Better together : A fresh look at collaboration within nursing

January / February 2018   Comments

Researchers see improved intra-professional relationships in nursing as key to helping achieve optimal patient and health-system outcomes

Canadian nurses proposed resolutions to CNA at its annual meeting of members in 2016 and 2017, related to supporting greater clarity for the RN role and providing national leadership on collaboration within nursing. That these related issues have come up in consecutive years indicates that nurses want to address them. As researchers with a passion for role clarity and intra-professional collaboration, our work is part of a growing number of studies on this complex dynamic.

Given the amount of time nurses spend working together in teams, and the number of care delivery models that require collaboration, it is surprising how little research has been done on fostering collaboration and consultation within nursing (Butcher, MacKinnon, Bruce, Gordon, & Koning, 2017). However, emerging Canadian research suggests that understanding the unique contributions of each nursing designation and strengthening collaboration between nurses will positively impact the profession and nurses’ contributions to patient and health-system outcomes.

In this article we describe the results of a consultation we facilitated during the June 2017 CNA annual meeting of members and outline some of the opportunities nurses have to provide input into future CNA initiatives on strengthening intra-professional collaboration.

The goals of the consultation were to (1) present an overview of the Canadian research on intra-professional collaboration, (2) explore issues found in the research, and (3) identify possible strategies to support collaborative practice among regulated nurses (RNs, NPs, licensed/registered practical nurses and registered psychiatric nurses). About 80 CNA members were in attendance, from all provinces and territories, representing the five nursing domains (i.e., practice, education, research, policy and administration). Based on a show of hands, the group included a broad range of participants, from students to those with over 40 years of nursing experience.

The evidence
We began the consultation by reviewing the Canadian research on intra-professional collaboration as it relates to the role of education. The expanded educational preparation and scopes of practice over the years have led to new care delivery models and staffing ratios. These changes in themselves present opportunities and challenges for nursing, yet since scopes of practice continue to evolve (for example, the introduction of RN prescribing), it is important that nurses are able to respond to and take advantage of current and future roles.

Overall, the research has shown that silos in nursing education (where diploma and degree students rarely interact) contribute to a lack of understanding about the different nursing designations. In addition, the lack of specific strategies to teach intra-professional collaboration during entry-to-practice nursing programs impedes the development of the competencies required to support it.

These silos can result in many misconceptions about the different designations within nursing and limit knowledge of what each can contribute to patient care (Limoges & Jagos, 2015, 2016). This pattern continues in practice when nurses are not given opportunities to learn about collaboration or one another’s roles (Lankshear, Rush, Weeres, & Martin, 2016; Moore, Prentice, & Taplay, 2015).

Nurses understand the importance of collaboration, yet they struggle to enact it in practice (Moore & Prentice, 2013). Guidance on teaching and supporting nursing collaboration is needed (Nelson et al., 2014; Canadian Interprofessional Health Collaborative, 2010), since strong collaboration can optimize scopes of practice and support nurses and other professionals to participate in patient-focused health care.

Joint education at every level and among different nursing designations is an important strategy to support collaborative practice. Students and nurses in practice recognize that role ambiguity and efforts to close off professional boundaries (using power relations or ideologically based barriers) impede safe patient care and transitions of care. They also recognize that leadership has a vital role in setting expectations for collaboration in practice settings (Lankshear et al., 2016; Limoges & Jagos, 2016). Offering opportunities to learn with, from and about each other enhances collaborative practice skills, and knowing more about the different designations helps address hierarchy and promote respect (Limoges & Jagos, 2016). Joint education can enable nurses to be receptive to one another, which requires trust in one another’s competence and confidence in one another’s knowledge and skill (Bainbridge & Wood, 2012; Baker, Egan-Lee, Martimianakis, & Reeves, 2011).

Exploring the issues
We then polled the participants to determine their level of agreement with statements drawn from the research, using colour-coded cards. Since we used an open polling method and participants could see individual responses, we explained the limits to confidentiality and gave them the option not to respond.

The six polling statements were as follows:

  1. Little attention has been given to intra-professional practice.
  2. Leadership has a vital role in setting expectations for collaboration in practice settings.
  3. Patient outcomes would be enhanced by stronger intra-professional collaboration.
  4. When [regulated nurses] are given a chance to come out of their silos and interact in a meaningful way, many challenges can be resolved.
  5. Nursing would have a stronger professional voice and image if we developed stronger collaboration between [the different designations].
  6. Overall, RNs do not have a good understanding of [the other scopes of regulated nursing] practice.

There was a high level of agreement for items 1 through 5. Statement 6 generated a more varied response, although most participants still agreed with it.

Participants held small group discussions to identify additional ideas related to intra-professional collaboration and achieve a degree of consensus on the challenges and opportunities. The groups were asked to record key points in connection with the following questions:

  1. What are the important considerations for intra-professional relationships and practice?
  2. What is the most important consideration when contemplating enhancing intra-professional collaboration?
  3. What is one consideration you would like to report to the entire group?

The small group discussions were used to support the third objective of the consultation: generating strategies to strengthen collaboration.

During the consultation, participants agreed that (1) enhanced intra-professional collaboration leads to safer patient care and supports nurses in focusing on patients rather than professional boundaries; (2) addressing professional boundaries, hierarchies and silos will support nurses in providing patient-centred care; (3) entry-to-practice educational reform, ongoing education for nurses in practice, and strong leadership are needed to develop and support the attitudes and skills for successful intra-professional collaboration; and (4) effective intra-professional relationships can strengthen the professional voice and image of nursing.

Overall, the participants acknowledged that strengthening intra-professional collaborative practice is essential for meeting patient care needs and adapting to new models of care that involve collaborative practice with other professions. They also recognized that effective intra-professional relationships enable nurses to take full advantage of the well-educated nursing workforce and help optimize the scope of practice of all nurses, along with their contributions to patient and health-system outcomes.

Survey and next steps
Based on the positive response to this consultation, CNA asked us to develop an online Delphi survey to let all Canadian nurses give their input on strategies to strengthen intra-professional collaboration. The survey is being conducted in two phases. In phase 1, we are asking respondents to identify the most important ideas generated in the consultation. In phase 2, based on the items they deem most important, we will ask them to determine priority areas for further action by CNA. Respondents will also have an opportunity to provide additional comments.

The survey link is available on the CNA website and its Facebook and Twitter pages. We encourage you to participate and share the link with your nursing colleagues.

We want to hear from you and work together to determine the next steps.

Results from the survey will be presented at the CNA annual meeting of members and biennial convention, June 18-20 in Ottawa.


Bainbridge, L., & Wood, V. I. (2012). The power of prepositions: Learning with, from and about others in the context of interprofessional education. Journal of Interprofessional Care, 26(6), 452-458. doi:10.3109/13561820.2012.715605

Baker, L., Egan-Lee, E., Martimianakis, M. A., & Reeves, S. (2011). Relationships of power: Implications for interprofessional education. Journal of Interprofessional Care, 25(2), 98-104. doi:10.3109/13561820.2010.505350

Butcher, D. L., MacKinnon, K., Bruce, A., Gordon, C., & Koning, C. (2017). Experiences of pre-licensure or pre-registration health professional students and their educators in working with intra-professional teams: A qualitative systematic review. JBI Database of Systematic Reviews and Implementation Reports, 15(4), 1011-1056. doi:10.11124/JBISRIR-2016-003009

Canadian Interprofessional Health Collaborative. (2010). A national interprofessional competency framework.

Lankshear, S., Rush, J., Weeres, A., & Martin, D. (2016). Enhancing role clarity for the practical nurse: A leadership imperative. Journal of Nursing Administration, 46(6), 300-307. doi:10.1097/NNA.0000000000000349

Limoges, J., & Jagos, K. (2015). The influences of nursing education on the socialization and professional working relationships of Canadian practical and degree nursing students: A critical analysis. Nurse Education Today, 35(10), 1023-1027. doi:10.1016/j.nedt.2015.07.018

Limoges, J., & Jagos, K. (2016). Joint education fosters collaboration and role clarity between practical and degree nursing students. Journal of Nursing Education, 55(11), 623-630. doi:10.3928/01484834-20161011-04

Moore, J., & Prentice, D. (2013). Collaboration among nurse practitioners and registered nurses in outpatient oncology settings in Canada. Journal of Advanced Nursing, 69(7), 1574-1583. doi:10.1111/jan.12017

Moore, J., Prentice, D., & Taplay, K. (2015). Collaboration: What does it really mean to nurses? Journal of Clinical Nursing, 24(13-14), 2052-2054. doi:10.1111/jocn.12859

Nelson, S., Turnbull, J., Bainbridge, L., Caulfield, T., Hudon, G., Kendel, D., . . . Sketris, I. (2014). Optimizing scopes of practice: New models for a new health care system.

Sara Lankshear, RN, PhD

Sara Lankshear, RN, PhD, is a faculty member with the BScN Collaborative program at Georgian College in Barrie, Ont. Her research interests include role clarity, intra and interprofessional collaboration and professional practice models.

Jacqueline Limoges, RN, PhD

Jacqueline Limoges, RN, PhD, is a BScN faculty member at Georgian College in Barrie, Ont. Her research examines how nursing education influences the division of labour, knowledge production and social relations between nurses in the workplace.

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