperception of thephysicians' view. The view points of the members of the other profession on the issue ofphysicians encroaching on the nurses' territory is misperceived by 7% of the physicians and 9%of the nurses. The misperceptions are not high on the issue of professional territoriality, butjudging from the percentages of direct perspectives, there appears to be a potential problembetween the physicians and the nurses in long term care on the issue. Based on the literaturereview, this finding is not surprising. The literature indicates that the physicians and the nursesare known to encroach on each other's professional territory (Fagin and Diers, 1983). Thisencroachment is a highly sensitive area and a major barrier to collaborative practice (Fagin,1992).119Issue No. 6 - Professional EthicsThe majority of nurses (89%) in long-term care facilities think of themselves as highlyethical, and most physicians (93%) share this view. Many nurses (85%) actually expect thatphysicians, indeed, will say that nurses are highly ethical. In fact, nurses have only an 8%misperception of the physicians' view on the nurses' level of ethics.The situation is slightly different for the physicians. A large majority of physicians (93%)say that they are highly ethical, but only 71 % of the nurses share this view. This difference willcome as a surprise to the physicians, because a majority of 93% of them perceive that nurses willsay that physicians are highly ethical. In fact, the physicians have a 22% misperception of thenurses' view on this issue.The profile of the 29% nurses who say that physicians are not highly ethical consists ofOriental registered nurses, who mostly are in their 40s and are diploma trained (see table 6). Ofnote is the high representation of Oriental nurses in this group. Perhaps there is a difference inoutlook on what constitutes ethical behavior based on one's ethnic background.Also of interest are the findings that 7% of physicians and 11 % of nurses say that they(physicians and nurses respectively) are not ethical. It appears ethics is an area of concern bothinterdisciplinary and intradisciplinary, which requires further exploration. Perhaps the changes intechnology in long term care have created new ethical dilemmas that need collaborative problemsolving both inter- and intradisciplinary.120Table 6^Demographic Data of the 29% Nurses who Say that Physicians in Long-Term CareFacilities are Not Highly Ethical.N = 19 = 100%GENDER: FEMALE^ N = 19 = 100%MALE N = 0 = 0%AGE (*):^20-30^ N = 1 =^5%31-40 N = 5 = 26%41-50 N = 8 = 42%Over 50^ N = 5 = 26%NUMBER OF YEARS THE NURSES HAVE CARED FOR PATIENTS IN LONG-TERMCARE FACILITIES (*):1-5 YEARS N = 6 = 32%6-10 YEARS N = 2 = 11 %11-15 YEARS N = 6 = 32%OVER 15 YEARS N = 5 = 26%EDUCATIONAL PREPARATION (*):DIPLOMA N = 14 = 74%SPECIALTY CERTIFICATION N = 2 = 11 %BACCALAUREATE N = 3 = 16%MASTERS N = 0 = 0%PROFESSIONAL DESIGNATION (*):RN N = 10 = 53%RPN N = 3 = 16%LGN N = 6 = 32%ETHNIC BACKGROUND:CAUCASIAN N = 7 = 37%ORIENTAL N = 11 = 58%NATIVE INDIAN N = 0 = 0%EAST INDIAN N = 0 = 0%OTHER N = 1 = 5%NURSES' JOB SATISFACTION:POOR N = 0 = 0%GOOD N = 16 = 84%EXCELLENT N = 3 = 16%(*) The percentages are rounded off, so they do not always add up to 100%121Issue No. 7 - Interprofessional Role ExpectationsA majority of physicians (75%) feel that nurses do not expect too much of the physiciansin long-term care facilities. An almost equal majority of nurses (76%) share this view. Yet, alarge number of nurses (61 %) perceive that physicians will say that nurses do expect too much ofphysicians. This perception turns out to be a 36% misperception on the part of the nurses, and isthe highest degree of misperception found in this survey among the nurses and the physicians inlong-term care facilities. It seems that some nurses believe that they are not expecting too muchof physicians, but they get the impression that physicians think differently. It will benefit thesenurses to know that 25% of the physicians feel that nurses expect too much of physicians. Thispercentage is high enough to validate the nurses' perception that physicians will say that nursesdo expect too much of physicians, but it may be important to show the nurses that it is only onequarter of the physicians.The nurses appear to be almost equally split on the issue of physicians' expectations ofnurses. A small majority (56%) think that physicians do not expect too much of them, but 44%of the nurses say that physicians do expect too much. The profile of the 44% nurses consistsmostly of Oriental licensed graduate nurses, who are in their 40s and are diploma trained. Mostof these nurses have worked between 6 to 10 years in long-term care facilities (see table 7). Ofnote is the high representation of licensed graduate nurses in this group. Although a majority ofphysicians (79%) believe that they do not expect too much of the nurses in long-term carefacilities, 21% say physicians do expect too much. The profile of the 21% of physicians does notsignificantly differ from the total group.The misperceptions of the other profession's view on the issue are small, the physicianshave a 6% misperception and the nurses have a 9% misperception. Both professions seem to befairly much in tune with what views are held by the other profession on the issue of thephysicians expectations of nurses. The problem seems to rest with the direct perceptions,122Table 7^Demographic Data of the 44% Nurses who Say that Physicians Do Expect TooMuch of Nurses in Long-Term Care Facilities.N = 29 = 100%GENDER: FEMALE^ N = 28 = 97%MALE N = 1 = 3%AGE (*): 20-30^ N = 0 =^0%31-40 N = 8 = 28%41-50 N = 17 = 59%Over 50^ N = 4 = 14%NUMBER OF YEARS THE NURSES HAVE CARED FOR PATIENTS IN LONG-TERMCARE FACILITIES:1-5 YEARS N = 4 = 14%6-10 YEARS N = 10 = 34%11-15 YEARS N = 7 = 24%OVER 15 YEARS N = 8 = 28%EDUCATIONAL PREPARATION:DIPLOMA N = 20 = 69%SPECIALTY CERTIFICATION N = 4 = 14%BACCALAUREATE N = 5 = 17%MASTERS N = 0 = 0%PROFESSIONAL DESIGNATION:RN N = 13 = 45%RPN N = 2 = 7%LGN N = 14 = 48%ETHNIC BACKGROUND:CAUCASIAN N = 8 = 28%ORIENTAL N = 18 = 62%NATIVE INDIAN N = 0 = 0%EAST INDIAN N = 2 = 7%OTHER N = 1 = 3%NURSES' JOB SATISFACTION:POOR N = 0 = 0%GOOD N = 24 = 83%EXCELLENT N = 5 = 17%(*) The percentage are rounded off, so they do not always add up to 100%123especially the ones expressed by the nurses, who are not together on whether physicians expecttoo much from the nurses. Based on these findings, the nurses appear to be confused on the issueof role expectations, which confirms earlier views expressed by Fagin (1992). The author pointsout that medicine and nursing overlap in many areas of their service to patients, which hascontributed greatly to the confusion around role expectations. This area needs further explorationto determine how problematic this issue is as a barrier to collaboration.Issue No. 8 - Professional StatusNone of the physicians feel that nurses have a higher status than physicians in long-termcare facilities. Furthermore, none of the physicians even expect nurses to think that nurses have ahigher status than physicians. These direct perspectives are in keeping with the traditional viewof the status of physicians and nurses (Ducanis and Golin, 1979; Ornstein, 1990). Of interest,however, is the small minority (9%) of nurses who feels that they do have a higher status thanphysicians. Accordingly, the physicians have a 9% misperception of the nurses' views on theissue. The profile of these 9% nurses consists mostly of Caucasian registered nurses, who areolder than 50 and are diploma trained (see table 8). Of note is the high representation of oldernurses in this group.A majority of 79% of the nurses feel that physicians do have a higher status than nurses inlong-term care facilities. Most nurses (86%) also expect that physicians will say that they have ahigher status than nurses. An equal number of physicians, indeed, say that they have a higherstatus. Accordingly, the nurses have no misperception of physicians' views on this issue. Ofinterest is the 14% of physicians, who say they do not have higher status than nurses. Thisperception goes against the traditional view. Their profile does not significantly differ from thetotal group of physicians in the survey.124Table 8^Demographic Data of the 9% Nurses who Say that Nurses Do Have a HigherStatus than Physicians in Long-Term Care FacilitiesN = 6 = 100%GENDER: FEMALE^ N = 6 = 100%MALE N = 0 = 0%AGE:^20-30^ N = 0 = 0%31-40 N = 2 = 33%41-50 N = 1 = 17%Over 50^ N = 3 = 50%NUMBER OF YEARS THE NURSES HAVE CARED FOR PATIENTS IN LONG-TERMCARE FACILITIES (*):1-5 YEARS N = 0 = 0%6-10 YEARS N = 2 = 33%11-15 YEARS N = 2 = 33%OVER 15 YEARS N = 2 = 33%EDUCATIONAL PREPARATION:DIPLOMA N = 5 = 83%SPECIALTY CERTIFICATION N = 0 = 0%BACCALAUREATE N = 1 = 17%MASTERS N = 0 = 0%PROFESSIONAL DESIGNATION:RN N = 5 = 83%RPN N = 1 = 17%LGN N = 0 = 0%ETHNIC BACKGROUND:CAUCASIAN N = 4 = 67%ORIENTAL N = 2 = 33%NATIVE INDIAN N 0 = 0%EAST INDIAN N = 0 = 0%OTHER N = 0 = 0%NURSES' JOB SATISFACTION:POOR N = 0 = 0%GOOD N = 5 = 83%EXCELLENT N = 1 = 17%(*) The percentages are rounded off, so they do not always add up to 100%125Issue No. 9 - Professional EthnocentrismThe subjects have been asked to comment on their defensiveness about their professionalprerogatives. Professionals may feel that they have certain prerogatives or privileges simplybecause they are "the physician" or "the nurse", and will go to great lengths to protect theseprofessional privileges. A sense of defensiveness of one's professional prerogatives partiallyreflects one's feelings of professional ethnocentrism.A large minority of physicians (43%) feel that nurses in long-term care facilities are verydefensive about their professional prerogatives. An almost equal number of nurses (53%),indeed, say that they are defensive. The majority of nurses (71 %), in fact, expect physicians tocome to this same conclusion. This perception on the part of the nurses is a 28% misperceptionof the physicians on the issue. It seems that almost half of the nurses see themselves definitely asdefending their prerogatives, and they also believe that they are not hiding this fact from thephysicians.A fairly large group of physicians (43 %) feel that they also are very defensive of theirprofessional prerogatives. A much larger group of nurses (77%) appear to have come to the sameconclusion. The physicians seem to be aware of these feelings among nurses, because they haveonly a 9% misperception of the nurses' view on the issue.Both professions appear to be fairly defensive groups of their respective prerogatives, andthis sense of professional ethnocentrism also appears to be mutually acknowledged by thephysicians and the nurses. Ducanis and Golin (1979) have cited professional ethnocentrism as aprimary barrier to collaborative team work. It is fundamental to the survival of the collaborativeteam that one acknowledges that all its members are equally important. Based on this view, thefindings of this survey on professional ethnocentrism among the physicians and the nurses inlong-term care facilities become a primary area of concern. It may be useful to exploreterritoriality issues together with ethnocentrism.126Issue No. 10 - Interprofessional TrustThe majority of nurses (73%) say that they do trust physicians' professional judgment.Most of the physicians (89%) perceive that nurses indeed will say that they do trust them.However, the physicians appear to have a 16% degree of misperception of nurses' views on thisissue. Eleven percent of physicians say nurses do not trust them.It should be noted, also, that a fairly large number of nurses (27%) say that they do nottrust the physicians' judgment. In addition, 14% of physicians say they do not trust nurses.The majority of physicians (86%) say that they do trust nurses' professional judgment. Anexact same majority of nurses (86%) indeed feel that physicians do trust them. The majority ofthe nurses (91 %), in fact, expects that physicians will say that they trust the nurses. Thereappears to be a 5% misperception on the part of the nurses of the physicians' view on this issue.For the most part, it appears that both professions do trust each other's professionaljudgment. The majorities of both professions also believe that they can count on the otherprofessional's trust. However, the 27% of nurses who do not trust physicians and the 14% ofphysicians that say they do not trust nurses is still noteworthy. Trust is a very central element inany collaborative relationship (Ornstein, 1990).Issue No. 11 - Interprofessional AdviceA rather large majority of nurses (95%) say that they do ask physicians for professionaladvice. Equally, a majority of physicians (75%) feel that nurses indeed do ask them for advice.In the reverse situation, it is noted that the majority of physicians (71 %) say that they also askthe nurses for professional advice. However, the majority of the nurses do not seem to share thisnotion. In fact, 65% of the nurses say that they feel that physicians seldomly ask nurses foradvice.127In the eyes of this majority of nurses the physicians are not asking the nurses forprofessional advice, yet the majority of physicians say that they do ask the nurses for theiradvice. Interestingly enough, a small majority of nurses (52%) perceive that physicians indeedwill say that they do ask nurses for professional advice. This perception turns out to be a 19%misperception on the part of the nurses of the physicians' views on the issue. Perhaps nursesacknowledge that physicians ask them many questions, but in the eyes of the nurses thesequestions do not necessarily get at the arsenal of the nurses' professional advice.These findings bring out a rather interesting difference between the majorities of physiciansand nurses in the way both professionals assess this issue. There might be a difference of opinionbetween the two professions on what constitutes "professional advice".Issue No. 12 - Interprofessional Utilization of CapabilitiesA small majority of physicians (64%) believe that nurses do fully utilize the capabilities ofthe physicians in long- term care facilities. This notion is shared by a majority of 85% of thenurses. In the reverse situation, a very small majority of nurses (55%) feel that physicians dofully utilize the capabilities of nurses. The group of physicians are split in half on the issue.Exactly 50% of the physicians say that they do fully utilize the capabilities of nurses. It appearsthat significant numbers of physicians (36%) and nurses (45%) believe that their capabilities arenot fully utilized by the members of the other profession. What is of interest is that half of thephysicians in the survey admit that they do not fully utilize the capabilities of nurses, and that15% of the nurses admit not to utilize the physicians fully either.On the issue of the utilization of the physicians, the physicians misperceive the views of thenurses by 17%, and the nurses misperceive the views of the physicians by 16%. On the issue ofthe utilization of the nurses, the physicians misperceive the views of the nurses by 19%, and thenurses misperceive the views of the physicians by 30%. Even though all these misperceptions are128considered to be small, it appears that both groups of professionals on this issue have developedmisperceptions of each other, which differ in one important aspect from all the misperceptionsthe professionals have of each other on any of the other issues. In this survey groups of 4misperceptions are computed per issue, two for each profession. As a group of 4, themisperceptions relating to the issue of interprofessional utilization of capabilities ranks as thehighest in comparison with all the other groups of misperceptions (see table 4, p. 107).In summary, it appears, therefore, that significant numbers in both professionals are notusing each others' capabilities as much as each profession wants to be used, and they also are notin tune with the views of the other professionals on the issue. This underscores the findings inthe literature that physicians and nurses do not have opportunities in their educational process tolearn about one another's capabilities (Fagin, 1992). Most interestingly, however, is that somephysicians and nurses admit not to use the other professions' capabilities. It appears that there isroom for improvement on the part of both professions. Both can gain a better perception of theother profession's views on the issue, and both professions can increase their utilization of thecapabilities of the members of the other profession.Issue No. 13 - Interprofessional CooperationIn terms of interprofessional cooperation, it appears that the physicians do not score as wellas the nurses are doing in long-term care facilities. A higher percentage among nurses (35%)believe that physicians do not cooperate well, compared to only 14% of the physicians, whobelieve that the nurses do not cooperate well.In their self-evaluation as cooperative team members, a large majority of nurses (95%) dobelieve that they cooperate well with physicians, and also a large majority of physicians (86%),in turn, think of themselves as cooperating well with nurses. In great parts, these notions areshared by the members of the other profession. The majority of physicians (86%), indeed, say129that nurses do cooperate well with them, and 65% of the nurses say that physicians do cooperatewell with the nurses.In their genuine efforts to become cooperative team members, it appears that physicianscould stand to gain the most from these findings. The fairly large majority of physicians (86%),who believe that they are good cooperative team members must realize that only 65% of thenurses share this view with them. It is encouraging to note that the physicians do appear to beaware of their reputation as cooperative team members. Among the physicians only 71 %perceives that the nurses, indeed, will say that physicians cooperate well with nurses. Thisperception is only a 6% misperception on the part of the physicians, but seen in the context ofthe other findings the physicians are wise to take a careful look at how well they are perceivedby the nurses as cooperative team members. At the same time, 14% of physicians say that nursesdo not cooperate well with physicians. It might be conjectured, that other issues such asterritoriality and ethnocentrism or defensiveness may influence the degree of interprofessionalcooperation. Strong sense of territoriality and ethnocentrism might correlate negatively withinterprofessional cooperation. This conjecture needs further exploration. In addition, there maybe differences in how cooperation is defined. This also needs further exploration.Issue No. 14 - Professional TrainingGenerally, both the physicians and the nurses are thought off as well trained. Highpercentages of physicians (96%) and nurses (80%) say that physicians in long-term care facilitiesdefinitely are well trained. The percentages for the nurses are assessed at somewhat lower levelsby the physicians. A majority of 75% physicians say that nurses are well trained and this notionis shared by 94% of the nurses. Of interest is the 25% physicians, who feel that the nurses inlong-term care facilities are not well trained.130The large majority of nurses (94%), who think of themselves as well trained must realizethat only 75% of the physicians have a similar view on the issue. With a degree of misperceptionof only 2%, it appears that the nurses are well aware what physicians will say about the traininglevels of nurses in long-term care facilities. With a quarter of the physicians thinking that nursesare not well trained, both professions will have to work hard to remedy the issue and avoidhaving it stand in the way of their collaborative team work. The question arises as to whether itis additional training that is needed for the nurses or an improved ability to articulate their uniqueareas of knowledge without becoming defensive. Ornstein (1990) suggests that nurses actuallyhave no choice in this instance. She feels that nurses should obtain additional training as well asimprove on their skills in articulation.A final point of interest is the 11 % of physicians who perceive that nurses will sayphysicians are not well trained, and the 20% of nurses who, indeed, say that physicians are notwell trained. This reflects a 9% misperception on the part of the physicians of the nurses' viewon how well the physicians are trained. This finding among one fifth of the nurses needs furtherexploration to determine what "well trained" means to these nurses. It may well be thatphysicians are in need of additional education specifically related to long term care.Issue No. 15 - Interprofessional RelationshipsBased on all the previously discussed findings, the specific findings for this last issue arenot a surprise. For the most part, both professions indicate that they have good relations witheach other, which is in keeping with what has been described in the literature (Fagin, 1992).Equally high percentages of physicians and nurses (both at 89%) express the view that nurseshave good relations with physicians in long-term care facilities. The two professions aresomewhat apart in their assessments of how well physicians relate to nurses, but still give the131physicians high marks. A large majority of the physicians (96%) feel that they do have goodrelations with nurses. This view was shared by the nurses, but at a lower percentage of 82%.The physicians appear to have no misperceptions at all of what nurses are saying about thephysicians' ways of relating with nurses in long-term care facilities. With a misperception of 1 %,the nurses are not far behind on this issue. . On the nurses' ways of relating with the physicians,the misperceptions are very low as well. Both the physicians and the nurses have a 3%misperception of each other on the issue. Both professions appear to be very well aware of theviews held by the members of the other profession on the issue of interprofessional relationships.However, as a final comment, physicians would benefit to know that 18% of the nursesthink physicians do not relate well with nurses. Almost one , out of every five nurses appears tohave a negative feeling about the physicians' ways of relating with nurses. Of note is the findingthat most of these 18% nurses have worked less than 5 years in long-term care facilities (seetable 9). Perhaps these nurses have recent work experiences in areas other than long term care,such as acute care. If this conjecture is valid, these nurses may be in a position to compare theircurrent professional relationships with physicians to the relationships they have had in theirprevious work settings. Such comparisons could shed some light on possible differences incollaborative practice as seen in long term care and other segments of the health care system. Ofinterest also would be to find out whether these nurses will agree with Fagin's observation(1992), that the relationship with the physicians is still a hierarchical one, where the nurse issubordinate to the physician. This would be suggested by the responses to many other relatedissues, including status, capabilities and role expectations.132Table 9^Demographic Data of the 18% Nurses who Say that Physicians Do Not Have GoodRelations with Nurses in Long-Term Care FacilitiesN = 12 = 100%GENDER: FEMALE^ N = 11 = 92%MALE N = 1 = 8%AGE:^20-30^ N = 1 =^8%31-40 N = 2 = 17%41-50 N = 7 = 58%Over 50^ N = 2 = 17%NUMBER OF YEARS THE NURSES HAVE CARED FOR PATIENTS IN LONG- TERMCARE FACILITIES:1-5 YEARS N = 5 = 42%6-10 YEARS N = 1 = 8%11-15 YEARS N = 3 = 25%OVER 15 YEARS N = 3 = 25%EDUCATIONAL PREPARATION:DIPLOMA N = 11 = 92%SPECIALTY CERTIFICATION N = 1 = 8%BACCALAUREATE N = 0 = 0%MASTERS N = 0 = 0%PROFESSIONAL DESIGNATION:RN N = 5 = 42%RPN N = 3 = 25%LGN N = 4 = 33%ETHNIC BACKGROUND (*):CAUCASIAN N = 6 = 50%ORIENTAL N = 4 = 33%NATIVE INDIAN N = 0 = 0%EAST INDIAN N = 1 = 8%OTHER N = 1 = 8%NURSES' JOB SATISFACTION:POOR N = 0 = 0%GOOD N = 8 = 67%EXCELLENT N = 4 = 33%(*) The percentages are rounded off, so they do not always add up to 100%133Summary of the FindingsTwo summaries are provided in this section. First, the findings are summarized on the 15professional issues included in the survey among the physicians and the nurses in long-term carefacilities. The second summary deals with the subjects' demographic correlates ofinterprofessional misperceptions and team work.Summary of the Findings on the 15 Professional IssuesThe physicians and the nurses in long-term care facilities do not seem to have majormisperceptions of each other's views on the 15 important professional issues. The degrees ofmisperceptions range from 0% to 36%, and are all considered to be very small. A majority ofthe misperceptions, in fact, are at 7% or lower.However, when considered in conjunction with the related direct views that have beenexpressed by the subjects in the survey, some of these issues do gain in significance. That is,they agree on many items on which one or both professional groups are dissatisfied. Themisperception may be small, but the issue that surrounds the misperception still may createproblems for the professionals involved. This point is true, for instance, for the misperceptionsrelating to the issue of professional territoriality. The misperceptions are between 5% and 14%.In other words, both professions have a fairly good idea of what the members of the otherprofession think on the issue of mutually encroaching onto each other's professional territory.Despite the fact that the one profession fairly well knows where the other one stands on theissue, both professions still are faced with a definite problem. Amongst the group of physicians,39% feels that nurses encroach on the physicians' professional territory. An even largerpercentage of nurses (61 %) feel that physicians encroach on their territory.These relatively large numbers of physicians and nurses, who feel that the other professionis encroaching on their territory, partially indicate that both professions have strong feelings of134professional ethnocentrism. The findings in the survey on the subjects' defensiveness of theirprofessional prerogatives seem to confirm that significant numbers among the professionalsindeed have these strong feelings of professional ethnocentrism.Despite these strong and somewhat negative feelings, majorities in both professionsgenerally also express very positive feelings about the other profession. Most of them feel thatthe members of the other profession cooperate well with them. In fact, large numbers ofphysicians and nurses indicate that they have good relations with each other. It is good to notethat both professions generally have expressed these positive feelings of each other, but a moredetailed look at their responses to some of the other issues in the survey still brings out someconcerns.As noted in the previous section, the majorities of physicians and nurses believe that themembers of the other profession are competent and well trained. In fairly large numbers bothprofessions also express their trust in the professional judgment of the members of the otherprofession. With all this expressed trust and belief in each other's competency, it is concerning tonote that significant numbers in both professions feel that their capabilities are not fully used bythe members of the other profession. This apparent discrepancy is surprising, especially when itis noted that both professions actually claim to understand the capabilities of the members of theother profession. They understand the capabilities, but they do not use them.Despite all the trust in the nurses' competency by the majority of physicians, it isnoteworthy to find that most nurses feel that physicians seldom ask the nurses for theirprofessional advice. It is not surprising, therefore, to find that a small majority of nurses feel thatphysicians do not expect too much of the nurses.An additional point, which likely will be of more concern to the physicians than the nurses,relates to the views of both professions on the issues of professional ethics and patient welfare.The physicians do not fare as well as the nurses on both these issues. Higher percentages of135nurses are seen to be ethical and highly concerned with the welfare of the patient in comparisonwith the correlating percentages among the group of physicians in long-term care facilities.A final point of interest to be included in this summary of the findings, concerns the issuesof professional status and professional autonomy. Large numbers in both professions believe thatphysicians have a higher professional status than nurses. Despite the acknowledged higher statusof the physicians, one fourth of the physicians feels that they have very little autonomy inlong-term care facilities.Summary of the Demographic Correlates of Interprofessional Misperceptions and TeamWorkTo complete the summary section of this chapter general profiles are included of thephysicians and the nurses, who participated in the survey. The profile of the 28 participatingphysicians consists mostly of Caucasian male family practitioners, who are in their 40s, andsome are over 50 years old. Most of these physicians have worked for more than 15 years inlong-term care facilities (see table 1, p. 76). Most of the 66 nurses in the survey are Caucasianor Oriental female registered nurses, who are diploma trained and are in their 40s. The nurseshave worked anywhere from a few months to more than 15 years in long-term care facilities (seetable 2, p. 78). The physicians and the nurses appear to be fairly close in their age distribution.The nurses, however, have a wider range in years of work experience in long-term care facilitiesas compared to the physicians. Of note is the difference in ethnic background between the twoprofessions. The fairly high representation of Oriental nurses compares significantly to the lowpercentage of Oriental physicians. Given that the majority of the nurses are diploma trained, it isobvious that the two groups of professionals are far apart in terms of their educationalpreparation. Finally, the two groups definitely differ with respect to their gender.136A total of 138 physicians had been invited to participate in the survey. Only 31 physicianshave responded, leaving the physicians with a response rate of 22%. In addition, of the 31questionnaires, 3 have been filled out incomplete. The rather low response rate seems to partiallyconfirm the notion that physicians have a limited interest in the administrative fimctioning of ateam (Hanlon and Gladstein, 1984).The response rate for the nurses is considerably higher at 62%. The questionnaire has beendistributed to 110 nurses, and 68 nurses have returned their copy. A comparison across the threedifferent professional designations shows that the registered nurses have a considerably lowerresponse rate than the licensed graduate nurses and the psychiatric nurses in the survey (see table3, p. 79). In all, two participants had returned an incomplete questionnaire, leaving a sample of66 nurses.From table 2 it is noted that all the nurses say that their job satisfaction is either good orexcellent. None of the nurses describe their job satisfaction as poor. The important aspect of jobsatisfaction, as noted in Chapter Two, is the argument that job satisfaction is increased as theprofessionals are exposed more to true collaborative team work. Based on the current findings itcould be concluded that the level of job satisfaction is not related to whether the nurses havenegative feelings about their collaborative experiences with the physicians. At the same time,however, one could also draw the conclusion that the relative low degrees of misperceptionpartially might have contributed to the positive feelings surrounding the nurses' job satisfaction.In this chapter all the findings have been discussed of the survey conducted among thephysicians and the nurses in 13 long-term care facilities in Vancouver, British Columbia. All themisperceptions and direct perceptions among the subjects have been reviewed under the headingsof the 15 separate professional issues found in the Interprofessional Perception Scale. Thesefindings have been summarized at the end of the chapter together with a summary of thesubjects' demographic correlates of interprofessional misperceptions and team work.137The next chapter is devoted to summarize the entire study and make some concludingremarks about the findings. The limitations of the study are outlined as well in this final chapterand also strategies are indicated that may be implemented to enhance team collaboration inlong-term care facilities. In addition, several suggestions are made to further explore theconcerns and the questions that have surfaced in the course of this study.138CHAPTER 6ConclusionIntroductionIn this final chapter of the report some concluding remarks are made about the findings ofthe survey on the interprofessional misperceptions among physicians and nurses in long-term carefacilities.The chapter has been divided into five sections. A summary of the study is provided in thefirst section. In the second section limitations of the study are discussed. The third section in thischapter indicates possible strategies that could be implemented to enhance team collaboration inlong- term care facilities. In the fourth section suggestions are made for further study. In thefinal section some concluding remarks are made to this study.Summary of the StudyMuch attention has been devoted to the beneficial consequences of collaborative team workin health care (Baggs and Schmitt, 1988). Appropriate collaboration among physicians and nurseswill benefit the patients, the physicians and the nurses, as well as the health care organizations.Some benefits are well documented by research in the literature. Improved patient outcome andincreased levels of job satisfaction, as well as a decrease in overall health care costs have beenindicated as some of the benefits of using the collaborative team concept (Ritter, 1989; Ornstein,1990; Fagin, 1992).Despite the research evidence in support of interprofessional collaboration, historically,physicians and nurses are reported to seldom function collaboratively (Nason, 1983). This lack ofinterprofessional collaboration can be related to a number of major barriers that prevent139physicians and nurses from entering a collaborative work relationship. Interprofessionalmisperceptions on major professional issues has been indicated as one barrier (Banta and Fox,1972; Jacobson, 1974; Ducanis and Golin, 1979).Fagin (1992) and Samuelson (1992) report minimal research that has been done to assessthe effects of interprofessional collaboration in long-term care facilities. A review of theliterature for this study did not reveal any research available on the level of interprofessionalmisperceptions among the physicians and the nurses in long-term care institutions. The purposeof this exploratory study has been to examine the interprofessional misperceptions among thephysicians and the nurses in long-term care facilities in the city of Vancouver, British Columbia.The findings of the study indicate that there is very little misperception among the twoprofessions. In fact, the highest degree of misperception is only 36%, and is found among thenurses. They have a 36% misperception of physicians' views on whether or not nurses expect toomuch of the physicians. The rating scale used for the determination of degrees of misperceptionrates any percentage under 40% as very little misperception.When the findings of this survey on misperceptions are taken together with the claim madeby Banta and Fox (1972), Jacobson (1974), and Ducanis and Golin (1979) that misperceptionsform a major barrier in the way of collaboration, it can be concluded that collaborative effortsbetween the physicians and the nurses in the long-term care facilities in Vancouver, BritishColumbia, are not obstructed by the barrier of interprofessional misperceptions. It should benoted that the above cited authors' claim that misperceptions (where they exist) would be abarrier to collaborative practice can be neither supported nor disputed by the findings of thissurvey. Their argument is that interprofessional misperceptions lead to a lack of collaborativepractice. The findings of this survey show that there are very few misperceptions, yet based onthe direct views expressed by the subjects, there appear to be other obstructions to collaborativepractice between physicians and nurses in the long-term care facilities of Vancouver.140In her review of the collaborative practices between physicians and nurses, Fagin (1992)states that there are major cognitive and perceptual obstructions between the two professions.Based on the direct perceptions expressed by the physicians and the nurses in this survey, itappears that both professions are challenged by a number of cognitive and perceptualobstructions. Both feel the other profession to be encroaching on their own professional territory.There also appears to be a rather strong sense of professional ethnocentrism among thephysicians and the nurses. On another issue, both professions feel that their capabilities are notfully used by the members of the other profession. Thus, their agreement is high (lowmisperception), buth their satisfaction is low. Both professions also have an additional concernabout their professional autonomy. Significant numbers of physicians and nurses feel that theyhave very little autonomy in long-term care facilities. The final problem only seems to beexperienced by the nurses and concerns their professional advice. A majority of the nurses feelthat the physicians seldom ask them for professional advice.Ornstein (1990) notes that the professional relationship between the physicians and thenurses has remained physician dominated. This study does confirm the physicians' dominance onthe teams in long-term care facilities. Large majorities of both professions indicate thatphysicians have a higher status than nurses. The perception of dominance definitely is reinforcedby this believe on the part of both professions that physicians have a higher status. In addition,most of the nurses in the survey also feel that physicians seldom ask them for professionaladvice. It seems that physicians are making the pertinent patient-care decisions on their own. Thenurses are not included in the decision process.Ornstein (1990) also notes that physicians generally have resisted collaborative efforts withnurses. Based on the findings in this survey, it is not quite clear where the physicians inlong-term care facilities stand with respect to their willingness to collaborate with the nurses. Onthe one hand, the physicians in the survey describe their relationships with nurses to be good.141The physicians also feel that there is a good degree of cooperation between the two professions.On the other hand, however, as just noted, the findings show that nurses feel that physiciansseldom ask the nurses for professional advice and do not fully use their capabilities. Yet, askingthe other professional for his or her professional advice and using each other's professionalcapabilities fully are very fundamental to the collaborative team concept.Although the focus of this study is on the physicians and the nurses, the important role ofthe administration of the long-term care facilities must not be overlooked. It can not be stressedenough that the role of the administrators is extremely crucial to the success of the collaborativeteam concept. Their management expertise is needed to guide the physicians and the nurses intheir collaborative efforts. It is highly important, in this respect, that the administrators areperceived as credible internal management consultants by the physicians and the nurses (Fried etal., 1988). They must be knowledgeable about the make-and-break issues in interdisciplinarycollaboration.It is crucial for the administrators to have the ability to cultivate the physician-nurserelationship, because a well functioning team of physicians and nurses is linked to the success ofthe individual long-term care facility (Eubanks, 1991). The administrators must be aware thatunless the physicians and the nurses are given support in their collaborative efforts, theseprofessionals may become instruments of frustration and even resort to sabotage of thecollaborative team concept (Samuelson, 1992).The findings of this study confirm that not all is well between the physicians and the nursesin long-term care facilities. There is a need for improvement in the work relationships betweenthe two professions. For the good of the patients, the professionals, and the long-term carefacilities, appropriate team collaboration has become a necessity for the physicians and thenurses.142Limitations of the studyThere are some obvious limitations to this study and survey, which must be carefullyconsidered when drawing conclusions from the findings. Even more caution is necessary for theinterpretation of the findings prior to attempting any form of remedy for some of the indicatedproblems.The limitations are centered around the sample size, the non-response bias, the externalvalidity, the instrument, and the demographic correlates of interprofessional misperceptions andteamwork.Sample SizeRelatively small numbers of physicians and nurses volunteered to participate in the survey.The numbers may, in fact, be too small to be truly representative of the populations of physiciansand nurses who work in long-term care facilities. If generalizable at all, the findings may only begeneralizable to the long-term care facilities in the city of Vancouver, British Columbia.The survey has been conducted during the summer months and many of the potentialsubjects may have been on vacation during the period of data collection, which may havecontributed to the low numbers of subjects in the survey.Non-Response BiasA potential bias may have emerged in the representation of certain subgroups in thepopulations of physicians and nurses in long-term care facilities. Those professionals, who haveshown an interest to participate in the survey, already may have a very positive outlook oninterprofessional issues. It is possible that those physicians and nurses, who refused toparticipate, did exactly so, because of their lack of interest in anything that relates tocollaborative team work, including this survey. The bias could be in the direction of the more143cooperative and satisfied physicians and nurses who have been willing to fill out thequestionnaire, or the bias could be in the direction of the less satisfied physicians and nurses whohave filled out the questionnaire as an outlet for their frustrations. Either bias could affect theinternal validity of the study.External ValidityGiven that each long-term care facility is unique, it is also possible that a bias emerged inthe representation of certain subgroups of long-term care facilities. The external validity,however, has been increased by randomly selecting the 13 long-term care facilities from auniverse of 22.InstrumentThe subjects may have experienced some difficulties with the wording of theInterprofessional Perception Scale, which was used as the instrument for data collection. Take forinstance the question, "Do physicians sometimes encroach on the nurses' professional territory?".The subjects, who have responded with "false", may have done so because they believe thatphysicians always encroach on nurses' territory. Other subjects, who have responded with"false", may have done so, because they believe that physicians never encroach on nurses'territory. The word "sometimes" is difficult to interpret when perceptions are being measured.The use of double negatives also may have caused some confusion among the subjects. Take, forinstance, the statement, "nurses expect too much of physicians". The subject, who feels that thisstatement is false, has to re-word the statement to say, "no, nurses do not expect too much ofphysicians in long-term care facilities".An additional problem may have been caused by the different definitions that subjects mayhave given to some of the professional issues. It is possible, for instance, as pointed out144previously, that not every subject will have defined the issue of professional advice in the sameway or will give the same meaning to the statement, "physicians are well trained". A true/falseresponse to an issue depends much on how one defines that issue.The subjects, however, have been encouraged to provide their first impression and not tospend too much time on any one statement. The content validity of the instrument is establishedby the direct nature of the questions posed.Demographic Correlates of Interprofessional Misperceptions and Team WorkThe numbers of subjects in the survey are not large enough to draw any conclusions aboutthe specific demographic correlates of professional misperceptions and team work. The pool ofdemographic data on the subjects is too small to confirm any real potential they might have forinfluencing the physicians and the nurses in their development of different perceptions andattitudes about the 15 professional issues.Similarly, the pool of data concerning the job satisfaction of the nurses is not large enoughto confirm the findings in the related literature on job satisfaction and collaborative team work. Aconsiderable number of subjects is required to detect any consistent correlation between lowlevels of job satisfaction and the interprofessional misperceptions surrounding the 15 issues. Inany event, it should be further noted that one's level of job satisfaction is likely to be the endresult of a number of different contributing factors. The membership of a well functioningcollaborative team is only one of those factors.Strategies Toward Improved Team CollaborationOrnstein (1990) points out that economic, political, technical, and social changes in thehealth care system have not spontaneously stimulated collaborative efforts between the physicians145and the nurses. It appears that there is a need for a more structured and deliberate plan of actionto move the two professions closer together in their work relations.There are a number of effective methods available to the physicians and nurses, as well asthe management of long-term care facilities to improve the work relationships among thephysicians and the nurses. The strategies are presented in this section as suggestions eitherspecifically meant for the physicians alone, or aimed at the nurses as a group by themselves, orspecifically meant just for the administration of long-term care facilities. A number of strategiesalso are suggested, which might be helpful for all three groups to engage in collectively.Strategies for the Physicians1. — The findings of the survey show that physicians are perceived to be dominant in thepertinent decisions in the development of patient care plans. Consider, for instance, the 65%nurses, who feel that physicians seldom ask nurses for professional advice, or the 45% nurses,who believe that their capabilities are not fully used by the physicians. Based on these findings, itseems important for the physicians to realize that nurses do not feel that physicians treat thenurses as true team members. The physicians must have a careful look at how they make theirdecisions in long- term care facilities. It is time for the physicians to review their old ways ofcollaborating with nurses.Fagin (1992) urges that physicians should reevaluate their traditional way of viewing thebroad, complex health care field. She adds that the physicians should begin to realize that theirsingle-discipline centered approach to health care is a chief barrier to a more collaborativebehavior of the health care team.2. — Again, the findings of the survey show that many physicians appear not to include thenurses in the decision- making process around patient care issues. Baggs and Schmitt (1988) havecommented that collaborative practice requires physicians and nurses to participate in many joint146meetings, which are time consuming. It seems that the physicians in long-term care facilities arenot in a position to take the time and discuss the care options with the nurses. As a rule,physicians are not compensated for meeting time (Ornstein, 1990). It is suggested, therefore, thatphysicians should lobby for appropriate compensation on a fee-for-service basis for committeework. With such compensation, physicians might be in a better position to participate in thecollaborative team concept.Strategies for the Nurses1. — In order for the nurses to become full partners with the physicians on thecollaborative teams, the nurses have to look at a comprehensive redesign of their role. (Eubanks,1991; Fagin, 1992). In the collaborative team context the nurses will take on a consultative roleto the physicians, which will require increased levels of responsibility and accountability. Thenurses must prepare themselves well for these increased levels.Marriner (1984) makes suggestions on how to be prepared to take on increased levels ofresponsibility. To begin with, the nurses must ensure that they fully understand the additionalconsultative activities for which they will be made responsible. Responsibility denotes obligation,the nurses, therefore, must decide to accept the obligation created by the increased levels ofresponsibility. Before they accept the obligation, however, the nurses should participate indeveloping clearly written directions with their superiors, which will clarify for the nurses whatis really expected of them in their consultative role to the physicians. These directions, in turn,need to be discussed with the physicians.Marriner (1984) also has made suggestions for the nurses on how to be accountable fortheir actions. Accountability refers to liability. In other words, the nurses are liable tosatisfactorily complete their work. The nurses must feel comfortable to take on this liability. Thenurses should feel confident and not fear failure and criticism. They should develop guidelines147and standards enabling them to take on the increased levels of accountability as full members of acollaborative team.In general, nurses will have to assert themselves in their new consultative role to thephysicians. They should ask for increased levels of control over their own activities. They shouldnot accept increased levels of responsibility and accountability without increased levels ofcontrol. Through these increases in control, responsibility and accountability the nurses will cometo realize that the opportunities for them to use the full scope of their knowledge and skills haveincreased as well. Based on the finding in the survey that 45% of the nurses feel that theircapabilities are not fully utilized by the physicians, it appears that the nurses in long-term carefacilities are eager to contribute more to the overall care delivery. The nurses must realize thatthe opportunities are there for them to increase their contributions, but that they will have to beprepared to take on the accompanying responsibilities and accountabilities. The nurses mustarticulate clearly their contributions to physicians.2. — From table 2 (p. 78), it is apparent that 77% of the nurses in the survey are diplomaprepared nurses. Ornstein (1990) questions whether nurses at the diploma levels are adequatelyprepared to handle the responsibilities and authority necessary in collaborative team work. Fagin(1992) makes it clear that upgrading the basic nursing education to a respected level (e.g., atleast the baccalaureate degree) will help nurse-physician relationships become more reciprocal.She argues that the current difference between the educational preparation of physicians andnurses perpetuates many of their interprofessional communication problems. It is suggested thatthe nurses in long-term care facilities make a commitment to upgrade themselves to thebaccalaureate degree.3. — The survey shows that 39% of the physicians feel that nurses in long-term carefacilities are encroaching on the physicians' professional territory. Nurses will have to beprepared to work with physicians, who feel that their territory is threatened. As part of their148preparedness, the nurses should be aware that professional territoriality is a sensitive issue. Thenurses should learn how to skillfully approach the physicians with the message that physiciansand nurses are in a position to complement each other's roles. It requires much skill to jointlydecide on who is going to do what for the patient.Ornstein (1990) suggests that nurses must develop skills in leadership, bargaining and alsonegotiating. With these improved skills the nurses will appear less threatening in their relationswith the physicians and eventually earn their collegiality. It is suggested that the nurses find waysto develop these helpful skills by signing up for workshops that specifically are designed to focuson these skills. Of course, these workshops could be made available to members of bothprofessions. Physicians would stand to gain just as much as nurses would from an increase inleadership and other skills.4. — Keddy et al. (1986) suggest that nurses should endeavor to educate the public aboutthe true value and role of nurses. The authors argue that until society recognizes the true value ofnurses and begins to equate their worth with that of the physicians, much of the conflict andfrustration between the two professions will remain. The nurses should speak up when they seethemselves portrayed in the media as temperature takers with small brains and big hearts orhandmaidens to physicians (Keddy et al., 1986; Nurse-Physician, 1989). The nurses shouldrecognize the consumers of health care services as allies. The nurses can teach the patients andtheir families how the profession of nursing contributes to their care.Strategies for the Administration of the Long-Term Care Facilities1. — Vance (1992) points out that new staff should be prevented from being absorbed bybad politics in the work-place. The author explains that new employees will need to learn theorganization's proper norms and practices. The administration of the long-term care facility,therefore, should spent a considerable portion of their time setting the standards and the149expectations for collaborative team work. The administration should create an organizationalculture that supports collaboration. This culture needs to be permeated by the patient centeredfocus spoken of by Joyce Clifford (Bocchino, 1991). This culture should be conveyed to newemployees early in their employment. All elements of collaborative team work already in place inthe facility should be pointed out carefully to the new physicians and nurses.2. — Eubanks (1991) and Fagin (1992) encourage the establishment of a corporate culturewhich supports physician-nurse collaboration. Ornstein (1990) suggests that the administrationdefines new roles and relationships in support of the collaborative team concept. Themanagement of the facility should have clearly spelled out job descriptions and functions, withwhich they can reinforce the new professional boundaries among the physicians and nurses. Thefacilities' policies and procedures on collaborative team work should be made binding to bothprofessions. The physicians and the nurses who want to practice their profession at a facility canbe asked first to sign an agreement to observe all the policies and the procedures of the facilityprior to becoming a member of the facility's team.3. — Davidhizar and Bowen (1992) stress that camaraderie in the work-place offers avaluable avenue for coping with stress and maximizing the pleasure experienced at work. Thework stress in long-term care facilities is well documented (Samuelson, 1992). The managementteam of a long-term care facility, therefore, should develop appropriate levels of camaraderieamong the physicians and nurses by organizing opportunities for the professionals to socializeand learn details about each other that go beyond their professional image of the physician or thenurse on the team. It has become quite apparent from the survey that there is a distinctprofessional distance between the physicians and the nurses in long-term care facilities. Thephysicians, for instance, are considered to have a higher status than nurses. A majority of 79%of the nurses acknowledge this difference, and 86% physicians have stated that they, indeed,have a higher status than nurses. The notion of a professional distance between the two150professions in the survey is reinforced further by the finding of a strong sense of professionalterritoriality among the subjects. The findings show that 39% of the physicians and 61% of thenurses in the survey feel that their professional territory has been threatened by the members ofthe other profession. It seems that significant numbers of physicians and nurses are veryterritorial in their approach to the delivery of care. With this professional distance betweenphysicians and nurses well established, the administration should try to get the two groups ofprofessionals as close together as possible in every aspect of their work relationship. Thedevelopment of a sense of camaraderie between the physicians and the nurses will enhance theattempt to bring the two professions closer together. Baldwin (1993) indicates that socializationstrategies have the potential to move the professionals toward more equality, which in turn willenhance the collaborative team concept.4. — Russell-Babin (1992) points out that the development of an effective collaborativeteam is a deliberate process in which the leader assumes a major role. This leadership role shouldnot be automatically assigned to physicians. The administration, therefore, should be verycognizant of who the leader needs to be on the different teams, and provide that person with allthe available support and directions. Baldwin (1993) suggests, for instance, that the leader mustbe encouraged to wield strong enough authority to create a participatory culture among the teammembers.5. — Nurses in long-term care facilities have very high patient workloads and find itdifficult, therefore, to participate in a collaborative practice (Ornstein, 1990). A rather effectiveand practical strategy for the administration of long-term care facilities, therefore, should be todevelop a more reasonable distribution of patient workloads. The administration is muchrestricted in this redistribution by the funding they receive from the government. Collectively theadministration must stress with the government the urgency of reducing the high patientworkloads in the long-term care facilities. The current staff-patient ratios in the facilities are151extremely stretched and allow the staff only to attend to the basic needs of their patients. Itfollows that not much time is available for team building in long term care (Samuelson, 1992). Intheir approach to the government, the administrators should link the relevant issues. They shouldexplain that the current funding for the staff-patient ratio does not enable physicians and nurses towork collaboratively. This lack of interprofessional collaboration, in turn, should be linked to theinability for the patients, the professionals, and the health care system to enjoy the benefits ofcollaborative team work as documented in Chapter Two of this study.6. — Nason (1983) makes the point that many collaborative teams remain only an illusion,because few institutions are willing to commit time and resources needed for the training of thephysicians and the nurses to work more collaboratively. It is suggested that the administrationsupports the professionals in their collaborative effort by providing them with the necessaryresources and tools needed for their training. The administration should lobby the government forbudget allocations towards seminars and workshops, which all promote the interprofessional teamconcept.7. — The administrators should assure themselves that they are fully aware of the issuesexplored in this study and particularly are familiar with the make-and-break potential of theseissues in collaborative team work.Strategies For All Three Professional Groups1. — Interprofessional education opportunities at the medical and nursing schools should beexplored and supported in an attempt to facilitate a better understanding among the physiciansand the nurses of each others' roles (Mechanic and Aiken, 1982; Keddy et al., 1986; Ornstein,1990; Fagin, 1992; Horder, 1992). All three professions should strive for the systematicdevelopment of an interdisciplinary educational program (Fagin, 1992). Horder (1992) points outthat increasingly more interest is shown in the idea of interprofessional education. The three152groups should use this window of opportunity to increase the offerings where different healthdisciplines can work and study together.2. — Ongoing education at the facility is a key to improvements in physician-nurserelationships (Anvaripour et al., 1991; Butterill et al, 1992). Administrators should encourage thedevelopment of workshops, where physicians and nurses discuss together the issue ofphysician-nurse collegiality. At these workshops open discussions should be encouraged aboutany contentious issues. Baldwin (1993) suggests that these discussion groups, for instance, couldaddress gender awareness and attitudes toward dominator and partnership models of team work.Fagin (1992) suggests that the real-life experiences with collaborative team work definitelyshould be discussed at these workshops. Take, for instance, the 18% physicians and the 36%nurses in the survey who feel that their capabilities are not understood by the members of theother profession. These frustrating feelings need to be discussed. In particular the positiveexperiences should be brought out in the open at these discussions and used as illustrations ofhow well the collaborative team concept, indeed, can work in the facility. Since educationalexperiences for collaborative skill building are a rarity in long-term care facility, this strategywarrants special attention (Samuelson, 1992).3. — The dynamics of the teams should be periodically reviewed by its members. A teamcan benefit from self- examination (Butterill et al., 1992). The review should be encouraged bythe administration of the facility and also be guided with pertinent management thought andpractice.4. — The idea of joint practice committees should be implemented in each long-term carefacility (Eubanks, 1991; Fagin, 1992). The deliberate use of interprofessional committees forcross-disciplinary projects will encourage better working relationships between the physicians andthe nurses. Epton et al. (1984) warn, however, that this strategy calls for considerablemanagement ability in guiding the physicians and the nurses in their collaborative efforts.153As a general cautionary remark, it should be noted that not all these suggested strategiesmay be suitable for all physicians and nurses in each long-term care facility. Their suitabilityneeds to be discussed by all parties prior to implementing any of these suggestions. It isimportant to have an open dialogue about these strategies and their consequences. Fagin (1992)also stresses the importance for the professional organizations of physicians and nurses to endorsethe appropriate strategies for improving interprofessional collaborations.A final comment should be made about the expected resistance to change that will becaused by any of the above suggested strategies. Anderson and Finn (1983) suggest that suchresistance may be overcome through gradual introduction of the strategy, joint participation bythose professionals effected by the strategy, and continuous support to the professionalsthroughout the implementation of the strategy.In addition to the strategies indicated above, the collaborative team concept for thephysicians and the nurses in long-term care facilities also is enhanced by further research. Thisstudy has given rise to a number of concerns and questions, which definitely are worth of furtherexploration.Suggestions For Further Study1. — As indicated before, the respective samples of physicians and nurses in this study arerather small. The survey bears repeating among a much larger number of physicians and nursesin long-term care facilities. Of interest is to see whether the results of this small survey are goingto be confirmed by larger samples of physicians and nurses.2. — There are differences between long-term care facilities and acute care facilities, whichmake each of these health care organizations unique. It would be of interest to assess the effect ofthe difference between long term care and acute care on the degree of interprofessional154misperception found among physicians and nurses in each of these respective facilities. It ispossible that a focus group approach to the interprofessional issues in nursing homes would yielda unique set of issues not captured in the Ducanis and Golin (1979) instrument.3. — Whether one professional thinks he or she is competent, or perceives the otherprofessional to think he or she is competent, or actually is perceived as competent, still does notconfirm either way that the professional, indeed, is competent. Actual existing competency levelsamong the physicians and nurses in long-term care facilities should be further explored.4. — The study indicates that considerable numbers of professionals in both groups believethey have very little professional autonomy. This finding raises a concern that needs to be furtherexplored. How do the physicians and the nurses in long-term care facilities define theirprofessional autonomy? On what basis do they feel they have very little autonomy? How can theyincrease their professional autonomy? These are some of the questions that could be made thefocus of a rather valuable study.5. — The study indicates that significant numbers in both professions feel that theircapabilities are not fully used by the members of the other profession. It also shows that 15% ofthe nurses and 50% of the physicians admit that they do not fully utilize the capabilities of theother profession. An exploratory study could be conducted to find out exactly what type ofprofessional capabilities are perceived not to be used by the members of the other profession. Afurther observational study could also have these perceptions confirmed. These additional studiescould try to clarify the reasons behind the interprofessional under-utilization of professionalcapabilities.1556. — Almost one third of the nurses in the survey believe that physicians in long-term carefacilities are not highly concerned with the welfare of the patient. Of interest would be to findout what concrete evidence the nurses have to come to this rather serious conclusion about thephysicians. The study also shows that a majority of nurses (97%) perceive that physicians willsay that they are highly concerned with the welfare of the patient. A further study on this issuecould explore whether the nurses believe that physicians only pretend to be concerned about thewelfare of their patients.7. — Of particular interest for further exploration is the issue of professional territoriality.This study has shown that both professions feel that members of the other profession areencroaching on their territory. Whether both professions are actually encroaching on the otherprofession's territory, and more importantly, in what manner, would be of great interest to allmembers on the team to have further explored.8. — The findings of the survey concerning the issue of professional ethics are veryinteresting and definitely need to be explored further. Almost one third of the nurses say thatphysicians are not highly ethical. What evidence are these nurses using as a basis for their criticalview of the physicians' sense of ethics? It seems that many Oriental nurses feel that physiciansare not highly ethical. Is there a significant cultural component to the issue of professional ethics?Of great concern is the 7% physicians and 11 % nurses, who admit that they are not highlyethical. These percentages are small, but in the context of professional ethics and health carethese findings are alarming and definitely need to be further explored.9. — The nurses in the survey appear to be almost equally split on the issue of physicians'expectations of nurses. It seems that the nurses are not sure of what the physicians could expect156from nurses. This area may need further exploration to determine how problematic the issue ofrole expectations is in long-term care facilities.10. — Both professional groups in the survey appear to be fairly defensive of theirrespective prerogatives, and this sense of professional ethnocentrism or chauvinism also appearsto be mutually acknowledged by the physicians and the nurses. These findings illustrate thepresence of a barrier between the two professions, which stands in the way of their collaborativepractice. This area of concern should be further explored. For instance, what prerogativesactually exist among the physicians and the nurses? Why do they see these items as prerogatives?What does it take for the respective professionals to give up these prerogatives for the sake ofcollaborative team work? Answers to these questions would increase the chances for the twoprofessions to get closer to the ideal concept of collaborative team work.11. — In Chapter Two the question was posed as to what develops first, interprofessionaltrust or collaborative practice between physicians and nurses? The literature seems to supporteither argument. This may be no more than another proverbial paradox of what came first, thechicken or the egg. Nonetheless, it would be interesting to find out more about the intricaciesbetween interprofessional trust and collaborative practice.12. — The findings of the study indicate that nurses feel physicians seldom ask the nursesfor professional advice. At the same time, however, a majority of the physicians say that they doask the nurses for professional advice. Additional studies could explore this discrepancy. Howdoes each profession define the issue of professional advice? What type of professional advice donurses think they could give physicians, if only they would ask the nurses? Do nurses give157professional advice, whether the physicians ask for it or not? These questions could be addressedthrough further study of the details surrounding professional advice.13. — The barrier to collaborative team work created by clinical uncertainty in health carehas been discussed in Chapter Two. It seems that quite opposite views are supported in theliterature. On the one hand clinical uncertainty is indicated as a barrier (Horder, 1992), on theother hand uncertainty in patient care is felt to be the driving force for health professionals towork collaboratively (Fried et al., 1988). Further exploration of this discrepancy wouldcontribute significantly to the enhancement of the collaborative team concept.14. — The study has stressed the importance of administrative support for the collaborativeteam concept. The existing long-term care facilities' policies and procedures on collaborativeteam work should be further explored. Are these policies actually written and used? Is the issueof team collaboration dealt with during the orientation programs of new staff? In what other waysis there evidence of the administrative support for the collaborative work relationships betweenphysicians and nurses? Are there any workshops or discussion groups organized on the topic?15. — Not much is known about the leadership function on collaborative teams inlong-term care facilities. Who are the leaders? Do they consistently come from one professionaldiscipline? To what extent are they actually instrumental in the development of the collaborativeteam concept in the individual facility? These question are just some of the interesting details onthe leadership function that could be explored through further study.16. — The benefits of self-examination for a team have been indicated. How many teamsin long-term care facilities actually do take time out for some self-examination? Of real interest158would be a before-after study, to determine whether an improvement is noted in team functioningfollowing a series of self-examinations.17. — The high patient workload makes it difficult for nurses in long-term care facilities tocommit fully to the collaborative team concept. What are the specific details of these patientworkloads that seem to form a barrier for the nurses to collaborate well with the physicians?Further study could explore these details.ConclusionThis exploratory study among 28 physicians and 66 nurses in long-term care facilities inthe city of Vancouver, British Columbia, has found some evidence of cognitive and perceptualobstructions in the way of the collaborative practice between the two professions. The twoprofessions do seem to have direct perceptions of each other on some important professionalissues. The findings, however, do not indicate that these perceptual obstructions are necessarilyformidable barriers. In fact, the misperceptions are all considered to be very little tonon-existent. More than half of the misperceptions among 57 tested were less than 7%. It shouldbe noted further that some misperceptions are even in a positive direction. For instance, theactual number of physicians, who believe that nurses are competent, is much higher thanexpected by some of the nurses. Nonetheless, some misperceptions are there, and they should notbe ignored. Ideally, both professions should know exactly where the members of the otherprofession stand on each of the professional issues. In addition, data from direct perceptionsprovided valuable information on barriers or obstructions that exist. Openly discussing thesebarriers and deliberate activities to change them are necessary for collaborative team work tooccur.159In closing, it bears repeating that there appears to be no longer an option for physiciansand nurses in long-term care facilities to collaborate. Fagin (1992) argues that physicians andnurses, together with the guidance of administrators, must participate collaboratively in thedelivery of health care in the coming decades. Although there are barriers to overcome, thephysicians and the nurses must realize that there is a common link between them that can serveas a uniting force (Ornstein, 1990). The author points out a desire on the part of both professionsto provide the patient with the highest possible level of care. It is clear that this desire can onlybe fulfilled when the physicians and the nurses in long-term care facilities fully commit to theproper use of the collaborative team concept and to the diminishing of perceptual obstructionsbetween them that prevent the realization of the concept.160REFERENCESAnderson, D. J., & Finn, M. C. (1983). Collaborative practice: developing a structure thatworks. Nursing Administration Quarterly, 8(1), 19-24.Anvaripour, P. L., Jacobson, L., Schweiger, J., & Weissman, G. K. (1991). Physician-nursecollegiality in the medical school curriculum: exploratory workshop and student questionnaireMount Sinai Journal of Medicine, 58(1), 91- 94.Baggs, J. G., & Schmitt, M. H. (1988). Collaboration between nurses and physicians. Image:Journal of Nursing Scholarship, 20(3), 145-149.Baldwin, C. (1993). Gender dominance in the work setting: implications for dietitians. TheJournal of the American Dietetic Association, 93(1), 25-26.Baldwin, L. M., Hutchinson, H. L., & Rosenblatt, R. A. (1992). Professional relationshipsbetween midwives and physicians: collaboration or conflict? American Journal of Public Health,82(2), 262-264.Banta, H. D., & Fox, R. C. (1972). Role strains of a health care team in a poverty communitySocial Science and Medicine, 6, 697-722.Beloff, J. S., & Korper, M. (1972). The health team model and medical care utilization: Effecton patient behavior of providing comprehensive family health services. Journal of the AmericanMedical Association, 219(3), 359-366.Bocchino, C. A. (1991). An interview with Joyce C. Clifford. Nursing Economic$, 9(1), 7-17.Butterill, D., O'Hanlon, J. & Book, H. (1992). When the system is the problem, don't blame thepatient: problems inherent in the interdisciplinary inpatient team. Canadian Journal ofPsychiatry, 37(3), 168-172.Cartwright, A. (1991). The relationship between general practitioners, hospital consultants andcommunity nurses when caring for people in the last year of their lives. Family Practice, 8(4),350-355.Davidhizar, R. & Bowen, M. (1992). Camaraderie: the key to making work fun. TodaysOR-Nurse, 14(8), 46-47.Ducanis, A. J., & Golin, A. K. (1979). The interdisciplinary health care team: A handbook.Germantown, Md: Aspen Systems Corporation.Epton, S. R., Payne, R. L., & Pearson, A. W. (1984). The management of cross-disciplinaryresearch. R & D Management, 14(2), 69-79.Ethics for nurses. (1991). RNABC News, May, 16-17.161Eubanks, P. (1991) Quality improvement key to changing nurse - M.D. relations. Hospitals,65(8), 26-30.Fagin, C., Diers, D. (1983). Nursing as metaphor. American Journal of Nursing, 83(9), 1362.Fagin, C. M., (1992). Collaboration between nurses and physicians: no longer a choice.Academic Medicine, 67(5), 295-303.Fleiss, J. L. (1981). Statistical methods for rates and proportions (2nd ed.). New York: JohnWiley & Sons.Fried, B. J., Leatt, P., Deber, R., & Wilson, E. (1988). Multidisciplinary teams in health care:lessons from oncology and renal teams. Healthcare Management Forum, 1(4), 28-34.Glendon, K., & Ulrich, D. (1992). Using cooperative learning strategies. Nurse Educator, 17(4),37-40.Gramelspacher, G. P., Howell, J. D., & Young, M. J. (1986). Perceptions of ethical problemsby nurses and doctors. Archives of Internal Medicine, 146(March), 577-578.Hanlon, M. D., & Gladstein, D. L. (1984). Improving the quality of work life in hospitals: Acase study. Hospital & Health Services Administration, 29(5), 94-107.Horder, J. (1992). Interprofessional education. Medical Education, 26(6), 427-428.Hughes, A. M., & Mackenzie, C. S. (1990). Components necessary in a successful nursepractitioner - physician collaborative practice. Journal of the American Academy of NursePractitioners, 2(2), 54-57.Huntington, J. A., & Shores, L. (1983). From conflict to collaboration. American Journal ofNursing, 83(8), 1184- 1186.Hutchison, P. (1993, May 13). Cull makes midwifes legal. The West Ender, p. A5.Jacobson, S. R. (1974). A study of interprofessional collaboration. Nursing Outlook, 22(12),751-755.Jenny, J. (1990). Self-esteem: a problem for nurses. The Canadian Nurse, 86(10), 19-21.Katzman, E. M. (1989). Nurses' and physicians perceptions of nursing authority. Nursing, 5,208-214.Keddy, B., Gillis, B. J., Jacobs, P., Burton, H., & Rogers, M. (1986). The doctor-nurserelationship: an historical perspective. Journal of Advanced Nursing, 11(6), 745-753.Koerner, B. L. & Armstrong, D. A. (1983). Collaborative practice at Hartford Hospital. NursingAdministration Quarterly, Summer, 72-81.Kurtz, M. E. (1980). A behavioral profile of physicians in management roles. In R. Schenke(Ed.), Physicians in management (33-34). Tampa, Florida: American Academy of MedicalDirectors.162Maine aims antitrust blow at MDs and saves the day for CRNAs. (1985). The American Journalof Nursing, May, 600-601 and 612.Marriner, A. (1984). Guide to nursing management (2nd ed.). Toronto: The C. V. MosbyCompany.Mechanic, D., & Aiken, L. H. (1982). A cooperative agenda for medicine and nursing. The NewEngland Journal of Medicine, 307(12), 747-750.Nason, F. (1983). Diagnosing the hospital team. Social Work in Health Care, 9(2), 25-45.Nurse-physician relationships. (1989). RNABC News, November/December, 20-24.Ornstein, H. J. (1990). Collaborative practice between Ontario nurses and physicians: is itpossible? Canadian Journal of Nursing Administration, 3(4), 10-14.Oulton, J. A. (1989). Collaboration - at what price? The Canadian Nurse, 85(7), 3.Pike, A. W. (1991). Moral outrage and moral discourse in nurse-physician collaboration. Journalof Professional Nursing, 7(6), 351-363.Porter, S. (1991). A participant observation study of power relations between nurses and doctorsin a general hospital. Journal of Advanced Nursing, 16(6), 728-735.Prescott, P. A., & Bowen, S. A. (1985). Physician-nurse relationships. Annals of InternalMedicine, 103(1), 127-133.Registered Nurses Association of British Columbia. (1990). New directions for health care.Vancouver, British Columbia.Registered Nurses Association of British Columbia. (1992). Guidelines for specialized nursingskills and delegated medical functions (Publication No. 51 Rev. 1/93). Vancouver, BritishColumbia.Ritter, H. A. (1989). Collaborative practice: what's in it for medicine? Nursing AdministrationQuarterly, 7(4), 31-35.Rooks, J. P. (1990). Nurse-midwifery: the window is wide open. The American Journal ofNursing, December, 30-36.Russell-Babin, K. (1992). Team building for the staff development department. Journal ofNursing Staff Development, 8(5), 231-234.Sackett, D. L., Haynes, R. B., & Tugwell, P. (1985). Clinical epidemiology - a basic sciencefor clinical medicine (2nd ed.). Boston: Little, Brown and Company.Samuelson, K. (1992). Team building in long term care. Canadian Nursing Home, 3(4), 6-8.Stein, L. I., Watts, D. T., & Howell, T. (1990). The doctor - nurse game revisited. The NewEngland Journal of Medicine, 322(8), 546-549.163Vance, C. (1992). Managing the politics of the workplace. Imprint, 39(1), 16-19.Wells, B. (1992). B.C.'s health minister is bringing health "closer to home". Nursing BC, 24(3),29-30.APPENDIX A164INTERPROFESSIONAL PERCEPTION SCALEFOR THEPHYSICIANSINTERPROFESSIONAL PERCEPTION SCALECode NumberAll answers are confidential. Do not sign this form.This is a study of interprofessional perceptions. It isintended to get at some of the ways various professions vieweach other and how they think others view them.Respondent data: Profession  PhysicianGender:Age:Female^Male20-30^31-40^41-50^Over 50Number of years you have cared for patients in long term carefacilities:^Area of practice: Family Practice^Other (please specify)^Ethnic background: Caucasian^OrientalNative IndianEast Indian^Other^Please fill in the information on this page, but do not signyour name.Note. Adapted from The Interdisciplinary Health Care Team(pp. 38-40) by A. J. Ducanis and A. K. Golin, 1979,Germantown, Maryland: Aspen Systems Corporation. Copyright1979 by Aspen Systems Corporation.-2-In answering the following items, do not spend too much timeon any one statement. Your first impression is what we want.Please answer with as much candor as possible. Answer the twoparts of each question as you proceed. The questionnaireshould take only about 15 minutes. Please answer each item.The focus of this study is on physicians, who have patientsat long term care facilities, and on staff nurses, who workin these same long term care facilities.As you look at the following page, you will see that inColumn 1 you should indicate whether you think the statementis true or false; and in Column II you should indicate howyou think the other professional would answer. Please placean X to indicate your answers.You may begin now.\ 3How WouldNursesAnswer?How WouldYou Answer?FALSE TRUE^FALSETRUE-3-Answer the following items in relation to NURSES IN LONG TERMCARE FACILITIESNURSES1. Arecompetent2. Have verylittleautonomy3. Understandthecapabilitiesofphysicians4. Are highlyconcernedwith thewelfare ofthe patient5. Sometimesencroach onphysicians'professionalterritory6. Are highlyethical7. Expect toomuch ofphysicians8. Have ahigher statusthanphysicians-4-Continue to answer the following items in relation to NURSESIN LONG TERM CARE FACILITIESHow WouldYou Answer?How WouldNursesAnswer?TRUE FALSE TRUE FALSENURSES9. Are verydefensiveabout theirprofessionalprerogatives10. Trustphysicians'professionaljudgment11. Seldomaskphysiciansprofessionaladvice12. Fullyutilize thecapabilitiesofphysicians13. Do notcooperatewell withphysicians14. Are welltrained15. Have goodrelationswithphysiciansHow WouldNursesAnswer?How WouldYou Answer?TRUE FALSE TRUE FALSE- 5 -Answer the following items in relation to Your Own ProfessionPHYSICIANS1. Arecompetent2. Have verylittleautonomy3. Understandthecapabilitiesof nurses4. Are highlyconcernedwith thewelfare ofthe patient5. Sometimesencroach onnurses'professionalterritory6. Are highlyethical7. Expect toomuch ofnurses8. Have ahigher statusthannurses-6-Continue to answer the following items in relation to YourOwn ProfessionHow WouldYou Answer?How WouldNursesAnswer?TRUE FALSE TRUE FALSEPHYSICIANS9. Are verydefensiveabout theirprofessionalprerogatives10. Trustnurses'professionaljudgments11. Seldomask nursesprofessionaladvice12. Fullyutilize thecapabilitiesofnurses13. Do notcooperatewell withnurses14. Are welltrained15. Have goodrelationswithnursesAPPENDIX B165INTERPROFESSIONAL PERCEPTION SCALEFOR THENURSESINTERPROFESSIONAL PERCEPTION SCALECode NumberAll answers are confidential. Do not sign this form.This is a study of interprofessional perceptions. It isintended to get at some of the ways various professions vieweach other and how they think others view them.Respondent data: Profession  Staff NurseGender:^Female^MaleAge: 20-30^31-40^41-50^Over 50 Number of years you have cared for patients in long term carefacilities:Educational preparation: Diploma^Baccalaureate^masters^Specialty Certification^Professional designation: RN^RPN^LGNEthnic background: CaucasianOriental^Native Indian^East IndianOther^How would you rate your job satisfaction: poor^goodexcellentPlease fill in the information on this page, but do not signyour name.Note. Adapted from The Interdisciplinary Health Care Team(pp. 38-40) by A. J. Ducanis and A. K. Golin, 1979,Germantown, Maryland: Aspen Systems Corporation. Copyright1979 by Aspen Systems Corporation.-2-In answering the following items, do not spend too much timeon any one statement. Your first impression is what we want.Please answer with as much candor as possible. Answer the twoparts of each question as you proceed. The questionnaireshould take only about 15 minutes. Please answer each item.The focus of this study is on physicians, who have patientsat long term care facilities, and on staff nurses, who workin these same long term care facilities.As you look at the following page, you will see that inColumn 1 you should indicate whether you think the statementis true or false; and in Column II you should indicate howyou think the other professional would answer. Please placean X to indicate your answers.You may begin now.-How WouldPhysiciansAnswer?FALSETRUEHow WouldYou Answer?FALSE TRUE•-3-Answer the following items in relation to PHYSICIANSPHYSICIANS1. Arecompetent2. Have verylittleautonomy3. Understandthecapabilitiesof nurses4. Are highlyconcernedwith thewelfare ofthe patient5. Sometimesencroach onnurses'professionalterritory6. Are highlyethical7. Expect toomuch ofnurses8. Have ahigher statusthan nurses-4-Continue to answer the following items in relation toPHYSICIANSHow WouldYou Answer?How WouldPhysiciansAnswer?TRUE FALSE TRUE FALSEPHYSICIANS9. Are verydefensiveabout theirprofessionalprerogatives10. Trustnurses'professionaljudgment11. Seldomask nurses'professionaladvice12. Fullyutilize thecapabilitiesof nurses13. Do notcooperatewell withnurses14. Are welltrained15. Have goodrelationswithnursesHow WouldPhysiciansAnswer?How WouldYou Answer?TRUE FALSE TRUE FALSE-5-Answer the following items in relation to NURSES IN LONG TERMCARE FACILITIESNURSES1. Arecompetent2. Have verylittleautonomy3. Understandthecapabilitiesof physicians4. Are highlyconcernedwith thewelfare ofthe patient5. Sometimesencroach onphysicians'territories6. Are highlyethical7. Expect toomuch ofphysicians8. Have ahigher statusthanphysicians- G-Continue to answer the following items in relation to NURSESIN LONG TERM CARE FACILITIESHow WouldYou Answer?How WouldPhysiciansAnswer?TRUE FALSE TRUE FALSENURSES9. Are verydefensiveabout theirprofessionalprerogatives10. Trustphysicians'professionaljudgments11. Seldomaskphysicians'advice12. Fullyutilize thecapabilitiesofphysicians13. Do notcooperatewell withphysicians14. Are welltrained15. Have goodrelationswithphysiciansAPPENDIX C166AGENCY CONSENT FORMpage 1 of 2AGENCY CONSENTApproval has been given to Albertus Roskam to distribute aquestionnaire to our regular full-time and part-time staffnurses.In granting him approval, it is understood that:- the title of his project is InterprofessionalMisperceptions among Physicians and Nurses in Long TermCare Facilities.- his research is for a graduate thesis in the program ofHealth Services Planning and Administration of theDepartment of Health Care and Epidemiology at theUniversity of British Columbia.- his faculty advisor is Dr. Larry Green, who can becontacted at 822 - 2258.- Albertus Roskam can be reached to answer any inquiriesby dialing 669-5042 at his home, or at his work872-0044.- the study tries to determine the degrees ofmisperception physicians and nurses in long term carehave of each other on collaborative professionalism.- the data will be collected by using a questionnaire,which has been previously validated, and is entitled"Interprofessional Perception Scale".- the identity of the subjects will be kept confidential,because they are being instructed not to sign thequestionnaire with their name.- the subjects are encouraged to fill out thequestionnaire at their own convenience and volition.- the return of the questionnaire by the subjects impliestheir consent.- a list is needed identifying the number of nurseseligible to participate in the survey.- the questionnaire, together with an explanatory letter,will be distributed to all eligible nurses.- an advertisement will be posted in the facility toencourage the nurses to complete the questionnaire.page 2 of 2- the questionnaire should take only about 15 minutes tocomplete.- the subjects will be asked to return their completedquestionnaires by placing them in an envelope located inthe staff room.- a follow up letter will be sent to all nurses as athank-you for those who have responded and a reminderfor those who have not completed the questionnaire.- a list is needed with the names and the addresses of allphysicians who admit residents to the facility.AgencyName PhoneAgency OfficialSignature^ Position^DateAPPENDIX D167INTRODUCTORY LETTERTO THEPHYSICIANSTHE UNIVERSITY OF BRITISH COLUMBIADepartment of Health Care and EpidemiologyFaculty of MedicineMather Building, 5804 Fairview AvenueVancouver, B.C. Canada V6T 1Z3Tel: (604) 822-2772Fax:(604) 822-4994Graduate Programs: (604) 822-5405Dear Physician:I am writing to invite you to participate in a survey, thepurpose of which is to learn more about the ways physiciansand nurses in long term care view each other. I am a graduatestudent in the program of Health Services Planning andAdministration in the Department of Health Care andEpidemiology of the Faculty of Medicine at the University ofBritish Columbia. The title of my graduate thesis isInterprofessional Misperceptions among Physicians and Nursesin Long Term Care Facilities, and the enclosed survey is amajor part of my thesis.There is a growing evidence in the literature that positivepatient care outcomes and job satisfaction are enhanced byappropriate collaboration between health professionals. nyultimate goal is to have the results of my study used as apOint of departure in educating physicians and nurses in longterm care on how they tend to view each other and to explorethe reasons for any misperceptions the one profession mayhave of the other. Such exploration hopefully will furtherguide the relationship between physicians and nurses toward agood collaborative work experience.The enclosed questionnaire should take no more than 15minutes of your time to answer. Please note that thecompletion of the questionnaire implies your consent. You mayrefuse to participate or withdraw from the study at any time.The questionnaire has been given a code number to assure thatthe information you give me will remain strictly confidentialand you will not personally be identified in the researchreport. The questionnaires will be destroyed at thecompletion of my study. There is no monetary compensation.The results will be presented at a seminar in the Departmentof Health Care and Epidemiology, and may be used for otherfuture presentations and publications./THE UNIVERSITY OF BRITISH COLUMBIADepartment of Health Care and EpidemiologyFaculty of MedicineMather Building, 5804 Fairview AvenueVancouver, B.C. Canada V6T 1Z3Tel: (604) 822-2772Fax:(604) 822-4994Graduate Programs: (604) 822-5405-2-I hope you will take a few moments now to complete thequestionnaire and return it to me in the enclosed self-addressed stamped envelope. If you have any concerns aboutthe survey, please feel free to contact me at work, 872 - 0044or at home, 669-5042. You may also contact my FacultyAdvisor, Dr. L. Green at 822-2258. Thank you in advance foryour willingness to participate.Albertus RoskamAPPENDIX E168INTRODUCTORY LETTERTO THENURSESTHE UNIVERSITY OF BRITISH COLUMBIADepartment of Health Care and EpidemiologyFaculty of MedicineMather Building, 5804 Fairview AvenueVancouver, B.C. Canada V6T 1Z3Tel: (604) 822-2772Fax: (604) 822-4994Graduate Programs: (604) 822-5405Dear Nurse:I am writing to invite you to participate in a survey, thepurpose of which is to learn more about the ways physiciansand nurses in long term care view each other. I am a graduatestudent in the program of Health Services Planning andAdministration in the Department of Health Care andEpidemiology of the Faculty of Medicine at the university ofBritish Columbia. The title of my graduate thesis isInterprofessional Misperceptions among Physicians and Nursesin Long Term Care Facilities, and the enclosed survey is amajor part of my thesis.There is a growing evidence in the literature that positivepatient care outcomes and job satisfaction are enhanced byappropriate collaboration between health professionals. Ayultimate goal is to have the results of my study used as apoint of departure in educating physicians and nurses in longterm care on how they tend to view each other and to explorethe reasons for any misperceptions the one profession mayhave of the other. Such exploration hopefully will furtherguide the relationship between physicians and nurses toward agood collaborative work experience.The enclosed questionnaire should take no more than 15minutes of your time to answer. Please note that thecompletion of the questionnaire implies your consent. You mayrefuse to participate or withdraw from the study at arty ti n e.The questionnaire has been given a code number to assure thatthe information you give me will remain strictly confidentialand you will not personally be identified in the researchreport. The questionnaires will be destroyed at thecompletion of my study. There is no monetary compensation,The results will be presented at a seminar in the Departmetof Health Care and Epidemiology, and may be used for otherfuture presentations and publications.THE UNIVERSITY OF BRITISH COLUMBIADepartment of Health Care and EpidemiologyFaculty of MedicineMather Building, 5804 Fairview AvenueVancouver, B.C. Canada V6T 1Z3Tel: (604) 822-2772Fax: (604) 822-4994Graduate Programs: (604) 822-5405-2-I hope you will take a few moments now to complete thequestionnaire and return it to an envelope located in yourstaff room. The envelope is labelled "Survey-Physicians andNurses in Long Term Care". If you have any concerns aboutthe survey, please feel free to contact me at work, 872-0044or at home, 669-5042. You may also contact my FacultyAdvisor, Dr. L. Green at 822-2258. Thank you in advance foryour willingness to participate.Albertus Roskam169APPENDIX FPOSTERHELP!^HELP!^HELP!^HELP!^HELP!HELP!^HELP!^HELP!^HELP!^HELP!HELP!^HELP!^HELP!^HELP!^HELP!INTERPROFESSIONAL MISPERCEPTIONSAMONG PHYSICIANS AND NURSES.IN LONG TERM CARE FACILITIESDEAR NURSES:CURRENTLY A SURVEY IS CONDUCTED AND I AM INVITING YOU TOPARTICIPATE.THE PURPOSE OF THE SURVEY IS TO LEARN MORE ABOUT THE WAYSPHYSICIANS AND NURSES IN LONG TERM CARE VIEW EACH OTHER.EACH OF YOU WILL RECEIVE A QUESTIONNAIRE WHICH I HOPE YOUWILL BE WILLING TO COMPLETE.THE INFORMATION YOU GIVE ME WILL REMAIN COMPLETELYCONFIDENTIAL.THE QUESTIONNAIRE SHOULD TAKE NO MORE THAN 15 MINUTES OF YOURTIME TO ANSWER.PLEASE TAKE A FEW MOMENTS TO COMPLETE THE QUESTIONNAIRE ANDRETURN IT TO THE ENVELOPE LOCATED IN YOUR STAFF ROOM. THEENVELOPE IS LABELLED "SURVEY - PHYSICIANS AND NURSES IN LONGTERM CARE".ANY CONCERNS ABOUT THE SURVEY CAN BE DIRECTED TO ME BYCONTACTING ME AT ANY OF MY TELEPHONE NUMBERS BELOW.YOURS SINCERELY,ALBERTUS ROSKAM, RNTELEPHONE (HOSPITAL): 872-0044TELEPHONE (HOME):^669-5042APPENDIX G170FOLLOW-UP LETTERTO THEPHYSICIANSTHE UNIVERSITY OF BRITISH COLUMBIA^'`Department of Health Care and EpidemiologyFaculty of MedicineMather Building, 5804 Fairview AvenueVancouver, B.C. Canada V6T 1Z3Tel: (604) 822-2772Fax:(604) 822-4994Graduate Programs: (604) 822-5405Dear Physician:About two weeks ago, I wrote to invite you to participate ina survey, the purpose of which was to learn more about theways physicians and nurses in long term care view each other.I am a graduate student in the program of Health ServicesPlanning and Administration in the Department of Health (areand Epidemiology of the Faculty of Medicine at the Universityof British Columbia. The title of my graduate thesis isInterprofessional Misperceptions among Physicians and Nursesin Long Term Care Facilities, and the enclosed survey is amajor part of my thesis.If you have not yet returned your questionnaire, would youplease take a few moments now to complete it (I have enclosedanother copy) and return it to me in the enclosed self-addressed stamped envelope. Your participation is needed inorder to have as complete a picture as possible of thephysicians' views. It will allow me to contribute toward abetter understanding among physicians and nurses in long termcare of each other's roles. Such heightened understanding canassist to promote collaboration between the two professions,and ultimately enhances positive patient care outcomes.As stated in my earlier letter, the questionnaire should takeno more than 15 minutes to complete. The completion of thequestionnaire implies your consent. You may refuse toparticipate or withdraw from the study at any time. Please beassured that the information you give me will remaincompletely confidential and you will not personally beidentified in the research report. The questionnaires will bedestroyed at the completion of my study. There is no monetarycompensation. The results will be presented at a seminar inthe Department of Health Care and Epidemiology, and may beused for other presentations and publications in the future.THE UNIVERSITY OF BRITISH COLUMBIADepartment of Health Care and EpidemiologyFaculty of MedicineMather Building, 5804 Fairview AvenueVancouver, B.C. Canada V6T 1Z3Tel: (604) 822-2772Fax: (604) 822-4994Graduate Programs: (604) 822-5405-2-If you have already returned your questionnaire, or if youhave decided not to participate, please disregard thisreminder and accept my thanks. If you have any concerns aboutthe survey, please feel free to contact me at work, 872 - 0044or at home, 669-5042. You may also contact my FacultyAdvisor, Dr. L. Green at 822 - 2258.Albertus Roskam/2>APPENDIX H171FOLLOW-UP LETTERTO THENURSESTHE UNIVERSITY OF BRITISH COLUMBIADepartment of Health Care and EpidemiologyFaculty of MedicineMather Building, 5804 Fairview AvenueVancouver, B.C. Canada V6T 1Z3Tel: (604) 822-2772Fax: (604) 822-4994Graduate Programs: (604) 822-5405Dear Nurse:About two weeks ago, I wrote to invite you to participate ina survey, the purpose of which was to learn more about theways physicians and nurses in long term care view each otherI am a graduate student in the program of Health ServicesPlanning and Administration in the Department of Health Careand Epidemiology of the Faculty of Medicine at the Universityof British Columbia. The title of my graduate thesis isInterprofessional Misperceptions among Physicians and Nursesin Long Term Care Facilities, and the enclosed survey is amajor part of my thesis.If you have not yet returned your questionnaire, would youplease take a few moments now to complete it (I have enclosedanother copy) and return it to an envelope located in yourstaff room. The envelope is labelled "Survey-Physicians andNurses in Long Term Care". Your participation is needed inorder to have as complete a picture as possible of thenurses' views. It will allow me to contribute toward a betterunderstanding among physicians and nurses in long term careof each other's roles. Such heightened understanding canassist to promote good collaboration between the twoprofessions, and ultimately enhances positive patient careoutcomes.As stated in my earlier letter, the questionnaire should takeno more than 15 minutes to complete. The completion of thequestionnaire implies your consent. You may refuse toparticipate or withdraw from the study at any time. Please heassured that the information you give me will remaincompletely confidential and you will not personally beidentified in the research report. The questionnaires will bedestroyed at the completion of my study. There is no monetatycompensation. The results will be presented at a seminar inthe Department of Health Care and Epidemiology, and may beused for other presentations and publications in the future.. .^2THE UNIVERSITY OF BRITISH COLUMBIA^1 ;2 -Department of Health Care and EpidemiologyFaculty of MedicineMather Building, 5804 Fairview AvenueVancouver, B.C. Canada V6T 1Z3Tel: (604) 822-2772Fax: (604) 822-4994Graduate Programs: (604) 822-5405-2-If you have already returned your questionnaire, or if youhave decided not to participate, please disregard thisreminder and accept my thanks. If you have any concerns aboutthe survey, please feel free to contact me at work, 872-0044or at home, 669-5042. You may also contact my FacultyAdvisor, Dr. L. Green at 822-2258.Yours sincerely,Albertus Roskam

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