Expanding Scope of Practice: Inter-professional Collaboration or Conflict?

Deborah Gardner, PhD, RN

Disclosures

Nurs Econ. 2010;28(4):264-266. 

In This Article

Quality and Efficiency vs. Volume

Unfortunately, expanding SOP is only the beginning of a wave of conflict within the world of health care providers and third-party payers. Most health care economists agree that to address the goal of reducing costs, real reform will only come when the financial incentives of the current system are altered to reward quality and efficiency rather than volume. However, most physicians (particularly those in primary care) and hospitals do not believe they are overpaid under the present system. Many have experienced decreased net income over the past years. All want to enter the new arena of ACOs and MCHs while firmly holding a "bottom line" position. The convergence of so many irreconcilable bottom lines creates conflicts that will play out in a variety of scenarios (e.g., Who will lead the ACO? Who can lead the MCH? Who will be allowed in or kept out? Who will decide the internal relationships?) Restructuring of the health care delivery and payment systems to decrease overall spending means there will be a smaller pie. With a smaller pie comes disputes over how to slice it up (Webb, 2010). The reality is that if dollars are limited, expanding the role of APNs may allow them to get a larger piece and that may make someone else's piece even smaller, particularly for those physicians in primary care. This reality is a key force behind the turf war that continues to escalate between APN and physician groups. But sharing the pie may be easier if everyone contributed to its creation and contents.

The SOP dispute is a complex amalgam of values, identities, and interest-based conflicts. Value-based and identity-based disputes are those in which the parties' values and identities are so important to the dispute that they interfere with each party's ability to settle interest-based issues.

Physicians and nurses continue to be educated in silos with little understanding of different health professionals' roles and norms, thus creating an us versus them mentality also known as identity conflicts. Members of groups with identities that place a high priority on being treated with deference have difficulty making compromises or respecting other groups. Self-conceptions relating to ideas of authority and legitimacy constitute barriers to successful conflict settlement. Physicians are taught to be the leaders as they are responsible for the patients. They are taught they must know how to handle all situations. These expectations are examples of the identity challenges physicians must face and change. Value-based disputes occur when people attempt to force one set of values on others. As people are socialized, they learn to center their judgments on values and procedures fundamental to their own common culture. One example of value differences between physicians and nurses is the lack of shared norms regarding communication (customary patterns and rules). What, how, and when information is relayed are often key sources for miscommunication and conflict. Conflicts of interest result when one or more of the parties believe that in order to satisfy his or her needs, the needs and interests of an opponent must be sacrificed. Interestbased conflict will commonly be expressed in positional terms (Maiese, 2003). An example of an interest-based issue is payment system reform.

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