True collaboration, one of the 6 healthy work environment standards defined by the American Association of Critical-Care Nurses, is described as continuous processes creating workplace cultural norms that engage every team member to actively participate in candid and constructive discussions that drive research-based care delivery decisions, policy creation, and workforce well-being practices.1,2  “Unlike the lip service that collaboration is often given, in true collaboration the unique knowledge and abilities of each professional are respected to achieve optimal, safe, quality care for patients”1  and healthy work environments for team members.2 

The adjective true describes the act of collaboration by exemplifying the intentional effort required to create and sustain healthy work environments where everyone, regardless of job title or role, can contribute in a meaningful way to accomplish shared outcomes.1,2  Although obtaining true collaboration may appear simple and a “no-brainer,” studies in health care organizations have found that perceptions of what collaborative environments look and feel like can differ across roles.3,4  In tandem with these perceptual differences, over the past 16 years, 5 studies exploring critical care nurse work environments indicate that the ability to sustain true collaboration in our workplaces remains a challenge.5 

The elusive nature of true collaboration is not necessarily associated with the definition of collaboration, but is instead related to the behaviors and actions people demonstrate to promote collaborative environments.6  In various studies, investigators have found that physicians rate collaboration with nurses higher than nurses rate collaboration with physicians.3,4,7,8  What accounts for these perceptual differences? There is no definitive answer, but investigators have found interrelated factors, such as the influence of reciprocity, group dynamics, peer relationships, communication styles, organizational structure, team training, and informal and formal leadership behaviors, that have an impact on collaborative relationships in the workplace.811 

How do we address these challenges and integrate true collaboration into our workplace culture? There is no research-based checklist or bundle listing specific tasks that lead to instantaneous collaboration. The good news is that research has identified strategies to create and sustain a workplace culture that fosters true collaboration.1,4,6,9,1214 

The first step to foster true collaboration in the workplace involves becoming more aware of how behaviors and actions affect others. This work requires a conscious effort to separate intention (what a person means to do) from action (the behaviors a person demonstrates). Learning how actions affect others is key to creating a collaborative atmosphere and entails openness, candor, and soul-searching.6,13,14  Begin this process by identifying a trusted colleague who can provide candid feedback. Ask them to share their observations and examples of how and when your actions demonstrated collaboration. Next, discuss with this colleague the situations when your intentions may not have matched your actions and ask for descriptions of how those behaviors stifled collaboration. Along with seeking feedback about areas to improve, spend equal time learning what you do well that promotes collaborative exchange. Learning what you do well and developing strategies to do what you do well more often help address improvement opportunities and enhance your ability to create collaborative moments with colleagues.6,9 

The second step to foster true collaboration, closing the perceptual gap between roles, allows the team to gain insight regarding how stakeholders (eg, colleagues, peers, and teammates) describe collaboration. Obtaining stakeholder feedback that describes true collaboration helps teams identify where similarities exist and allows differences to surface. While reviewing this feedback data, it is important to recognize that the differences are not wrong—they are just different. Disseminating this information via an in-person or online team setting provides a learning opportunity for the group to increase awareness and discuss perceptual similarities, areas of divergence, and behaviors that derail and promote collaborative efforts.

The third step involves celebrating true collaboration. Although many organizations have processes to dissect errors, few devote processes to explore all the right that is occurring in the workplace. Recognizing in a meaningful way the behaviors that foster collaborative growth and acknowledging workplace cultures that embrace true collaboration are equally important as identifying barriers that derail teamwork. Letters from patients and families, DAISY award nominations, survey responses, and feedback from both peers and leaders often provide real-time stories of the true collaboration regularly occurring in the workplace and its positive impact on patients, family members, and colleagues. Talking about the team’s collaborative efforts and successes identifies, recognizes, and reinforces behaviors associated with the true collaboration that is occurring in the workplace.14,15 

An example of using feedback to describe the impact of true collaboration is the DAISY team award nomination below, written by a nurse in the medical-surgical intensive care unit at Baptist Medical Center in Jacksonville, Florida, describing the team’s collaborative behaviors during a challenging 2-hour resuscitation16 :

Staff moved effortlessly around each other, working together in a calm manner, ultimately to the point where we got her back and she survived. I have personally been involved in many codes. I pride myself on my “we can do it” attitude…. [T]his code shook me to my core, as it did the whole team. However, we never lost hope, we never gave up. We supported the doctor, the mother at the bedside, the father on the phone, and most importantly we never gave up on the patient and as a result, she survived and went home to finally open the Christmas presents that her family had holding for her.

Despite the high stakes and emotion associated with the situation described above, the team’s collaborative efforts enabled them to calmly persevere; deliver clinical care; and provide emotional support to the mother at the bedside, the father on the phone, and the team members involved in the resuscitation. Sharing this feedback with staff creates opportunities for team members to recognize and celebrate the positive impact of their collaboration and inspires the creation and sustainment of collaborative environments.15 

The fourth step to foster true collaboration is to promote shared expertise. True collaboration’s foundation of mutual respect, trust, skilled communication, optimism, knowledge, and pursuit of optimal patient outcomes creates an environment where team members’ expertise can emerge regardless of tenure or title.1  The group dynamics that arise from true collaboration encourage team members, even the least experienced, to speak up because the cultural norms rely on collective knowledge to guide research-based care delivery.6  True collaboration does not imply a free-for-all that lacks leadership. Instead, formal and informal leaders in collaborative environments consistently engage the team by seeking input from others, actively listening, and rendering decisions on the basis of the clinical picture, best practice, patient needs, and team member advice.6,7,9,13  Often, this practice is done “on the fly.” For example, the physician leading a code summarizes what has been done and asks the team, “What else should we do or try? Have we forgotten anything?” Formal and informal leaders seeking collaboration from others creates an environment where team members feel safe to speak up.2,5,17 

The fifth step to foster true collaboration is to promote collaboration by acquiring team skills.4,6,9,12  The integration of team skills into various aspects of health care personnel training has increased over the past 2 decades; however, many organizations continue to emphasize individual performance evaluation and devote less effort to assessing team efforts.9,14,17  With the emergence of programs like TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety),14  Crew Resource Management,14  and interprofessional debriefs,2  there is a shift to recognize the value of team-focused skill building and collaborative practice. Along with the methods mentioned in steps 1 through 4, team-focused skill building provides people with knowledge and collaborative practice strategies they apply to their daily work routines.

True collaboration consists of deliberate behaviors, learned skills, and shared accountability that purposefully promote the creation and sustainment of work environments built upon trust, respect, 2-way communication, and the pursuit of common goals.1,2,6,13  Bringing this summary to life is real-time feedback via a DAISY team award nomination about the outcome of true collaboration involving a patient, his family, and the critical care unit at UT East Health Texas – North Campus in Tyler.18 

Our critical care TEAM learned of a patient’s struggles and was able to make his dying wish come true[,] which was to be married in the eyes of God before he left this world. After hearing this story, the servant hands and hearts of our caregivers went to work and brought it to fruition in less than 12 hours. Led by their caring, compassion, and empathy, they were able to provide a miracle wedding. The TEAM showed up the next day with 4 white dresses and 4 pairs of shoes for the bride to choose from.

On the Groom’s side, the TEAM provided a black button-up shirt and dressed him to be the fanciest one on the unit, except for his bride, all while carefully navigating IV [intravenous] access, chest tubes, foley, Bipap [bilevel positive airway pressure], and cardiac monitoring leads….

From our bedside caregivers in the critical care unit who cleaned and decorated the critical care hallway to make it look like a wedding aisle … to our gift shop caregivers for donating their time, talents, and efforts for decorating the patient’s door and room to not look so much like a hospital … to our caregivers who decorated the desk outside the room with sparkling grape juice wine cups, the wedding cake, napkins, cups, forks, and “Just Married” decorations … to our caregivers who played music and blew bubbles while the bride walked down her miraculous ICU [intensive care unit] wedding aisle … to our critical care team, who raised over $700 to place in a wedding card for the new couple in under 12 hours … to our 5th floor team who came down to help in any way they could … to our Chaplain who coordinated with the Hospice Chaplain and passed around a [B]ible for everyone to sign … to the Hospice Chaplain who dropped all his plans that day to give the bride a ride to the hospital and ensure that the two would have to chance to say “I do.”

With true collaboration in our workplace, we can create life-changing moments for our patients, their families, and our teams. The outcomes of our true collaboration are truly necessary and extraordinary.

1
American Association of Critical-Care Nurses
.
AACN Standards for Establishing and Sustaining Healthy Work Environments: A Journey to Excellence
. 2nd ed.
American Association of Critical-Care Nurses
;
2016
.
2
Traylor
AM
,
Tannenbaum
SI
,
Thomas
EJ
,
Salas
E
.
Helping healthcare teams save lives during COVID-19: insights and countermeasures from team science
.
Am Psychol
.
2021
;
76
(
1
):
1
13
. doi:
3
House
S
,
Havens
D
.
Nurses’ and physicians’ perceptions of nurse-physician collaboration: a systematic review
.
J Nurs Adm
.
2017
;
47
(
3
):
165
171
. doi:
4
Pun
BT
,
Jun
J
,
Tan
A
, et al
.
Interprofessional team collaboration and work environment health in 68 US intensive care units
.
Am J Crit Care
.
2022
;
31
(
6
):
443
451
. doi:
5
Ulrich
B
,
Cassidy
L
,
Barden
C
,
Varn-Davis
N
,
Delgado
SA
.
National nurse work environments - October 2021: a status report
.
Crit Care Nurse
.
2022
;
42
(
5
):
58
70
. doi:
6
Lefton
R
,
Buzzotta
V
,
Sherberg
M
.
Improving Productivity Through People Skills
.
Ballinger
;
1980
.
7
McCauley
K
,
Irwin
RS
.
Changing the work environment in intensive care units to achieve patient-focused care: the time has come
.
Am J Crit Care
.
2006
;
15
(
6
):
541
548
. doi:
8
O’Leary
KJ
,
Manojlovich
M
,
Johnson
JK
, et al
.
A multisite study of inter-professional teamwork and collaboration on general medical services
.
Jt Comm J Qual Patient Saf
.
2020
;
46
(
12
):
667
672
.
9
Zajac
S
,
Woods
A
,
Tannenbaum
S
,
Salas
E
,
Holladay
CL
.
Overcoming challenges to teamwork in healthcare: a team effectiveness framework and evidence-based guidance
.
Front Commun
.
2021
;
6
(
1
). Accessed August 15, 2023.
10
Brown
R
.
Social Psychology
. 2nd ed.
Free Press
:
1986
.
11
Coyle-Shapiro
J
,
Diehl
M
,
Chang
C
.
The employee-organization relationship and organizational citizenship behavior
. In:
Podsakoff
PM
,
Mackenzie
SB
,
Podsakoff
NP
, eds.
The Oxford Handbook of Organizational Citizenship Behavior
.
Oxford University Press
;
2016
.
12
Kester
K
,
Pena
H
,
Shuford
C
, et al
.
Implementing AACN’s healthy work environment framework in an intensive care unit
.
Am J Crit Care
.
2021
;
30
(
6
):
426
433
. doi:
13
Griffiths
AJ
,
Alsip
J
,
Hart
SR
,
Round
RL
,
Brady
J
.
Together we can do so much: a systematic review and conceptual framework of collaboration in schools
.
Can J School Psychol
.
2020
;
36
(
1
):
59
85
. doi:
14
Buljac-Samardzic
M
,
Doekhie
KD
,
van Wijngaarden
JDH
.
Interventions to improve team effectiveness within health care: a systematic review of the past decade
.
Human Resources for Health
.
2020
;
18
(
1
). Accessed September 3, 2023.
15
Lefton
C
.
Strengthening the workforce through meaningful recognition
.
Nurs Econ
.
2012
;
30
(
6
):
331
339
.
16
The DAISY Foundation
.
Adult Tower 4A MSICU
.
August
2023
. Accessed September 29, 2023.
17
Dinh
JV
,
Schweissing
EJ
,
Venkatesh
A
, et al
.
The study of teamwork processes within the dynamic domains of healthcare: a systematic and taxonomic review
.
Front Commun
.
2021
;
6
:
1
8
. Accessed August 28, 2023.
18
The DAISY Foundation
.
Critical Campus
.
January
2022
. Accessed September 29, 2023.

Footnotes

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