CS 649 Database Management Systems Fall 2017 Instructor.docx

CS 649 Database Management Systems Fall 2017
Instructor: Prof. Ping-Tsai Chung
Mini-Project
(Total: 400 Points) Due: December 11, Monday, 2017
Consider the Company Database given in the handout. This
Database contains 6 relations,
namely: EMPLOYEE, DEPARTMENT, DEPT_LOCATION,
WORKS_ON, PROJECT
and DEPENDENT. Each table is defined in the handout.
Please send your work in one file to my email account
[email protected] (i.e.,
[email protected]) and submit a hard copy in class, Thanks.
(I) (80 Points) Using any two available ER Tools to draw the
ER Diagram for the Company
Database. The Requirements were discussed in the class. Write
two-page report to discuss your
comparative results.
Note that ER Tools such as ERWin Software,

http://erwin.com/products/data-modeler,
ERDPlus, https://erdplus.com/, ER Assist Tool and Smartdraw,
https://www.smartdraw.com/
(II) (50 Points) First using Oracle SQL * Plus, create the
schema of this database. You need to
check the database referential integrity to decide the order to
create tables. Then follow the
Oracle syntax to create tables, please see Create-Tables-Notes-
Company-DB at the end of this
notes for your reference, and
https://docs.oracle.com/cd/B28359_01/server.111/b28310/tables
003.htm#ADMIN11004
https://www.techonthenet.com/oracle/tables/create_table.php
https://www.w3schools.com/sql/sql_create_table.asp
https://www.javatpoint.com/oracle-create-table
http://www.sqlinfo.net/oracle/oracle_Create_table.php
Continue by inserting the data records as presented in the
handout. You should print out
the result of final tables.
If you want to learn “Insert Multiple Records”, please see an
example at the end of this notes

for your reference.
(III) (100 Points) Solve the following queries in SQL. For each
query, you need to specify the
SQL and show the result of each query if applied to the
Company Database.
(a) Retrieve the names of employees in department 5 who work
more than 10 hours per
mailto:[email protected]
http://erwin.com/products/data-modeler
https://erdplus.com/
https://www.smartdraw.com/
https://docs.oracle.com/cd/B28359_01/server.111/b28310/tables
003.htm#ADMIN11004
https://www.techonthenet.com/oracle/tables/create_table.php
https://www.w3schools.com/sql/sql_create_table.asp
https://www.javatpoint.com/oracle-create-table
http://www.sqlinfo.net/oracle/oracle_Create_table.php
week on the 'ProductX' project.
(b) List the names of employees who have a dependent with the
same first name as
themselves.
(c) Find the names of employees that are directly supervised by
'Franklin Wong'.

(d) For each project, list the project name and the total hours
per week (by all
employees) spent on that project.
(e) Retrieve the names of employees who work on every project.
(f) Retrieve the names of employees who do not work on any
project.
(g) For each department, retrieve the department name, and the
average salary of
employees working in that department.
(h) Retrieve the average salary of all female employees.
(i) Find the names and addresses of employees who work on at
least one project located
in Houston but whose department has no location in Houston.
(j) List the last names of department managers who have no
dependents.
(IV) (30 Points) Solve the following queries in SQL. For each
query, you need to specify the
SQL using the concept of nested queries and show the result of

each query if applied to the
Company Database.
(k) Retrieve the names of all employees who work in the
department that has the employee with
the highest salary among all employees,
(l) Retrieve the names of all employees who supervisor’s
supervisor has ‘888665555’ for ssn.
(m) Retrieve the names of employees who make at least $10,000
more than the employee who is
paid the least in the company.
(V) (70 Points) Specify the following queries in (III) (a), (b),
(c), (e), (f), (i), (j) on the
Company relational database schema using the Relation Algebra
Statements (i.e., the
relational operators). Also, show the intermediate result of each
query if applied to the
Company Database.
(VI) (70 Points) Specify the following queries in (III) (a), (b),
(c), (e), (f), (i), (j) on the
Company relational database schema in both tuple and domain
relational calculus.

Subject: Syntax for Inserting Multiple Records in one Oracle
Insertion Statement
You can use the following Oracle Insertion Statement Syntax to
insert multiple
records:
INSERT ALL
INTO table_name (column1, column2, column3) VALUES
('val1.1', 'val1.2',
'val1.3')
('val2.1', 'val2.2',
'val2.3')

('val3.1', 'val3.2',
'val3.3')
SELECT * FROM dual;
Example: (for Inserting Multiple Records in one Oracle
Insertion Statement into
DEPARTMENT table)
INSERT ALL
into Department(Dname, Dnumber, Mgr_ssn, Mgr_start_date)
VALUES
('Research', 5, 333445555, '05,22,1988')
VALUES
('Administration', 4, 987654321, '01,01,1995')
VALUES
('Headquarters', 1, 888665555, '06,19,1981')
SELECT * FROM dual;

Database Notes - Using an ALTER TABLE statement Prof. P.
T. Chung
Using an ALTER TABLE statement
The syntax for creating a foreign key in an ALTER TABLE
statement is:
ALTER TABLE table_name
add CONSTRAINT constraint_name
FOREIGN KEY (column1, column2, ... column_n)
REFERENCES parent_table (column1, column2, ...
column_n);
Example:
ALTER TABLE products
add CONSTRAINT fk_supplier
FOREIGN KEY (supplier_id)

REFERENCES supplier(supplier_id);
Nurs Admin Q
Vol. 32, No. 1, pp. 40–48
Copyright c© 2008 Wolters Kluwer Health | Lippincott
Williams & Wilkins
Interdisciplinary Collaboration
for Healthcare Professionals
Lori Fewster-Thuente, MSN, RN;
Barbara Velsor-Friedrich, PhD, RN
Interdisciplinary collaboration has the capacity to affect both
healthcare providers and patients.
Research has shown that the lack of communication and
collaboration may be responsible for as
much as 70% of the adverse events currently reported. The
purpose of this article is 2-fold: to exam-
ine factors that may influence interdisciplinary collaboration
and consequently patient outcomes
and to examine the relationship between interdisciplinary
collaboration and King’s theory of goal
attainment as a theory to support the phenomenon of
interdisciplinary collaboration. Key words:
communication, goal attainment, healthcare professionals,
interdisciplinary collaboration
INTERDISCIPLINARY COLLABORATIONis a vital
phenomenon to healthcare
providers and patients. The level of collab-
oration that takes place among providers
can directly impact patient outcomes. Joint

Commission currently reports that almost
70% of patient adverse events cite the lack of
collaboration and communication between
providers as a main cause of error.1 An
increase in nurse-physician collaboration and
communication can improve both patent
outcomes2–6 and provider satisfaction.7,8
The purpose of this article is to exam-
ine factors that may enhance or inhibit in-
terdisciplinary collaboration, which, in turn,
may impact patient and nursing outcomes.
Factors such as gender, age, culture, and
level of education of the nurse or physician
can directly impact the perceived level of
collaboration.8–10
From the Marcella Niehoff School of Nursing, Loyola
University Chicago, Chicago, Ill.
We thank Dr Imogene King for her expertise and guid-
ance in the creation of this article.
Corresponding author: Lori Fewster-Thuente, MSN, RN,
Loyola University Chicago, 6525 North Sheridan Rd,
Chicago, IL 60626 (e-mail: [email protected]).
An equally important purpose of this article
is to examine a theory that has the potential
to both support and improve nurse-physician
collaboration. Currently, there are no specific
structured models or theories found in the
literature that provide a base for interdisci-
plinary collaboration. This article will exam-
ine the relationship between the concept of
interdisciplinary collaboration and King’s the-

ory of goal attainment. Historically, the theory
of goal attainment has focused on the interac-
tion between the nurse and the client; how-
ever, King stated, “it can be used not only by
nurses with their patients but by any individ-
ual in any interactions with other profession-
als” (I. King, personal communication, April
11, 2006).
The theory of goal attainment has been
used to guide nursing practice and research
for approximately 30 years. King’s theory
has been used by nurses, administrators, and
other healthcare providers in more than 13
countries.11 As one can see, this theory has
depth and scope beyond bedside nursing.
The theory has also been used with nurs-
ing administration12,13 and to guide nursing
curricula.14 King’s theory has been tested in
research and used in every patient popula-
tion from infants to the elderly. Specific mod-
els such as the Wicks family health model15
40
Interdisciplinary Collaboration for Healthcare Professionals 41
and the Advance directive decision making
model16 have been derived from it to guide
nursing practice.11 The theory has helped
develop research instruments and facilitated
other middle-range theories such as the The-
ory of Group Power.12 Use of the theory
of goal attainment to foster interdisciplinary

collaboration with the intended outcome of
improved patient and nursing outcomes is
presented.
REVIEW OF LITERATURE
A review of the literature reveals similar def-
initions among clinicians on the definitions of
collaboration. As stated by Lindeke and Siek-
ert, “Collaboration is a complex process that
requires intentional knowledge sharing and
joint responsibility for patient care.”17
The American Nurses Association18 defines
collaboration in nursing by looking at 4 main
components:
• a partnership with mutual valuing
• recognition of separate and combined
spheres of responsibility
• mutual safeguarding of legitimate inter-
ests of each party
• recognized shared goals
In healthcare, collaboration is defined as
“a complex phenomenon that brings together
two or more individuals, often from different
professional disciplines, who work to achieve
shared aims and objectives.”19 This definition
was chosen as the working definition as it in-
cludes other disciplines and how they work
to reach a common goal.
There also seems to be a consensus among

authors regarding the defining attributes of
the concept of collaboration. Attributes of
collaboration include shared power based
on knowledge, authority of role, and lack
of hierarchy.20 Wells et al21 determined the
following attributes related to collaboration:
open communication, cooperation, assertive-
ness, negotiation, and coordination. As a
result of a concept analysis, Henneman et al
determined that the following attributes were
associated with collaboration: “joint venture,
cooperative endeavor, willing participation,
shared planning and decision-making, team
approach, contribution of expertise, shared
responsibility, nonhierarchical relationships,
and shared power based on knowledge and
expertise.”22
The term teamwork is often used as a syn-
onym to collaboration.23 However, the litera-
ture shows that teamwork is 1 attribute of a
collaborative relationship.24,25 Topics such as
joint practice, communication, and collegial-
ity are similar to collaboration but have differ-
ent meanings and will, therefore, not be ad-
dressed in this article.26
The review of literature did not reveal
a specific theory that was used to sup-
port or encourage interdisciplinary collabo-
ration. Although not specifically developed
to address interdisciplinary collaboration, the
transaction process of King’s theory of goal
attainment, when used by healthcare pro-
fessionals, results in collaboration among

nurses, physicians, and allied healthcare
professionals.
THE THEORY OF GOAL ATTAINMENT
King27 developed a conceptual system,
which consists of 3 interacting systems: per-
sonal, interpersonal, and social. Each system
contains its own defining concepts. The per-
sonal system includes individuals interacting
with their environment and incorporates the
concepts of growth and development, self,
space, time, perception, and body image. The
interpersonal system involves human beings
interacting with one another in a variety of
environments. The concepts associated with
the interpersonal system are communication,
interaction, role, stress, and transaction.
Societal systems consist of groups of 2 or
more individuals interacting, each working in
its role, toward a collective goal. Healthcare
organizations are an example of a social
system that consists of groups of those
individuals in society who interact with one
another for a common purpose, the better
patient care. There are groups within groups
in each hospital, such as a palliative care team
in an oncology ward, which set goals with
42 NURSING ADMINISTRATION QUARTERLY/JANUARY–
MARCH 2008
individual patients and families, and work

toward achieving those goals. The concepts
of a social system are power, status, authority,
and decision making.27
Utilizing this conceptual system as the
foundation, King developed the theory of
goal attainment. Briefly stated, the theory
of goal attainment addresses the interactions
of nurses with their clients to achieve health
outcomes and attain goals. King determined,
“The focus of nursing is human beings inter-
acting with their environment leading to a
state of health for individuals, which is their
ability to function in social roles.”27
The theory of goal attainment utilizes the
concepts of perception, communication, in-
teraction, and transaction. It is an interaction-
transaction process in which nurses and
clients interact to mutually define and set
goals. They proceed through the transac-
tion phase, the means by which to achieve
goals, toward goal attainment.13 Nurses work
to help individuals maintain or regain their
health and return to their highest level of
functioning.27
The interactions between team members
and the client are what contributes to the
strength of the process. Interactions are de-
fined as “process of perception and communi-
cation between person and environment and
between person and person, represented by
verbal and non-verbal behaviors that are goal-
directed.”27 These interactions cause all in-
volved to feel respected and positive about

the mutual goals set.
The interaction-transaction process can
be used in any interaction with 1 or more
individuals in healthcare situations. When
this process is utilized by the members of the
interdisciplinary teams, within the theory of
goal attainment, the result is collaboration
and hopefully the best patient outcome.
It is through interdisciplinary collabora-
tion and patient communication that goals
for client’s health outcomes are developed
and implemented. In the following quote
substituting “physician” or other healthcare
provider for “client,” interdisciplinary collab-
oration is supported when overlaid with the
theory of goal attainment.
Nurse-(physician) interactions are characterized by
verbal and nonverbal communication in which in-
formation is exchanged and interpreted by trans-
actions in which values, needs and wants of each
member of the dyad (team) are shared, by percep-
tions of the nurse, (physician), and the situation, by
self in role of nurse, self in role of (physician), and
other stressors influencing each person and the sit-
uation in time and space.28

Healthcare providers seek to improve the
health of their patients. However, health can
be a multidimensional goal for both providers
and patients, and may have different mean-
ings for different people. Although King’s the-
ory of goal attainment is focused on nurs-
ing, in which it is the work of nursing
to help patients optimize their resources to
achieve maximum potential for daily living,
other healthcare professionals also participate
in that work. The path to improved health
through collaboration and goal attainment is
besieged with barriers that both patients and
providers must attempt to overcome every
day. It is important to know and understand
the barriers in order to overcome them.
BARRIERS
The barriers to goal attainment between
nurses and clients are the same as the barri-
ers to collaboration among members of the in-
terdisciplinary healthcare team. The review of
literature discussed the following barriers to
collaboration: patriarchal relationships, time,
gender, culture, and lack of role clarification.
These barriers can also inhibit the ability to set
and attain goals. A discussion of these barriers
follows.
Patriarchal relationship
The primary relationship in the theory of
goal attainment is between the nurse and
the client in which the nurse is the author-

ity figure. Historically, the nurse-physician re-
lationship has been one of hierarchy and
power with the balance of power going to the
physician. The literature regarding this topic
dates back to 1967 when Dr Stein wrote a
hallmark article, “The Doctor-Nurse Game.”29
In this article, the relationship between the
doctor and the nurse was described as one
where the nurse played a very subservient
role to the physician. Although advances have
been made, this type of portrayal is fea-
tured still today in television and films. In
this model, it is difficult for collaboration to
occur.
Revenue generation amplifies the patriar-
chal relationship. As physician services are
billed separately, it is easy to see that physi-
cians contribute to the bottom line of the or-
ganization. The work of nursing is generally
compiled into the overall hospital bill. Accord-
ing to Fagin,30 the direct impact to the bot-
tom line puts the balance of power in favor
of the physician. Collaboration can take place
only when hierarchy is not present, and ev-
eryone’s knowledge is valued and taken into
account.
The patriarchal relationship is important
to study as physicians are seen as the lead-

ers of the interdisciplinary team. Therefore, it
is important to understand their perspective
and imperative that they participate in the re-
search. As noted in the Baggs et al8 study, lack
of time or interest is the reason why many
physicians have chosen not to participate in
interdisciplinary collaborative research. Wells
et al21 found that physician participation is a
statistically significant element to successful
execution of interdisciplinary collaboration.
Goal attainment is a mutual process be-
tween any 2 individuals who have formed a
relationship such as a nurse and a client. The
nurse has the knowledge base and expertise
to work in collaboration with the patient to
develop health-related goals and, therefore, is
in the position of power. Nurses who are un-
comfortable in leading and directing patients
may feel a conflict over the role they play in
the patient’s care. Similarly, a patient who is
used to being in the position of power may
have difficulty in working with a healthcare
provider who may be younger or seem inex-
perienced.
Time
Time, or lack of it, was also found to be a
barrier to collaboration and goal attainment.
As collaboration is a vital step in the attain-
ment of goals, it is imperative that time is al-
lotted for team members, including the client,
to collaborate.4,31

Because of the nursing shortage, nurses to-
day have larger patient loads and a limited
amount of time to spend with each patient.
These factors may not allow for mutual goal
setting or attaining. The use of the services
of temporary or agency nursing staff may
cause additional confusion as the nurse may
not be aware of the organization’s practices
and policies. In addition, the organization may
not have a structured communication process
that allows the team members to discuss pa-
tient situations and set appropriate goals. To
add to the situation, more nurses are work-
ing part-time and, therefore, may not know pa-
tients or physicians as well, and may not feel
comfortable approaching a physician they do
not know. Combine part-time workers with
increased patient loads, and there is little time
for healthcare providers to interact with each
other and their patients.32 Collaboration re-
quires trust, and to build trust, people need
time for interaction.
Utilizing King’s theory, Rundell33 studied
the interaction of patients and nurses in an in-
tensive care step-down unit and found com-
munication between the two increased as the
time spent in the unit increased. Time is re-
quired on the part of both, the patient and the
provider. Providers who take time to commu-
nicate with their patients can help clarify the
roles that they each play.
Lack of role clarification
Because of the nursing shortage and eco-

nomic changes, unlicensed assistive person-
nel are providing a great deal of patient care
that was previously rendered by nurses. Physi-
cian roles too are changing. Druss et al34
found that by 1997, 36% of outpatient care
was provided by nonphysician clinicians such
as advanced practice nurses and physician as-
sistants. This is up from 30.6% in 1987.
Lack of role clarification is difficult for
providers. Without distinct role boundaries as
to who has responsibility for the patient, it is
MARCH 2008
difficult to determine with whom one would
collaborate. The collaboration between the
team members and their patients is a result of
the transactions that occurred. Transactions
occur when human beings are observed in-
teracting with their environments.27 It is each
person, acting in his or her role with the
client, that helps complete a step toward goal
attainment. The interaction of these roles and
the mutual goals that result together form the
interdisciplinary collaboration.
Interdisciplinary collaboration plays an im-
portant role in eliminating errors, duplica-
tions in care, and clarifying of roles. When
collaboration takes place among the nurse,
client, and physician, each person under-

stands the goals and the process through
which to attain those goals.
In addition, lack of role clarification can
make it difficult for patients to know who is
caring for them. Many of the patient goals can
be worked on by other personnel than the
nurse; that is, a patient goal is to be ambula-
tory; therefore, the certified nursing aide may
assist the patient in a walk. However, the goals
need to be mutually determined by the patient
and the interdisciplinary team; therefore, it is
important for patient understanding and com-
fort to know the team members and the roles
that they fulfill.
It remains a common misunderstanding
among patients that roles are clarified by gen-
der. The misunderstanding is that a female
healthcare provider who comes into a pa-
tient’s room must be a nurse and the male
provider is a physician.
Gender
Historically, women were nurses and men
were physicians. However, as healthcare
evolves, more men are becoming nurses, and
more women are becoming physicians. Al-
though men represent only 7% of the nursing
population, medicine is almost equally repre-
sented by both men and women.10
However, the impact of male physician’s
dominance over female nurses still comes
into play. A vignette-based survey was con-

ducted, which studied the female nurses’
(n = 197) responses to physician gender.35
The authors found that when both the physi-
cians and nurses were female, the level of
collaboration was higher and the balance of
power more equal. The study also found that
nurses were less likely to confront a male
physician. This fact reinforces the dominant
role of the male physician. The study did not
explore why nurses were less likely to con-
front male physicians.
A study by Wear et al10 supported the con-
cept that female nurses are more collabora-
tive with female physicians. The results from a
qualitative survey showed that female nurses
reported higher level collaboration with fe-
male physicians than with male physicians.
Gender issues between providers and pa-
tients still occur today. For example, elderly
women, now a large population of patients,
may not be comfortable with a male nurse
providing their care. Conversely, a man from
a male-dominated country may not take direc-
tion from a female nurse or physician.
Culture issues are similar to gender issues
in that they are based on misunderstanding
or the lack of knowledge. These issues tend
to occur when people have preconceived no-
tions about how things should be, as opposed
to how they are.
Culture

The final barrier to collaboration to be dis-
cussed is culture. Culture can be discussed
from a country, organizational, professional,
or an individual perspective.9,22,36 The United
States has a culture that values autonomy, in-
dependence, and free thinking. This mindset
can impact the client’s desire to take direc-
tion from the healthcare provider as to the
types of goals to be set. In addition, when the
provider and client are from different cultures
or speak different languages, many issues can
occur: lack of translators, difference in ideas
for goals, and lack of understanding regarding
various cultures and religious practices.
The disciplines of medicine and nurs-
ing are rooted in vastly different theoretical
frameworks that impart a culture for the care
each provides. These ideas strongly contrast
with collaboration. Headrick et al36 found
healthcare professionals to be autonomous in
their work. However, the international study
by Hojat et al9 found that US physicians, al-
though still dominant, were less hierarchy-
based than those in other countries.
In addition to a country’s culture, each
individual organization has its own culture.
If the organizational culture is one that
promotes hierarchy, there is likely to be little

collaboration. However, if the organizational
culture models and rewards collaborative
behavior, there is more of a chance that
collaboration will occur. An article by Arford
discussed the accountability organizations
have to create a climate of collaboration.
The values and beliefs of the organization
are echoed in team members’ desire to
collaboration and communication.37
Barriers such as patriarchal relationships,
time, gender, lack of role clarification, and
culture can have a negative impact on pa-
tient outcomes. There can be many poten-
tially harmful outcomes to patients when such
barriers inhibit providers and patients from
collaborating. On the flip side, there can be
positive outcomes for patients and providers
when collaboration takes place and goals are
attained.
PATIENT OUTCOMES
The goal of interdisciplinary collaboration
is to achieve the positive health outcomes for
patients. The theory of goal attainment is also
focused on positive health outcomes, as these
outcomes are a direct measure of the quality
of care provided.28 Interdisciplinary collabo-
ration and goal attainment are related as col-
laboration is necessary to attain the desired
goals and reach these outcomes.
Lack of collaboration can have a negative ef-
fect on patient outcomes. Organizations such
as the Institute of Medicine and Joint Commis-

sion have published many studies and reports
such as To Err Is Human,38 which discuss in
part that healthcare teams who fail to collab-
orate have increased mortality and failure-to-
rescue (deaths within 30 days of admission
among patients who experienced specific
complications) rates. Accreditation agencies
such as the Joint Commission have now put
collaboration practice guidelines into place
for healthcare organizations and are requiring
their implementation for accreditation.39 The
organizations are graded on such things as in-
terdisciplinary practice plans.
Negative patient outcomes related to col-
laboration have also been found by Baggs
et al.8 In this study, it was determined that the
lower the level of nurse-reported collabora-
tion, the higher the risk of a negative outcome
such as readmission to the intensive care unit
or mortality. This point is also supported by
the theory of goal attainment in that patient
goals cannot be attained if collaboration does
not take place.
A study by the Patient Safety Culture and
Teamwork40 surveyed high-risk area nurses
in the intensive care unit, emergency depart-
ment, and operating room (n = 261). The
survey measured the levels of communication
and collaboration of nurses with physicians
and other staff members. The survey of nurses
found that almost 70% felt the quality of col-
laboration with physicians was low or merely
adequate. However, to keep patients safe, al-

most all nurses surveyed felt that commu-
nication and collaboration were at par with
skill. They further discovered that 85% of the
respondents felt that more input should be
garnered from team members when making
patient-care decisions.
The strongest evidence that supports the
idea that interdisciplinary collaboration and
the theory of goal attainment can impact pa-
tient outcomes positively is found in the cur-
rent literature. A randomized controlled trial
was conducted by Curley et al,6 in which pa-
tients and staff were randomized to 6 wards.
Three wards received an intervention that
included daily interdisciplinary rounds. Dur-
ing these rounds, patient-care decisions were
made jointly by nurses, therapists, and physi-
cians in cooperation with the patient. The
MARCH 2008
other three served as the control group.
Although no differences in mortality were
found, there was a statistically significant de-
creased length of stay and reduced hospital
charges.
Higgins7 conducted a prospective correla-
tional study of collaboration related to pa-
tient outcomes. The study tested 4 hypothe-
ses, of which 1 was found to be statistically
significant. Higgins found that the nurses’ per-

ception of collaboration with physicians pos-
itively correlated with their level of satisfac-
tion regarding their decision-making process
of when and where to transfer a patient (cor-
relation coefficient of 0.28, P = .000). These
patients were found to have fewer readmis-
sions to the intensive care unit, decreased
length of stay, and decreased mortality.
Use of the transaction process in the the-
ory of goal attainment is imperative for posi-
tive patient outcomes. Research findings have
shown that the collaboration that results from
interactions and transactions between pa-
tients and their healthcare providers results
in goals being set and attained. The theory of
goal attainment can be an important step to
ensure patient safety.
NURSING BENEFITS
The theory of goal attainment benefits
nurses as well as clients. Patient goal attain-
ment directly correlates to nursing satisfac-
tion, as a major goal of nursing is to see pa-
tients return to a functional state of health.
Nurses are also satisfied when collabora-
tion is sought regarding patient care, and
are dissatisfied when they are not. A cause
of nurse dissatisfaction is lack of joint deci-
sion making. This is an important component
of collaboration to nurses. Baggs et al8 con-
ducted a longitudinal descriptive correlation
study, using the Collaboration and Satisfaction
about Care Decision questionnaire to survey

healthcare providers and their patients. The
sample included nurses (n = 150), attending
physicians (n = 82), residents (n = 74), and
patients (n = 1432). A correlation was found
between nurses’ level of dissatisfaction and
nurses’ perception of unequal decision mak-
ing. However, in this study, lack of collabora-
tion did not correlate to retention issues.
A large cross-sectional survey of 820 nurses
and 621 patients revealed that on units where
nurses report positive working relationships
with physicians, there was a significantly
lower burnout rate for nurses. In addition, pa-
tients from these same units were twice as
likely to be “highly satisfied” with their care.5
Studies have revealed the positive out-
comes of interdisciplinary collaboration for
providers and patients. A significant theory,
such as the theory of goal attainment, can
guide practice and support the concept of in-
terdisciplinary collaboration. There are a few
practices that have demonstrated increased
interdisciplinary collaboration.
INTERVENTIONS TO ACHIEVE
COLLABORATION
Two methods that aid collaboration and
incorporate patient goal setting have been
studied and published. Curley et al6 intro-
duced, via a randomized controlled trial, an
intervention of daily interdisciplinary rounds,

which resulted in decreased length of stay
and reduced hospital charges. Those who
conducted daily rounds included a physi-
cian, nurse, social worker, nutritionist, and
pharmacist, and consisted of the healthcare
providers, discussing each patient and setting
short-term and long-term goals. The data in-
dicated that this method worked, as patients
achieved those goals in a shorter time and
were discharged from the hospital.
The other method is collaborative practice
order sets for common diagnoses. The use
of standardized care plans that are interdis-
ciplinary in nature and have been developed
by interdisciplinary teams increases the daily
collaboration among providers and provides
goals for patients with similar diagnoses.
The quasi-experimental study conducted by
Wells et al21 found that these paths provide
a means of collaboration and communication
between providers and patients, in both the
development and the implementation of the
paths.
These 2 interventions, while having pos-
itive results, have been limited in their im-
plementation. A structured approach that fo-
cuses on mutual goals being set and attained
may lead to significant positive patient out-
comes.

SUMMARY
Healthcare providers have recognized that
interdisciplinary collaboration is essential in
the healthcare system to achieve quality care
of individuals and groups in communities.
The research thus far has found positive pa-
tient outcomes associated with positive nurse-
physician relationships. To date, however, the
interventions to achieve collaboration have
been limited in scope and dimension. The ap-
plication of the concepts of the goal attain-
ment theory can provide a framework for in-
terdisciplinary collaboration to move forward
in improving outcomes and reducing adverse
events. Future recommendations can include
testing the use of the transaction process with
healthcare professionals.
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SHORT REPORT
Primary health care teams: team members’
perceptions of the collaborative process

SHERRY L. DIELEMAN1, KAREN B. FARRIS2, DAVID
FEENY1
,4,
JEFFREY A. JOHNSON3
,4, ROSS T. TSUYUKI4
,5 & SANDRA BRILLIANT1
1
Faculty of Pharmacy and Pharmaceutical Sciences, University
of Alberta, Edmonton, AB Canada,
2
College of Pharmacy, University of Iowa, Iowa, USA,
3
Department of Public Health Sciences,
Faculty of Medicine & Dentistry, University of Alberta,
Edmonton, AB Canada,
4
Institute of
Health Economics, Edmonton, AB Canada and
5
Division of Cardiology, Faculty of Medicine &
Dentistry, University of Alberta, Edmonton, AB Canada
Introduction
Collaboration and health care teams are common in hospitals
and long-term care facilities, but

teams are often not available to providers in the community
where most practitioners work
independently. A team environment could provide support for
these community-based health
care providers as well as allow for more efficient sharing of
information.
This paper examines the perceptions of pharmacists, physicians
and nurses as they worked
together in community-based teams to provide care to 199 high-
risk community dwelling
individuals. The study was part of a larger demonstration
project from September 1999 to
April 2000 (Côté et al., 2002; Farris et al., 2003).
Methods
Twenty-two providers were invited to participate in the project
to form six primary healthcare
teams. The teams included family physicians, community
pharmacists, office nurses and home
care nurses. Informed consent was obtained and ethical approval
was received from the
University of Alberta, Health Research Ethics Board.
A simple pre and post-test design was used to evaluate the
impact of team care on providers’

attitudes. Questionnaires were administered at the beginning,
twice during the study and at
the end. The basic questionnaire contained five questions
examining job satisfaction (Melville,
1980), nine questions examining role recognition and
experience in the team (Young, 1994),
and nine questions addressing satisfaction with the collaborative
process, care decisions and
quality of care (Baggs, 1994). Three questions, developed by
the research team, were added to
Correspondence to: Karen B. Farris, College of Pharmacy,
University of Iowa, Iowa City, IA 52240, USA. Tel:
319.384.4516; Fax: 319.353.5646; E-mail: [email protected]
JOURNAL OF INTERPROFESSIONAL CARE, VOL. 18, NO.
1, FEBRUARY 2004
ISSN 1356–1820 print/ISSN 1469-9567 online/04/010075–04 #
Taylor & Francis Ltd
DOI: 10.1080/13561820410001639370
measure the perception of the team’s impact on the quality of
patient care. Each question was
scored on a Likert-type scale from 1 (disagree strongly) to 7
(agree strongly). Open-ended
questions were also included.

The teams were divided into two groups based on qualitative
analysis of team process
meetings (Dieleman, 2003). One group consisted of the most
successful and best functioning
teams and the other group contained the remaining teams. The
scores for the two groups were
compared at Time 4 focusing on decision making and
collaboration. In addition, Time 4
scores were subtracted from Time 1 scores to give an indication
of change in the two groups
over the study period.
Results
The 22 providers ranged in age from 23 to 52 years, with a
mean age of 38.8 years (SD = 8.7).
All physicians were male and all the nurses were female.
Pharmacists were essentially all female
with the exception of one male.
Five items were found to be significantly different over the four
time periods as shown in
Table 1. Job satisfaction of providers compared to their current
jobs improved over time (4.8
(SD = 1.1) at baseline to 5.5 (SD = 0.9) at end of study, p =
0.02). The examination of the six

teams as two groups based on their ability to function well is
shown in Table 2. The better
performing teams all had positive change scores.
Table 1. Perceptions of Working in a Primary Health Care Team
Mean (Std. Deviation)
1,2,3
Collective Activities (n = 22) Time 1 Time 2 Time 3 Time 4
Liaise about care 6.5 ( + 0.6) 6.7 ( + 0.6) 6.6 ( + 0.7) 6.7 ( +
0.6)
Others not confused about my professional role
4
5.3 ( + 1.5) 5.6 ( + 1.6) 5.9 ( + 1.4) 6.3 ( + 1.2)***
Team meeting useful 6.7 ( + 0.5) 6.5 ( + 0.9) 6.4 ( + 0.9) 6.8 ( +
0.5)
Do not need more patient information (n = 21) 2.6 ( + 1.2) 4.1 (
+ 1.7) 4.2 ( + 1.5) 4.1 ( + 1.8)***
Feel part of a team 6.5 ( + 0.6) 6.5 ( + 0.8) 6.4 ( + 0.9) 6.8 ( +
0.4)***
Other professionals’ notes are available (n = 21) 5.7 ( + 1.1) 5.7
( + 1.4) 5.3 ( + 1.5) 5.8 ( + 1.4)
Working with others is helpful 6.6 ( + 0.6) 6.5 ( + 0.7) 6.6 ( +
0.7) 6.9 ( + 0.4)*
Referrals are appropriate (n = 16) 5.9 ( + 1.0) 5.6 ( + 1.3) 5.6 (
+ 1.1) 6.1 ( + 1.2)
Do not see too many patients
4
(n = 21) 3.8 ( + 1.6) 3.9 ( + 2.0) 3.1 ( + 1.9) 3.7 ( + 1.9)

Equity in decision making process
5
(Bagg’s Collaboration Score) (n = 21)
5.9 ( + 0.7) 5.8 ( + 0.6) 5.7 ( + 0.9) 5.9 ( + 0.9)
Satisfaction with decision making process
4
6.2 ( + 0.5) 6.1 ( + 1.3) 6.3 ( + 1.2) 6.3 ( + 0.8)
Satisfaction with decisions 5.0 ( + 1.3) 5.5 ( + 1.2) 5.9 ( + 1.0)
5.6 ( + 1.5)
Perceived Impact
Improves quality of patient care 6.7 ( + 0.6) 6.5 ( + 0.9) 6.4 ( +
0.9) 6.7 ( + 0.6)
Improves medication use
4
5.9 ( + 1.4) 6.0 ( + 0.9) 5.9 ( + 1.4) 6.3 ( + 0.8)
Improves patients’ health status 5.7 ( + 1.5) 6.1 ( + 1.0) 6.1 ( +
0.8) 6.5 ( + 0.7)**
1
Tests across time used Repeated Measures ANOVA
2
Scale 1 = Disagree Strongly and 7 = Agree Strongly
3
Expectations measured at Time 1
4
Original question negatively worded

5
Originally based on a combined score of 7 questions (Baggs,
1994), Cronbach’s alpha reliability = 0.89 at
Time 1
*p 5 0.04 significant difference Time 1 to Time 4
**p 5 0.03 significant difference Time 1 to Time 4
***p 5 0.01 significant difference Time 1 to Time 4
76 SHERRY L. DIELEMAN ET AL.
Content analysis of the open-ended questions in the final
questionnaire identified many
common themes among the providers and teams. The general
themes included the
development of a better understanding of other team members,
an increased comfort level
when interacting with other professionals, and a preference to
work in a team environment
when providing care for high-risk individuals.
Five of the teams responded by explaining the working in the
team gave them a better
appreciation of the other team members’ perspectives and roles
in health care.
I have an even greater understanding of my team’s work load,

time constraints and the
broad scope their jobs involve. When we each work in an
isolated cage it’s hard to truly
understand what’s going on in another professional’s ‘cage’.
(Pharmacist)
Specifically the role of the pharmacist and home care nurse
were mentioned as being better
understood.
Working in the Collective was a very good experience for me
especially to find out the
pharmacist’s role and how essential they are for patient care.
(Home Care Nurse)
Communication was also enhanced within the team. Providers
indicated that trust and respect
for each other was important to the way their teams operated.
Our making of a decision making community made it possible to
come up with decisions
using consensus. We seemed to trust each other and respect
each other. (Physician)
Discussion
The providers found that working in a team environment was
very useful when they dealt with
complex primary-care patients. They identified open

communication, respect for other team
members, understanding of their roles and expertise, and being
open to learning as important
for collaboration.
When the skills and roles of other community health care
workers are understood, effective
teamwork is possible (Galvin et al., 1999; Long, 1996). In this
study, the providers came to rely
Table 2. Comparison of change scores in primary health care
teams
Mean (Std. Deviation)
1,2
Team Activities
Teams 1, 5 & 6
(n = 11)
Teams 2, 3 & 4
(n = 11)
All Teams
(n = 22)
Working with others is helpful 0.5 (0.7) 0.2 (0.6) 0.3 (0.6)
Equity in decision making process

3
0.3 (0.5) 7 0.1 (1.4) 0.1 (1.1)
Satisfaction with decision making process
4
* 0.5 (0.5) 7 0.5 (1.4) 0.0 (1.1)
Satisfaction with decisions** 1.5 (1.6) 7 0.4 (1.7) 0.5 (1.9)
1
Change scores (Time 47Time 1)
2
Comparison between teams used Mann – Whitney U-test
3
Originally based on combined score, n = 10 for Teams 1, 5 and
6 and n = 21 for All Teams
4
Original question negatively worded
*p = 0.03 significant difference between the best functioning
teams (1, 5 and 6) and the other teams
**p = 0.02 significant difference between the best functioning
teams (1, 5 and 6) and the other teams
PRIMARY HEALTH CARE TEAMS 77
on their fellow team members for support. Before they could
trust other providers, each person

had to learn about that provider. More precisely, providers
needed to know what knowledge,
skills and abilities other providers could offer to the team.
Communication was an important part of the team environment.
Providers felt that they
were able to access the patient information that they needed.
This access enabled better patient
care and communication among the team. In the present study,
the teams found that taking
the time to be comfortable with each other enhanced
communication.
When providers’ satisfaction with their current job was
compared with their final satisfaction
in the team, the level of satisfaction had increased. This
coincides with other studies that have
found that a collaborative work environment can positively
affect job satisfaction (Abbott et al.,
1994; Byers et al., 1999).
The small number of self selected providers limits the
generalizability of this study. A larger
sample size would allow for an examination of the differences
between the various professions
and groups with unique patient populations. The addition of a
control group would further

ensure that the results reflected the effects of working in the
team.
Conclusion
While much has been written about collaboration, few studies
have systematically examined
the perceptions of health care workers collaborating in the
community. This study is important
as it adds empirical information about community teams,
including the importance of open
communication, respect, and understanding the expertise of
other members.
Acknowledgements
This project received financial support from the Health
Transition Fund, Health Canada and
Alberta Health. The views expressed herein do not necessarily
represent the official policy of
Health Canada or Alberta Health.
References
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GALVIN, K., ANDREWES, C., JACKSON, D., CHEESMAN,
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78 SHERRY L. DIELEMAN ET AL.

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