Effective Individual Contributions on Iranian Nurses Intraprofessional Collaboration Process: A Qualitative Study.

Introduction: The staffs' attitudes, beliefs, ideologies and dutifulness, along with their individual characteristics particularly their personality traits are among the factors that are known to affect their performance. The aim of this study was to determine the effect of individual contributions to the process of intraprofessional collaboration among Iranian nurses.
Methods: Twenty-three nurses from three different areas, namely Tehran, Tabriz and Ilam hospitals participated in this qualitative study. The participants were selected through purposive sampling. Data were collected using deep and unstructured interviews. Interviews were simultaneously analyzed using conventional content analysis method after being transcribed.
Results: Several essential factors contributing to the process of effective collaboration among Iranian nurses were identified: (a) nurses' perspectives and beliefs, (b) personal experiences, (c) individual characteristics and, (d) personal problems.
Conclusion: The findings indicate that the features and characteristics of individual contributions are very important and effective on nurses' intraprofessional collaboration. Thus, attention must be paid to these factors in order to overcome problems and obstacles that are encountered on the way of achieving effective collaboration.

Introduction

Collaboration is a complex process that requires effective communication, individual responsiveness and shared responsibility in taking care of patients.[1] Effective collaboration requires a teamwork approach to achieve high-quality results that cannot be attained individually.[2,3] The main purpose of collaborative work in the health care setting is to ensure quality comprehensive patient care. This type of high-quality, individualized patient care delivery is achieved through collaborative efforts of the entire health care team.[4]

Evidence from the literature identifies numerous benefits of effective collaboration in the health care workplace environment: (a) improved quality of patient care, (b) improved multidisciplinary work group satisfaction, (c) improved individual performance, (d) improved decision making, (e) reduced rate of absenteeism and tardiness and (f) improved components of professional performance such as coordination, shared responsibility and innovation.[5] In addition, effective collaboration and teamwork are reported contribute to the enhanced patient recovery and reduced length of hospital stay, which in turn positively impacts overall health care costs.[6]

Concentrating our efforts on effective collaboration would lead to improved patient outcomes and overall healthcare system.[7] In the nursing profession, collaboration and teamwork are considered as essential elements of delivering safe and quality patient care.[2]

Promotion of collaboration among nurses is critical in establishing an effective and safe clinical environment.[8] Collaboration is a core competency required of all nurses.[9] Reviews of literature demonstrate that studies carried out on this topic are mostly related to the interprofessional relationships between physicians and nurses[10,11]and are limited to the particular area of health care ( e.g. intensive care units, emergency wards and oncology).[12]

Review of literature on this subject of interest revealed that the majority of published studies are focused on the concept of interprofessional collaboration,[13]obstacles to collaboration,[14] collaboration occurrences,[15] collaboration outcomes and collaborative relationships[16]and measuring collaboration.[17,18] The literature on the concept of intraprofessional collaboration among nurses is limited. Intraprofessional collaboration is a complex and multifaceted process, which does not take place by itself. Numerous factors have either positive or negative effects on intraprofessional collaboration.[9] These factors are not discussed in the current literature and some are yet to be identified.

An individual nurse’s contribution is one of the main factors that can affect intraprofessional collaboration. A person's cultural background, knowledge and experience influence his or her outlook, behavior and performance. Such differences in perspectives may negatively affect the nursing collaborative efforts. Early recognition of these differences may help to identify the required strategies to overcome obstacles and facilitate effective intraprofessional nursing collaboration. It is hoped that the investigation of such variables by applying qualitative research that consists of multiple methods for gathering data and studying events, norms and values from the participants' perspectives, would enable us to study this phenomenon deeply, understand it clearly and identify it comprehensively.[19] Our study aims to investigate factors that exert either positive or negative impacts on the intraprofessional nursing relationships and collaborations.

Materials and methods

This is a qualitative study utilizing an inductive content analysis approach, allowing themes to emerge from the data to identify and explain factors affecting collaboration among nurses. The goal of the analysis was to generate categories and themes to describe the perceptions and experiences of the participants as a group. As a first step, the data was merged and sorted by general themes. Then, codes were generated and classified into categories. Purpose-based sampling was used to select participants. Twenty-three respondents were recruited from three hospitals in the cities of Tabriz, Tehran and Ilam. The inclusion criteria were based on the following elements: (a) level of education, nurses with B.Sc. degree or higher; (b) specialty care experience; (c) prior clinical experience; (d) expression of interest in the topic of discussion; and (e) being fluent in the Persian language. The demographic characteristics of participants were collected prior to the interviews solely with the intent of recruiting a variety of respondents across ages and genders. A total of 23 (16 females and 7 males) participants participated in the study including 19 Bachelors in nursing and 4 nursing diploma, with age range of 22–42 years, and mean age of 32.4 (7.1) years.

After obtaining the participants' informed consent, unstructured interviews were conducted to collect the data. The interviews were digitally recorded, then transcribed into Microsoft Word document for further analysis. An interview with each participant was carried out in 1 or 2 sessions in a private room at the participant’s place of employment. The interview time ranged from 30 to 90 minutes with an average of 45 minutes. Researcher involved the study from May 2013 until June 2014. Data collection took place during three work shifts: morning, evening and night.

Participation in a study was voluntary and the participants could choose to exit the study at any stage of the interview process. The participants' responses were kept confidential. This study was approved by the Committee of Ethics at Tabriz University of Medical Sciences (No: 91191); letters of approval were provided to the participating hospitals.

The unstructured interviews were built on open-ended questions. For example, the participants were asked to describe their regular working shifts at the hospital, their responsibilities, the nature of collaborative work and their engagement in collaborative activities. Special methods were employed to ensure the rigor of the study based on Guba & Lincoln's criteria.[20] Member checks and respondent’s validation were used to confirm the accuracy of the collected data and the extracted codes. To carry out member checks, the texts of interviews, codes and extracted categories were studied by two different nursing scholars. In addition, the findings were reviewed and confirmed by two independent qualitative analysis experts.

The participants demographic characteristic including age range: 22-42; and Mean 32.4 (7.3); years; gender (male: 7 and female: 16) and marital status (single: 4 and married: 19).

Results

This study completed with participation of 23 nurses have has discrepancies. The following sections describe the results of the interviews, which are organized according to the thematic categories which emerged. The participants' experiences and statements about the instances of their individual contributions fall under four thematic categories of 1) Nurses’ perspectives and beliefs, 2) personal experience, 3) individual characteristics and 4) Personal problems.

1.Nurses’ Perspectives and Beliefs

The two main factors identified by the nurses in this category were (1) an individual person’s attitude towards collaboration, and (2) the nurses' personal beliefs.

1-1. Individual person’s attitude towards collaboration

An individual’s attitude toward working in group setting is identified as an important factor that can influence collaborative relationships. The results of this study suggest that while some nurses are willing to engage in collaborate activities with other nurses, others prefer to work individually. The majority of the participants, however, remarked that they consider collaboration as a part of their nursing responsibilities. One of the participants stated: "First of all, it is part of our duty to help others, because we are responsible for our patients."

It was also noted that some of the nurses only performed the assigned responsibilities and did not feel that they had to go beyond their duties to lend a hand to a coworker or engage in collaborative activities. One of the participants stated: "When we divide labor, when a nurse is finished with the work that she has to do for the patients, she goes for a rest. For example, I might be busy doing something for a patient and not have the time to take care of other patients. I have to cover them but they [other nurses] do not help. She [another nurse] thinks that if she covers her own patient, there won't be any need to help others. That’s how they think."

Some participants expressed that helping others in certain situations was viewed as being forced to perform someone else's work and not viewed as a collaborative effort of achieving a shared goal or a mission. One participant considered a lack of interest in teamwork as a reason for not collaborating with others: "Some guys don't like teamwork and are not interested at all in teamwork; that's why they don't collaborate in teamwork." Another participant mentioned that a lack of interest on the part of individual nurses is a major obstacle to intraprofessional collaboration: "When I was talking to one of these nurses, she said that if she had to be honest, she had just been accepted as a nursing student and was not really interested in nursing. She didn't like her job, so she didn't take part in teamwork and collaborative activities." The lack of leadership support and engagement was identified by the nurses as factors that had a negative effect on nursing collaborations. An experienced nurse shared her perspective: "We had a colleague who didn't work well. She is on another ward now. She works well, and everyone is satisfied with her. You may dislike your head nurse, so you go and work in another ward."

1-2. Nurses' personal beliefs

Religious and ethical beliefs were also mentioned as factors positively affecting nursing collaborations. In most cases, religious beliefs are known to lead to proper care of the patients and the recognition of the participants’ expectations as nurses, even in the situation of low job satisfaction. One of the participants noted: "When I thought to myself, I said I had to work for God's sake, and the salary that I get must be Halal. We must take into account God's satisfaction." Another nurse stated: "In my opinion, we, nurses, have two dimensions: a spiritual and a material dimension. I have seen nurses for whom the spiritual dimension is more important, and thus have more collaboration."

One of the participants describing her perspective on intraprofessional collaboration and her religious beliefs mentioned: "If we don't help each other, the patients will be hurt most, and the personnel will have to be responsible before God … What matters is that which we have taken an oath for and we work for. What remains is whether I have been a good nurse, whether I have done my job properly and in the Doom's day we will definitely be acknowledged".

2. Personal experiences

2-1. Experiences of receiving nursing services by self-family hospitalization

Thinking about one's own experience as a patient is important in that it enables nurses to view the situation from the patient’s perspective. In this respect, one participant stated: "The patient may be one of my own family members, my brother or my father. Then, I would have higher expectations of my colleagues. We must understand a patient and his companions' expectations. For example, when my uncle was in hospital, I expected more of my colleagues." Another participant expressed: "When I was hospitalized myself, I saw how the nurses worked for me. One of the nurses used unfitting catheter on my vein. This made me become more aware of what I do on the job."

In addition to the individuals' religious and ethical beliefs, the most frequently mentioned topic during the interview was the participants' motivation to perform their nursing duties. One participant stated: "Taking conscience into account, we are content with ourselves in our subconscious that we are doing the right thing."

3. Individual characteristics and personality rats

Participants identified numerous personality traits that, from their perspective, influenced nursing collaboration. The most frequently mentioned qualities and characteristics are identified in this study. One participant stated: "People are different. Everyone has their own personality; everyone's behavior depends on his or her personality, just as my behavior is also dependent on mine. Those individuals pick up their personalities and take them to other places. They don't work in the new places, either."

A nurse with 13 years of clinical experience talked about how the nursing job contributed to the formation of her personality: "I've worked in different wards. Working with patients who suffered from different mental illnesses has given me a good feeling of calmness. First of all, a nurse must be calm. Secondly, she must be patient. She must not be angry and must have a serious and kind appearance. When she talks to somebody, her interlocutor must trust her."

Other participants pointed out that the more experienced nurses refuse to engage in collaborative nursing activities. One participant stated: "For instance, a person is theoretically and practically very good, but she doesn't have any work experience. She becomes a colleague of the one who has worked for 25 years. The experienced guy doesn't let her do some of the work. Being proud of herself, she doesn't let her colleague work."

4. Personal problems

Personal problems were identified as exerting a major impact on the individuals’ performance and willingness to engage in collaborative activities. A head nurse of one of the nursing units shared: "Oh! Some persons have problems at home; they come here and create problems. They are aggressive. They take hospital problems to home and home problems to hospital. They don't have the ability to collaborate. When someone is nervous, we cannot ask him to collaborate."

Another head nurse described her experience as: "For example, a problem has occurred to someone at home, or she doesn't have any energy to work that day or is not in a good mood at all. This has happened many times. Our clinical system is scheduled in a way that a person who must be on duty, must be there in hospital under any circumstances. It happened to me when I came to work with the worst headache, migraine. However, would I have the same efficiency when I am fine and when I am sick?"

Stress was identified as another contributing factor. An experienced nurse shared: "I myself had a little baby three years ago. I came to work. My collaboration with others did not decrease, but I was agitated. My mind was preoccupied. I tried to write down everything on my hand or on a piece of paper so that I wouldn't forget them. The help I provided for my friends declined as my time decreased. Deep in my heart, I was not satisfied with myself. One, who hasn't got any problems, is mentally ready to work with satisfaction in the working environment. Her mind is not at home, and she does not keep saying to herself; I have left a sick person home and come to work. I have left my baby there or let's say I am a debtor. She is not nervously waiting for her shift to finish soon and go home. She does her job calmly.” The experience of this participant clearly demonstrates the negative effects of personal issues and life stressors on an individual nurse’s performance. Stress reduction and support are factors that may have positive effects on the nurse’s willingness to engage in collaborative work.

Discussion

The findings of this study showed that individual contributions have an effective role in the manner of nurses' working together and satisfying the clients' expectations. The individuals' religious and ethical opinions and beliefs enhance his/her dutifulness; furthermore, his/her or own family experiences of being hospitalized, personality traits and individual problems are also important variables that affect their collaboration.

Included in individual contributions are religious beliefs and opinions of the participants such as belief in God and being responsive to Him; these are the factors found to encourage the nurses in this study most to be dutiful and feel responsible so as to work properly and help colleagues, prioritizing the patients' needs' satisfaction and trying to achieve God's content, which will lead to their own satisfaction as well as that of their clients.

Despite the shortages and conflicts that might arise in the workplace, this factor i.e. the nurses’ and clients' satisfaction will compensate for all those challenges and will lead to the sense of responsibility and provision of care on their part. Religious beliefs is a category based on our Islamic and religious culture and in many studies reference has been made to the importance of its role in controlling and overcoming physical and mental problems.[21,22] The nurses' beliefs and personal values have been emphasized and paid attention to as an effective criterion that improves personal and professional performance.[23] In other studies, conscience, religious beliefs and commitment were also the most important features that mediated the participants' responses to occupational frustration and affected caregiving behavior.[24,25]

Attitude as something that determines behavior consists of a relatively stable method of thinking, feeling and behaving towards individuals, groups or social topics or, in more general terms, any event that takes place in an individual's environment;[26] It is a permanent system which consists of cognitive and emotional elements and a willingness to act.[27] The findings of this study indicate the individuals' attitudes, viewpoints and ways of thinking about their profession and their definition of collaboration. In addition, their interest in the working environment and their colleagues is a factor that affects their performance in the workplace.

Moreover, according to the findings, the personal experiences of being hospitalized or the hospitalization of a family member would help nurses put themselves in the shoes of colleagues or clients which is itself an important factor affecting collaboration among nurses. Having experienced the same illness can have an important role in increasing the nurses' knowledge and enriching the way they provide the patients with clinical care. Besides that, having experience in a particular field or lack of colleague's knowledge and expertise is an important factor that affects the way nurses collaborate with each other. However, what is of great importance in acquiring experience is an individual's own experience in paying attention to patients' needs and colleagues' conditions when they encounter problems.

The results of other studies also show the effect and importance of nurses' attitudes and those of other professional groups on the way they collaborate, with the ones who have more positive attitudes collaborating better with other groups.[1,28] However, there are various factors that could affect attitude. Sterchi came to the conclusion that the working history affects the type of attitude and the people who had worked for a longer time, possessed a more positive attitude.[29]

Besides attitudes, beliefs, ideologies and dutifulness, the staffs' individual characteristics, particularly their personality traits, are among other factors that could affect their performance. In this study, the findings show that the nurses' personality traits, including their calmness or being stressed out influence their performance. Rafiee et al., state that despite the existence of many problems in the organization of hospitals and the stress that nurses have to go through, personality traits such as conscience, beliefs, commitment and responsibility and altruism affect caregiving behaviors and do not let them be inattentive to patients' needs.[25] Sanagou et al., also stated that faculty members were able to work under many conditions without organizational awards with the aim of working for God's sake and giving service to patients and students.[24]

Conclusion

The study findings reinforce the notion that individual contributions are factors that affect nurses' performance in an intraprofessional collaborative environment. In addition, we discovered that the motivation to be productive in the workplace and an interest in assisting colleagues can have positive effects on their performance in the workplace. Nurses who have experienced hospitalization or spent time in hospital with a relative are more inclined to engage in collaborative work and help a fellow colleague. This phenomenon is based on the fact that nurses with a prior experience as patients can better relate to the everyday challenges that their colleagues experience while managing a heavy workload of patients. This study explored the factors that have positive or negative contributions to intraprofessional collaboration among nurses in Iran. Our study was exploratory in nature. Further research is needed to show a link between identified factors and their contribution to intraprofessional collaboration.

Acknowledgments

This is a report of a database from a thesis entitled "collaboration process between nurses" approved supported by Tabriz University of Medical Sciences. The editing assistance of Dr. Jemma Ayvazianis gratefully appreciated. In addition, we personally thank all the participants who took part in this study.

Ethical issues

None to be declared.

Conflict of interest

The authors declare no conflict of interest in this study‏.