The current status of nurses–doctors collaboration in clinical decision and its outcome in Tanzania

Abstract Aim The aim of this study was to establish the current level of collaboration between nurses and medical doctors (MDs) in the making of clinical decisions. Design Descriptive qualitative design was applied in this study. Methods Semi‐structured interviews were conducted to collect qualitative data. Contents were arranged according to their similarities, whereas content analysis was used to identify explanatory themes. Results Nurses feel disrespected when medical doctors (MDs) ignore their opinions. The impression of lower level of education of nurses is seen as a cause to their opinions been ignored by the medical doctors. Nurses sometimes adhere to the instructions of MDs, but on other times, they carry on with their own proposed treatment. Implications for nursing practices Involvement of nurses in clinical decisions will enable nurses to effectively advocate for patients.


| INTRODUC TI ON
Collaboration is essential in clinical practice; particularly, it increases health workers motivation, reduces treatment errors, increases effective care and reduces the weakness of professional performance (Foth, Block, Stamer, & Schmacke, 2015;Zamanzadeh, Irajpour, Valizadeh, & Shohani, 2014). Generally, collaboration is defined as working with other persons to accomplish the targeted goal/s (Zamanzadeh et al., 2014). Collaborative approaches differ depending on discipline, but each approach is result oriented. Patient's recovery depends on collaboration between different healthcare providers, and such medical collaborations help to bring solutions in situations requiring complex treatment (Green & Johnson, 2015).
Without collaboration of healthcare professionals, it is impossible to meet all of the patient's demands (Mahdizadeh, Heydari, & Moonaghi, 2017).

Collaboration between nurses and medical doctors (MDs) in clin-
ical facilities is a kind of teamwork, which is reported to result into quality healthcare services. On the other hand, lack of collaboration between nurses and MDs increases medical errors and also leads to suboptimal healthcare services (Elsous, Radwan, & Mohsen, 2017); collaboration between nurses and MDs should, therefore, focus on respect, good communication and shared clinical decision power (Elsous et al., 2017).
Although collaboration is essential to clinical facilities, nurses in Tanzania complain of lack of respect from MDs and the absence of shared clinical decision-making power (Langway, 2017). Meanwhile, the guiding principle of medical ethics requires MDs at all levels to recognize and respect the expertise of other health workers.
Additionally, the same principle requires MDs to collaborate with other health workers in the interest of providing the best possible holistic healthcare services (MAT, 1995). Inarguably, teamwork is more significant than skills and knowledge in the provision of quality healthcare services (Ishijima, Eliakimu, Takahashi, & Miyamoto, 2014).
A clinical decision is defined as the process that starts from assessing patients and diagnosis and ends up with the decision of what is to be done after the assessment and diagnosis is conducted (Catarina & Campos, 2009). However, MDs are not ready to listen to and accept the modes of treatments of patients as proposed by nurses (Johnson, 2009). It is, moreover, argued that nurses should be involved in shared clinical decision power for patient's treatments since they spend more time with patients and tend to understand the needs of patients better than MDs (Mcclelland, Switzer, & Pilcher, 2012).
Literature about nurse-MDs collaboration in Tanzania is limited.
The few that have been conducted rather reported the distresses among nurses due to lack of respect from other healthcare professionals (Häggström, Mbusa, & Wadensten, 2008). This study, therefore, intends to establish the nature and level of collaboration between nurses and MDs in the making of clinical decisions in Tanzania. Findings from this study could be factored into strategies for improving healthcare delivery in Tanzania.

| Nurses in Tanzania
In the Tanzanian perspective, nurses are defined as authorized licensed professionals with adequate knowledge and competency to carry out quality nursing care to individuals, families and communities, and they are categorized according to their different academic training levels such as certificate, diploma, advanced diploma, bachelor degree, master degree and doctorate degree (TNMC, 2014). The curricula for training nurses include both theory classes and clinical practices. Besides, they are also trained to provide holistic nursing care in aspects of culture and spiritual care (Tjoflåt et al., 2018).
Tanzania has a national population of 47,524,276. There are 31,618 nurses and midwives with different levels of the abovementioned certificates. Approximately, there is a one nurse or midwife ratio per 1,374 populations, as against the World Health Organization (WHO) recommendation of one nurse/midwife per 492 populations (Tarimo, Moyo, Masenga, Magesa, & Mzava, 2018).
All nursing activities in Tanzania including registering and enrolment of nurses, establishing standards of proficiency and issuing licence to the nurses are regulated by the Tanzania nursing and midwifery council (TNMC) (TNMC, 2010). This council has established principles that govern the practice of nursing and ensure the provision of quality care to patients.
Nurses are also trained to work as members of the multidisciplinary team to protect the interest of clients (TNMC, 2014). A nurse, therefore, can prescribe medicine and perform minor surgeries and other complex tasks if only he or she possesses the knowledge and in the absence of an MD (TNMC, 2014). The code of ethics and professional conducts for nurses in Tanzania emphasizes that nurses must maintain professional competence and collaborate with other healthcare providers as a team (TNMC, 2015).

| Medical doctors (MDs) in Tanzania
In 2012, the doctor to population in Tanzania ratio was 0.3 per 10,000 (Sirili et al., 2019). Recently, these statistics have changed to one medical doctor per 20,010 people, regardless of the WHO recommendation of one medical doctor to 4,000 people (Tarimo et al., 2018). In postindependence, the country introduced subcadres within the profession with the aim of carrying out task-shifting roles for doctors to aid the shortage of MDs within the country. These included Assistant Medical Officers (AMOs) and Clinical Officers (COs) (Sirili et al., 2019). In 2015, the country had 11 medical schools producing students with diploma, advanced diploma and degree programme (Sirili et al., 2019).

| Design
A descriptive qualitative study was conducted to obtain cases deemed rich in information (Lambert & Lambert, 2012). The study purposively sampled nurses and doctors in Tanzania. Each was asked to respond to their lived clinical experiences about collaboration between nurses and doctors.

| Setting and sampling technique
The study was conducted in five hospitals located in Dar es Salaam, Tanzania. Two were public hospitals ranked as referral hospitals, and three private hospitals. Nurses and medical doctors (MDs) recruited into the study had either certificate, diploma or degree from recognized training schools. Purposive sampling method was applied in recruiting the participants. Frequent and similar responses from different healthcare providers indicated that the information was saturated.

| Ethical consideration
The research proposal was submitted for ethical clearance to the ethical committee at University of Dodoma. It was confirmed to have no harm to healthcare providers. Informed consent was obtained from all participants, and information collected from healthcare providers was kept confidential.

| Data collection procedures
The data were collected from October-November 2018. Semi-struc- Healthcare providers and researchers agreed on the interview day, time and place. A reminder text message was sent to each participant one day before the interview. The interviews were conducted in quiet places to avoid distractions and other interferences (Tjoflåt et al., 2018). Each interview was started by introduction to establish trust from participant. The interviews were not hastily performed for participants to have time to share their experiences and perceptions.

| Data analysis
The analysis started with transcription (Bailey, 2008). All audio-recorded data were converted into written Swahili. The Principal Investigator and his assistant did transcription separately and later exchanged the transcripts to make comparison for the identification of missing information. Transcripts were later translated into the English language by the cooperation of both researchers (Smith, Chen, & Liu, 2008). Contents were arranged according to their similarities, and later, content analysis was used to identify explanatory themes (Graneheim & Lundman, 2004).

| Sample characteristics
Twelve healthcare providers dominated by nurses and MDs participated in the study. Most of them were females. The demographic characteristics are summarized in Table 1.

| Overview
Three major themes and sixteen subthemes were identified from this study: (a) Actions taken by nurses when MDs reject their opinion, (b) Factors influencing MDs in the rejection of nurse's advice and (c) The impact of doctors' rejection on nurse's advice. The abbreviation "P" is frequently used in this section of the result to signify the "participant". Refer Table 2   I decided to report the concern during a departmental meeting held the next morning. Later, the MD realized I was right and accorded me with respect henceforth.

| Actions taken by nurses when MDs reject their opinion
Till date, I'm one of the first person he hold discussion with whenever he encounters any problem during patient's treatment.

| Factors influencing MDs to reject nurse's advice
MDs understand that nurses are professionals only to receive MD's order, but not to be involved in decision making about patient's treatment. Most healthcare providers said when MDs reject nurse's suggestions, it might affect the nurse's performance: The work motivation for nurses diminishes when they find their opinions are not appreciated by MD.
(P5, EN) Silence among nurses is because they understand that even if they speak their suggestions will not be accepted, therefore they choose to remain silent.
(P4, RN) If the MD has shouted in front of patients, those patients will absolutely feel that nurses are incompetent in their practices and more acknowledge the works of MDs.
(P7, RN) The effect may extend further to the community, as the patient can report the situation to relatives and the community as well, which may affect the reputation of the hospital and staff: The number of patients coming to hospital having nurse-doctors disagreement in clinical decision decreases that directly affects hospitals business.

| D ISCUSS I ON
Most respondents reported that nurses must be allowed to participate in clinical decisions on the treatment of a patient. This is consistent with the nurse's guiding principle, which encourages nurses to collaborate with other healthcare providers as members of a team (TNMC, 2015). This study showed nurses' suggestions as important in a patient's recovery, which is opining to an already existing literature (Kvande, Lykkeslet, & Lisa, 2017).

| Actions taken by nurses when doctors reject their opinion
Some nurses confidently approach MDs to enquire about the rationale of rejecting their opinions. Others sought colleague views on why their opinions were rejected by the MDs. Other nurses joined in one voice to ensure their opinions were adhered to when they feel they are right. This is similar to another study where nurses joined hands and with one voice denounced the habit of an MD by writing a letter to the administration of a particular health facility to express their discomfort in working with an MD (Maddineshat, Rosenstein, Akaberi, & Tabatabaeichehr, 2016).
Many nurses in different healthcare facilities are carrying out various tasks as part of an indirect reaction on the rejection of their opinions. For example, a nurse just goes ahead to administer a drug on a patient once s/he believes it is the right medication and the MD has refused to accept their opinion. This conforms to another study that reported same because nurses were tired of their opinions been ignored. Nurses added or reduced the dosages of medications contrary to the orders given by MDs and sometimes avoided administering the medications outright (Foth et al., 2015).

| Factors influencing doctors rejecting nurses' opinion
Healthcare providers reported the existing traditional belief that MDs perceive themselves as superior to nurses and try to keep clinical decision-making to themselves. Again, other studies revealed that MDs perceive themselves to be more powerful and competent than nurses (Achilles, 2010;Fagin & Garelick, 2004;Hoffman et al., 2004;Krogstad, Hofoss, & Hjortdahl, 2004). Another study also reported that MDs perceived nurses as their assistants (Elsous et al., 2017). These findings are contrary to the document prepared by Tanzania nursing and midwifery council, which shows that nursing is an independent profession and self-regulated to function in a broader setting (TNMC, 2014).
Nurses are ignored in decision-making because they are regarded to have no authority (Johnson, 2009;Murata, 2014) and are considered as tools for carrying out MD's orders (Fagin & Garelick, 2004 Further, some nurses give opinions on patient's treatment based on their experiences, which is a reason for the rejection of opinions by MDs. Tangible opinions should be derived from evidence (references) and not from one's experiences. This conforms to a study where nurses drew clinical decisions primarily from the experiential knowledge that was insufficient (Thompson, 2014).

| Impacts of doctor-rejecting nurse's advice
One-sided clinical decision from MDs results in patient's suboptimal healthcare services. Motivations to work become affected on the part of the nurses and healthcare facilities are affected financially because its reputation is affected, which leads to a reduction in the number of patients who uses the facility. As suggested by other studies, lack of professional collaboration in decision-making does not only affect professionals; rather, the unpleasant outcome extends to the community at large (Johnson, 2009).

| Limitations of the study
The study was only conducted in one region, while Tanzania has a total of 28 regions making generalization impossible. Despite the fact that the information was saturated, the sample size was also small, as large sample size in qualitative studies helps to explore new and rich information, which result in more understanding of a phenomenon (Vasileiou, Barnett, Thorpe, & Young, 2018). This study did not include non-healthcare providers, especially patients/clients who could have confirmed the impact of nurse-doctor disagreement in clinical decision about patient's treatment.

| CON CLUS ION
Nurses understand patient's progress deeper compared with other healthcare providers since they stay with patients for longer periods, especially when patients are on admission. "Advocacy" is an important task to be performed by nurses to ensure the rights of patients are well protected and treatments given to patients are safe and of a standard quality. Therefore, clinical decisions concerning patient's treatment should not be done in isolation by MDs; rather, it should be made with nurses included since multidisciplinary teamwork is important. Shared clinical decision power between nurses and MDs will improve interprofessional relationship that will lead to job satisfaction and effective clinical performances.

ACK N OWLED G EM ENTS
The authors wish to acknowledge the contributions from the School of Nursing of Zhengzhou University in China for the innovative ideas