Differences in communication within the nursing group and with members of other professions at a hospital unit

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1 ORIGINAL ARTICLE Differences in communication within the nursing group and with members of other professions at a hospital unit Beate Andre, Torunn H Nøst, Sigrun A Frigstad and Endre Sjøvold Aims and objectives. To investigate what differences exist in nurses communications with each other as opposed to their communications with members of other healthcare professions. Background. Difficulties have been reported related to the introduction of interdisciplinary collaboration in hospitals even when their efficacy has been demonstrated. Design. This paper is a report of a project that was a cross-sectional survey design. Method. Nurses and assistant nurses received questionnaires that examined two different components of interdisciplinary collaboration. Using the psychometric method known as Systematizing Person-Group Relations to gather data and for analysis, the method aims to investigate the dominant aspects of the particular work environment by identifying key characteristics of interdisciplinary collaboration. Results. The respondents reported significant differences in six of the 12 factors; high scores on caring, acceptance, engagement and empathy characterised communication with members of their own professional group as low scores on the same factors characterised communication with other healthcare professions. Conclusion. Findings in this study suggests that nurses behave in a more loyal, accepting and critical manner when communicating with each other than they do when communicating with members of other healthcare professions. Nurses are more influenced by behaviours characterised by assertiveness and resignation in their communication with members of other healthcare professions. The findings indicate that nurse s experience mixed emotions and behaviours that influence their communications with healthcare personnel from other professions. Relevance to clinical practice. Nurses often hold key positions on interdisciplinary collaboration; therefore, they must develop the communicative skills required in this position to be able to improve the quality of patient care in hospitals, related to nurses experiences and skills. What does this paper contribute to the wider global clinical community? Nurses have key positions on interdisciplinary collaboration that require high-level communication skills. Nurses must further develop their communication skills to use them effectively for communicating with healthcare workers from other professions. Improving nurses communicative efficacy can contribute to better health outcomes for patients. Key words: communication, nursing, professions, work environment Accepted for publication: 14 May 2016 Authors: Beate Andre, RN, RMN, PhD, Faculty of Medicine and Health Sciences, Department of Public Health and Nursing, Norwegian University of Science and Technology (NTNU), Trondheim; NTNU Center for Health Promotion Research, Trondheim; Torunn H Nøst, RN, MSc, Faculty of Medicine and Health Sciences, Department of Public Health and Nursing, Norwegian University of Science and Technology (NTNU), Norway, NTNU Center for Health Promotion Research, Norway; Sigrun A Frigstad, RN, MSc, Department of Nursing Science, Norwegian University of Science and Technology (NTNU), Trondheim; Endre Sjøvold, PhD, Department of Industrial Economics and Technology Management, Faculty of Social Sciences and Technology Management, NTNU, Trondheim, Norway Correspondence: Beate Andre, Faculty of Medicine and Health Sciences, Department of Public Health and Nursing, Norwegian University of Science and Technology (NTNU) 2) NTNU Centre for Health Promotion Research. NTNU NO Trondheim, Norway. beate.andre@ntnu.no 956 Journal of Clinical Nursing, 26, , doi: /jocn.13410

2 Original article Introduction This article seeks to investigate the differences between nurses communications with each other and with members of other professions at a university hospital unit. The authors believe that interdisciplinary collaboration can potentially offer more coherent services for patients (D Amour et al. 2005, Crawford et al. 2012), but previous research suggests that there are significant barriers to achieving integrated collaboration among healthcare professionals (Andre et al. 2013, Andre et al. 2013a). In this paper, we investigate the existence of differences in communication within the nursing group and between nurses and other healthcare professionals. Background Nursing communication and behaviour in interdisciplinary collaboration Previous research has identified four communicative skill sets of nursing professionals, namely collaboration, credibility, compassion and coordination (Apker et al. 2006, Andre et al. 2008, McCaffrey et al. 2012, Andre et al. 2015). The findings emphasise that communicative behaviours, such as expectation from others and professionalism, are associated with skill sets that nurses enact in their interaction with other healthcare professions. The conclusions consider that the communicative obligations of professional nurses who serve in interdisciplinary collaboration are of an academic and strategic nature (Apker et al. 2006, Andre et al. 2015). The tactical and functional use of influence and expertise may support the attempts of nursing leaders in hospitals, education, research and administration to influence the process of improving the effectiveness of interdisciplinary collaboration (Jansen 2008). The concept of collaboration can be defined in many ways here taken from Bronstein (2003): collaboration is an effective interpersonal process that facilitates the achievement of goals that cannot be reached when individual professionals act on their own (Bronstein 2003, p 299). This definition can include interdependence, newly created professional activities, flexibility, collective ownership of goals and reflection on the collaborative process (Bronstein 2003). Interdependence may be characterised by formal and informal time spent together, oral and written communication and respect for colleagues professional opinions and input (Bronstein 2003). Another definition is presented by Sicotte et al in 2002, and referrers to the WHO s Health Manpower definition of the primary healthcare team (WHO, 1985): Differences in communication A group of persons who share a common health goal and common objectives determined by community needs, to which the achievement of each member of the team contributes, in a co-ordinated manner, in accordance with his/her competence and skills and respecting the functions of others WHO, 1985, p 89 This emphasis on interdisciplinary collaboration is consistent with the efforts that many countries are making to encourage an interdisciplinary collaborative approach. In addition, this definition also emphasise the importance of common objectives and respect for other profession as essential, also found in other studies (McCaffrey et al. 2012). The discussion in this article is based on the second definition (WHO, 1985). Interdisciplinary collaboration was, and is still, perceived as the type of work organisation that enables and integrated approach to quality care delivery (Sicotte et al. 2002, Crawford et al. 2012, Andre et al. 2013b). However, different health care professionals tend to pursue their own aspirations and to maintain their professional autonomy and jurisdiction rather than opening their practice to collaborative behaviour. It seems like their relationships appear to be based more on disciplinary parallelism that exacerbates the combination of practices rather than promoting interdisciplinary collaboration focused on the patients needs (Sicotte et al. 2002). Communication in interdisciplinary collaboration Several researchers have reported that introducing interdisciplinary collaboration has been challenging (Leonard et al. 2004, Mills et al. 2008, McCaffrey et al. 2012), although they have proved to be an important key factor to improvements in the delivery of health care in the hospital setting (Shaw et al. 2007, McCaffrey et al. 2012). Several reasons have been suggested to explain why introduction of such collaboration are challenging, including differences in education, traditions and professional connections of each member, (Rogers & Lingard 2006, Rothstein & Hannum 2007) and differences in status and degree of autonomy (Skjørshammer 2003). Professional autonomy may have the effect of stimulating boundaries between professions (Shaw et al. 2007). Hence, differences in status among various healthcare professions can increase boundaries, status and autonomy may influence on the interdisciplinary collaboration (Rogers & Lingard 2006, Leggat 2007, Rothstein & Hannum 2007). Different professional interventions and approaches to the same health problem seem to be encouraging an explanatory problem solving, with focus on how to solve the problem, and not who solved the problem at Journal of Clinical Nursing, 26,

3 B Andre et al hand (Sicotte et al. 2002, Andre et al. 2015, Frigstad et al. 2015). This impact of these different approaches may be seen in critical care cases and communication in stressful situations, as found in an earlier study (Andre et al. 2015). Work culture, relationships and the arrangement of working conditions are important factors for patient safety (Alfredsdottir & Bjornsdottir 2008). Studying communication and collaboration in healthcare organisations is critical, given the effects these factors can potentially have on patient safety (Makary et al. 2006, McCaffrey et al. 2012). Earlier studies have highlighted the need for cultural change related to both language and behaviour to enhance collaboration and communication among nurses and physicians (Crawford et al. 2012). Separated professional worlds Glouberman and Mintzberg (2001) have presented a theory of the different worlds that exists among the various healthcare professions, more developed in the framework of role-theory. Healthcare organisations can be characterised by these different professional worlds; physicians are influenced by the world of cure and nurses by the world of care. In addition, members of the various healthcare worlds can differ in their perceptions of the same problem (Glouberman & Mintzberg 2001). For instance, while physicians enter the operating theatre to perform a specific procedure and leave when they have completed their task, nurses are present at both the intervention and the follow-up care (Makary et al. 2006, Crawford et al. 2012). One consequence of that is that nurse s aim for a more holistic approach to the patient and their health problems than physicians do (Nortvedt 2005, Steinsbekk & Launsø 2005). Significant variance in the experience of interdisciplinary collaboration is present in the operating room, with physicians experiencing the interdisciplinary collaboration with others as good, nurses perceive the interdisciplinary collaboration only as fair (Makary et al. 2006). When hospital organisations are faced with the need to make modifications and changes, interdisciplinary collaboration are often suggested as a measure that can address these needs (Scott et al. 2005). However, this intervention can be challenging because there are rational borders between the various professions and their cultures in the healthcare setting (Andre et al. 2008). With this knowledge, we explored the following research question: What differences exist in nurses communications with each other as opposed to their communications with members of other healthcare professions? Method The following description of the applied methodological approach is based on the same data set reported in an earlier article (Andre et al. 2015). However, it discloses new findings based on different data from the Systematizing Person-Group Relations Instrument (SPGR). This study seeks to examine communication and interaction among healthcare staff to acquire understanding and knowledge about the work environment. The study was the result of a joint research group established between a university hospital and a university college/nursing department (Andre et al. 2015, Frigstad et al. 2015) and was conducted during autumn 2013 and spring Design This article reports a study using a cross-sectional, correlation research approach. The intention is to compare two perspectives emerging from our results: communication within a professional group and communication with other professional groups. Effective communication among several professions is critical to attain efficient and seamless collaboration (Andre et al. 2013b). Sample and recruitment The SPGR questionnaires were distributed and completed in conjunction with an educational intervention focusing on implementing nursing diagnoses. The nursing staff (n = 101) in the selected unit was invited to participate at the seminars. The respondents filled in the questionnaire when other people were present in the room, and with researcher present to answer questions regarding the questionnaire. Night-shift positions did not participate and that in addition to employment over <50% as an inclusion criteria, can explain some of the participation rate of 70%. Assistant nurses perform a different role than registered nurses. However, for all practical purposes in this article, assistant nurses are regarded as equal to registered nurses. The Systematizing Person-Group Relations instrument The respondents were asked to describe their communication in their work environment concerning two different perspectives: their communication within their own professional group and their communication with members of other professions. The SPGR was used for data collection and analysis (Hare et al. 2005, Sjøvold 2006, 2007, Sjøvold et al. 2005). The SPGR method is based on the Semantic 958 Journal of Clinical Nursing, 26,

4 Original article Differential scaling technique developed by Osgood (1957). Previous studies (Koenigs et al. 2002, 2005) have reported the validity and reliability of the SPGR instrument. Data collection and description of the tool The following itemised presentation of the SPGR instrument is presented similarly to the methodological descriptions in an earlier study (Andre et al. 2015). The 24 questions were rated separately, according to the following descriptions: the behaviour occurred (1) never or seldom (1 point), (2) sometimes (2 points), or (3) often or always (3 points) concerning the two different predefined perspectives on communication. In the SPGR instrument, the organisational culture is defined by the groups dominant behaviour such as Control and Nurture (C- N), Opposition and Dependence (O-D) and Withdrawal and Synergy (W-S). The individual dimensions contain of two factors (Table 1). The SPGR tool represents a balance setup, which implies that if there is less of one element, for example, criticism or assertiveness, then there is an excess of the opposing element, i.e. loyalty or acceptance. The Control dimension is of key importance when analytical, task-oriented, or autocratic performance among the respondents is the rule, as opposed to the Nurture dimension, which focuses on the performance of care, empathy or spontaneity. The Opposition dimension is central when critical, assertive or self-sufficient performance is the rule, as the Dependence dimension emphasises domination of passive and obedient performance. Synergy and Withdrawal comprise the two opposing factors; the Synergy dimension defines engagement and constructive, goal-oriented performance as opposed to the Withdrawal dimension, which describes restriction from contribution and a commitment as the dominant behaviour (Sjøvold et al. 2005, Andre et al. 2015). the study. All data gathered were anonymised. The Regional Committees for Medical and Health Research Ethics in Norway assessed the study as a quality assessment project of the actual hospital. Based on that the actual department management in addition to the privacy ombudsman at the hospital sanctioned the study. Data analysis Independent samples student s t-test was conducted to explore for differences between the two selected perspectives on communication, nurses communications with each other as opposed to their communications with members of other healthcare professions, based on the findings from this study. The relevant data were analysed using the Statistical Package for Social Sciences (SPSS INC., Chicago, IL, USA) version 21.0 for Windows. All research hypothesis were tested at the 005 significance level for the two-tailed test. Cheeked for normality gave acceptable results in our sample for the test used. Results Study group Differences in communication The response rate of the 101 nurses working in the department were 69% (n = 70). The study group consisted of nurses (886%, n = 62), assistant nurses (86%, n = 6) and nursing mangers (29%, n = 2), and there were two males and 68 females. The main body of the material (66%) was found in the category years and years (Table 2). The university hospital involved in the study had in 2013, 993 beds and 59,016 hospitalisations. The department in which the study was conducted consisted of four units and 41 beds see Table 2. Ethical considerations The ethical guidelines of voluntary participation and the possibility of withdrawal at any point were followed. The participants were informed about the purpose and aim of Table 1 Elements of group constitution based on SPGR instrument Dimensions Factors Short description C-N Control Structure, logic, authority Nurture Caring, social orientation, openness O-D Opposition Criticism, rebellion Dependence Loyalty, conformance, submission W-S Withdrawal Passive resistance Synergy Engagement, constructive goal-oriented teamwork Findings from the SPGR study The results associated with to the two perspectives, communication within one s own professional group and communication with members of other professions are presented in Table 3. Findings suggested statistically significant differences with a confidence interval of 95% in six of the 12 factors; three of the factors showed significant differences in a p < 001 level. N1, caring (p = 0001), D1, loyalty (p = 0004) and S2, empathy (p = 0000), while three were at a p < 005 level O1, criticism (p = 0044), D2, acceptance (p = 0032) and S1, engagement (p = 0012), showed significant differences when comparing the two perspectives. The results revealed that nurses working in the department described communication with members of other Journal of Clinical Nursing, 26,

5 B Andre et al Table 2 Demographic data Sex Female % Male 2 286% Age (Years) % % % % % Job title Nurse % Nursing assistant 6 86% Other 2 29% Manager Yes 3 29% No % professions with significantly lower mean values on several factors. Caring (N1, mean 694 vs. N1 own profession, mean 809, p = 0001), engagement (S1, mean 730 vs. S1 own profession mean 812, p = 0012) and empathy (S2, mean 642 vs. S2 own profession 786, p = 0000) all had lower scores in communication with members of other professions. The factors for criticism (O1, mean 242 vs. O1 own profession mean 302, p = 0044), loyalty (D1, mean 685 vs. D1 own profession mean 767, p = 0044) and acceptance (D2, mean 724 vs. D2 own profession mean 789, p = 0032) had significantly lower mean values in communications with members of other professions. Two factors displayed higher scores in communication with members of other professions vs. own profession, namely, assertiveness (O2, man 367 vs. O2 mean 337 own profession) and resignation (W1, mean 174 vs. W1 mean 156 own profession), but these differences are not significant. Discussion Generally, the results show that nurses demonstrate effective skills when communicating with each other. The synergy factors (S1, engagement and S2, empathy) promote engagement and constructive, goal-oriented behaviour and the nursing staff working in the department defined their working environment with high scores on the two factors when communicating within nursing profession. The findings reveal that communication between healthcare providers was significantly different in relation to communication within their own group and other professions concerning caring, criticism, loyalty, acceptance, engagement and empathy. These results point out that communication is understood differently within the nursing group as opposed to other professions and seem to have an influence on how interdisciplinary collaboration is perceived and conducted. The intention of this study was to reveal how nurses perceive their communication in relation to two different perspectives: communication within their own profession and communication with members of other professions. Furthermore, when we compared respondents scores from the two different perspectives, positive factors such as engagement (S1), empathy (S2) and caring (N1) scores were high when communication within own profession compared to the scores on communicating with members of other professions. At the same time, for negative factors such as criticism (O1), loyalty (D1) and acceptance (D2), had also high scores when communication within own profession Table 3 Communication within own and other profession groups Factors Code Typical behaviour Own profession Other profession Ruling C1 Controlling, autocratic, attentive to rules and procedures Task-orientation C2 Analytical, task-oriented, conforming Caring N1 Taking care of others, attentive to relations (0001)** Creativity N2 Creative, spontaneous Criticism O1 Critical, opposing (0044)* Assertiveness O2 Assertive, self-sufficient Loyalty D1 Obedient, conforming (0004)** Acceptance D2 Passive, accepting (0032)* Resignation W1 Sad appearance, showing lack of self-confidence Self-sacrifice W2 Passive, reluctant to contribute Engagement S1 Engaged, inviting others to contribute (0012)* Empathy S2 Showing empathy and interest in others (0000)** *p < 005, **p < 001 (n = 70). 960 Journal of Clinical Nursing, 26,

6 Original article compared with scores when communicating with other professionals. For effective interdisciplinary collaboration, it is understandable that professionals in different aspects of healthcare must communicate more effectively within their own groups. This is due to the differences in worlds, culture and behaviour (Glouberman & Mintzberg 2001, Crawford et al. 2012), which can also lead to different perceptions and understandings of patients and their health problems (Nortvedt 2005, Steinsbekk & Launsø 2005). Communication with colleagues belonging to the same world does not challenge the understanding and perception of the situation and will therefore be less complicated. Earlier findings suggest educational programs or use of tools to improve not only collaboration and communication among nurses and physicians but also respectful and nonhierarchal behaviour have been recommended (WHO, 1985, Crawford et al. 2012, McCaffrey et al. 2012). Findings in this study showed that assertive and self-sufficient behaviour (O2) and sad appearance and showing lack of self-confidence (W1) had higher scores when communication with other professions. In addition, the factors caring (N1), engagement (S1) and empathy (S2) showed lower scores when communicating with members of other professions. Having a lower status level may lead to a perception of being inferior, provoked and aggressive (Rogers & Lingard 2006, Leggat 2007, Crawford et al. 2012). The respondents reported lack of self-confidence and lack of caring regarding communication with other professions, and this may be because of status differences as reported in other studies (Skjørshammer 2001, 2003, Rogers & Lingard 2006, Leggat 2007, Rothstein & Hannum 2007, Crawford et al. 2012). Nurses strive for a more holistic approach to patients health problems than, for example, physicians do (Nortvedt 2005, Steinsbekk & Launsø 2005), but they seem to lack the selfconfidence and engagement to promote this endeavour and approach through interdisciplinary collaboration and communication. Both communication skills and behaviours are important for promoting nurses communication in interdisciplinary collaboration (Apker et al. 2006, Crawford et al. 2012, McCaffrey et al. 2012). Thus, there is a need for nurses to become more self-confident and engaged when communicating with other healthcare professionals. The results of this study show that when nurses communicate with each other, they seem to apply important communication skills such as caring, attentiveness, inviting gestures/ openness, empathy and interest in others. Nurses often have key positions on interdisciplinary collaboration and must develop their skills to use such positions to increase the quality of patient care in hospitals, related to nurses experiences and skills. Academic and strategic conclusions can be made related to the communicative obligations for professional nurses on interdisciplinary collaboration (Apker et al. 2006). Earlier research has revealed that both communicative skills and behaviours are important for improving nurses communication in interdisciplinary collaboration and that nursing leaders must promote the emergence of collaborative practice among nurses (Apker et al. 2006, Erenstein & McCaffrey 2007, Jansen 2008, Crawford et al. 2012, Andre et al. 2015). When hospital organisations are coping with changes and challenges, interdisciplinary collaboration are often suggested as ways to address these situations (Scott et al. 2005). However, this can be challenging because there are rational borders among the different professions and their cultures in health care (Glouberman & Mintzberg 2001, Andre et al. 2008). Nurses must use their key positions on interdisciplinary collaboration to develop communication among different healthcare professionals. The findings of this study reveal that nurses possess and demonstrate effective communication skills when they communicate with each other. These skills must also be applied to their roles on interdisciplinary collaboration to promote their development and thereby enable them to play a part in addressing and managing changes and challenges in health care. Limitations and strengths The study was conducted in a setting in which nurses communicate with each other and with other healthcare professionals. Only nurses and assistant nurses participated in the study and only their perception is presented. Furthermore, this study was conducted in Norway with a population of Norwegian healthcare workers. Working conditions are usually favourable for workers in Norway and these findings may not be transferable to other contexts without considering these facts. Communication within the nursing group and with members of other professions at a hospital unit has not previously been described. The result from this study offers a suggestion as to the direction that future research might take in following studies. Conclusion Differences in communication In this study, we have found that nurses behave in a more loyal, accepting and critical manner when communicating with each other than they do when communicating with members of other healthcare professions. In addition, they are more influenced by behaviours characterised by assertiveness and resignation in their communication with members of other healthcare professions. The findings Journal of Clinical Nursing, 26,

7 B Andre et al indicate that nurses experience mixed emotions and behaviours that influence their communications with healthcare personnel from other professions. Caring, engagement and empathy represent behavioural skills that are important on interdisciplinary collaboration, and nurses in this study used these skills in relation to communication within their own professional group. Therefore, it seems imperative that nurses develop their communicative and attitudinal skills so that they can also use these skills effectively when they communicate with healthcare workers in other professions. Further research must focus on how they can achieve that. in hospitals. Nurses must use their key positions on interdisciplinary collaboration to promote further development and improvement of communication among different health professions. Both communicative skills and behavioural skills are important for promoting nurses communication in interdisciplinary collaboration. Acknowledgements To Norwegian Nurses Organization for supporting this study with funding. Relevance to clinical practice The results of this study demonstrate that nurses communication skills appear to be different within their own professional group than they are with members of other professions. The findings further demonstrate that nurses possess and use effective communicative skills when they communicate with each other. There is a need for nurses to develop more self-confident and engaged attitudes in their communications with members of other healthcare professions. Nurses often play key roles on interdisciplinary collaboration and must therefore develop their skills to be able to use their position to increase the quality of patient care Contributions Study design (BA, THN, SAF, ES); Data analysis (BA, ES) and Manuscript preparation (BA, THN, SAF, ES). All authors have approved this version and agree to be accountable for all aspects of work ensuring integrity and accuracy. Conflict of interests The authors declare that they have no conflict of interests. References Alfredsdottir H & Bjornsdottir K (2008) Nursing and patient safety in the operating room. Journal of Advanced Nursing 61, Andre B, Ringdal GI, Loge JH, Rannestad T & Kaasa S (2008) The importance of key personnel and active management for successful implementation of computer-based technology in palliative care: results from a qualitative study. Computers Informatics Nursing 26, Andre B, Sjøvold E, Holmemo M, Rannestad T & Ringdal GI (2013) Expectations and desires of palliative health care personnel concerning their future work culture. Journal of Hospital Administration 2, 46. Andre B, Ringdal G, Loge JH, Rannestad T, Laerum H & Kaasa S (2008) Experiences with the implementation of computerized tools in health care units: a review article. International Journal of Human-Computer Interaction 24, Andre B, Sjøvold E, Rannestad T, Holmemo M & Ringdal GI (2013a) Work culture among healthcare personnel in a palliative medicine unit. Palliative and Supportive Care 11, Andre B, Sjøvold E, Rannestad T & Ringdal GI (2013b) The impact of work culture on quality of care in nursing homes a review study. Scandinavian Journal of Caring Sciences 28, Andre B, Frigstad SA, Nøst TH & Sjøvold E (2015) Exploring nursing staffs communication in stressful and non-stressful situations. Journal of Nursing Management 24, E175 E182. Apker J, Propp KM, Ford WSZ & Hofmeister N (2006) Collaboration, credibility, compassion, and coordination: professional nurse communication skill sets in health care team interactions. Journal of Professional Nursing 22, Bronstein LR (2003) A model for interdisciplinary collaboration. Social Work 48, Crawford CL, Omery A & Seago JA (2012) The challenges of nurse-physician communication: a review of the evidence. Journal of Nursing Administration 42, D Amour D, Ferrada-Videla M, San Martin Rodriguez L & Beaulieu M-D (2005) The conceptual basis for interprofessional collaboration: core concepts and theoretical frameworks. Journal of Interprofessional Care 19 (Suppl 1), Erenstein CF & McCaffrey R (2007) How healthcare work environments influence nurse retention. Holistic Nursing Practice 21, Frigstad SA, Nøst T H & Andre B (2015). Implementation of free-text format nursing diagnoses at a University Hospital s medical department. Exploring nurses and nursing students experiences on use and usefulness. A qualitative study. Nursing Research and Practice, 2015, 11. Glouberman S & Mintzberg H (2001) Managing the care of health and the 962 Journal of Clinical Nursing, 26,

8 Original article Differences in communication cure of disease Part I: differentiation. Health Care Management Review 26, Hare AP, Sjøvold E & Baker HG (2005) Analysis of Social Interaction Systems: SYMLOG Research and Applications. University Press of America, Lanham, Maryland. Jansen L (2008) Collaborative and interdisciplinary health care teams: ready or not? Journal of Professional Nursing 24, Koenigs RJ, Hare SE & Hare AP (2002) SYMLOG Reliability and Validity. Symlog Consulting Group, San Diego. Koenigs RJ, Hare SE, Hare AP & Cohen MA (2005) Reliability and validity. In Analysis of Social Systems (Hare AP, Sjøvold E, Baker HG & Powers J eds). University Press of America, New York, pp Leggat SG (2007) Effective healthcare teams require effective team members: defining teamwork competencies. BMC Health Services Research 7, 17. Leonard M, Graham S & Bonacum D (2004) The human factor: the critical importance of effective teamwork and communication in providing safe care. Quality and Safety in Health Care 13 (Suppl 1), i85 i90. Makary MA, Sexton JB, Freischlag JA, Holzmueller CG, Millman EA, Rowen L & Pronovost PJ (2006) Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder. Journal of the American College of Surgeons 202, McCaffrey R, Hayes RM, Cassell A, Miller-Reyes S, Donaldson A & Ferrell C (2012) The effect of an educational programme on attitudes of nurses and medical residents towards the benefits of positive communication and collaboration. Journal of Advanced Nursing 68, Mills P, Neily J & Dunn E (2008) Teamwork and communication in surgical teams: implications for patient safety. Journal of the American College of Surgeons 206, Nortvedt P (2005) On the fact-value distinction and the phenomenology of caring. Nursing Philosophy 6, Osgood CE (1957) The Measurement of Meaning. University of Illinois Press, Urbana and Chicago. Rogers DA & Lingard L (2006) Surgeons managing conflict: a framework for understanding the challenge. Journal of the American College of Surgeons 203, Rothstein WG & Hannum S (2007) Profession and gender in relationships between advanced practice nurses and physicians. Journal of Professional Nursing 23, Scott JT, Rundall TG, Vogt TM & Hsu J (2005) Kaiser Permanente s experience of implementing an electronic medical record: a qualitative study. BMJ 331, Shaw M, Heyman B, Reynolds L, Davies J & Godin P (2007) Multidisciplinary Teamwork in a UK Regional Secure Mental Health Unit a Matter for Negotiation? Social Theory & Health 5, Sicotte C, D Amour D & Moreault M-P (2002) Interdisciplinary collaboration within Quebec community health care centres. Social Science and Medicine 55, Sjøvold E (2006) Maturity and effectiveness in small groups. Nordic Psychology 58, Sjøvold E (2007) Systematizing Person- Group Relations (SPGR) - a field theory of social. Small Group Research 38, Sjøvold E, Hare A & Sjovold E (2005) Bions theory on group emotionality. In Analysis of Social Interaction Systems (Hare AP, Sjøvold E, Baker HG & Powers JP eds). University Press of America, New York, pp Skjørshammer M (2001) Co-operation and conflict in a hospital: interprofessional differences in perception and management of conflicts. Journal of Interprofessional Care 15, Skjørshammer M (2003) Anger behaviour among professionals in a Norwegian hospital: antecedents and consequences for interprofessional cooperation. Journal of Interprofessional Care 17, Steinsbekk A & Launsø L (2005) Empowering the cancer patient or controlling the tumor? A qualitative study of how cancer patients experience consultations with complementary and alternative medicine practitioners and physicians, respectively. Integrative Cancer Therapies 4, WHO (1985) Health manpower requirements for the achievement of health for all by year 2000 through primary health care. Report of a WHO Expert Committee. Journal of Clinical Nursing, 26,