The importance of interdisciplinarity in accommodating patient needs among norwegian nurses

Introduction: Nurses’ roles in specialist and substance use


Funding information
This study's data collection and executive report were funded by the Norwegian Nurses' Organisation. The article is based on these data, but it considers other research questions and analyses than the report. The funding source did not have any role in analysis of the data, writing of the article or the decision to submit the article for publication.

Accessible summary
What is known on the subject: • Previous studies of interdisciplinarity and nursing responsibilities have mainly focused on outcomes such as patient safety, job satisfaction and organizational factors.
• Mental health nurses often describe role confusion in relation to other health professionals.
• Opportunities for interdisciplinary communication with other professionals may benefit health care.
What the paper adds to existing knowledge: • The current large-scale study is the first to investigate whether mental health and SUD nurses' perceptions of their opportunities to accommodate patients' needs are related to interdisciplinarity in the treatment unit and a nursing role with clearly defined responsibilities.
• Strong interdisciplinarity was associated with greater perceived opportunities to accommodate patients' psychosocial, somatic, and economic and legal needs, while strictly defined nursing roles/responsibilities were related to weaker opportunities to do so.
What are the implications of practice: • The findings highlight the need to address how mental health and SUD nurses organize practice to meet patients' diverse needs • Interdisciplinary teamwork could strengthen nurses' ability to address patient needs • Finding the best possible balance of providing service in teams or individually could improve resource utilization at the same time as strengthening patient care, and making sure that the patients' various needs are met.

A bs tr ac t
Introduction: Nurses' roles in specialist mental health and substance use disorder (SUD) treatment services are multidimensional and complex. Their responsibility, autonomy and interdisciplinary collaboration may be of importance for their perceived opportunities to accommodate patients' health needs. Previous studies of

| INTRODUC TI ON
Nurses represent the largest professional group in both specialized mental health and specialized substance use disorder (SUD) treatment services (Abram, 2018). Services in the two sectors have much in common and share many patients with dual diagnoses who move across the two sectors (Brousselle et al., 2010;McGovern et al., 2014).
Patients with mental health conditions and SUD mobilize numerous specialized resources and face challenges and comorbidity across a wide range of domains, such as somatic health disorders as well as social, economic and legal problems (Delaney et al., 2013;Donald et al., 2005;Frasch et al., 2013;Kedote et al., 2008). This requires the nurses in these sectors to address several problem domains and needs simultaneously (Fung et al., 2014). The role is often multidimensional, with nurses expected to be caretaker, role model and coordinator of health services (Goulter et al., 2015). The nurse-patient relationship is frequently highlighted as the most central element of "good nursing practice" (Goulter et al., 2015), but nursing also should include "organising work" (Allen, 2014). This usually entails collaboration and co-ordination with providers and family carers, as well as "care space governance" (Mendes, 2015), with the latter including maintenance of quality, safety and cost-effectiveness.
A potential barrier to the accommodation of patient needs (i.e. opportunity to meet patients' needs in different domains, such as somatic and mental health) is that the nurses may not have sufficient competence in specific domains. An integrative review found that mental health nurses in the United Kingdom were not routinely supported by somatic healthcare education (Blythe & White, 2012).
The review revealed that many nurses also described role ambiguity related to their role as somatic health carers. A study of psychiatric nurses in an inpatient ward concluded that nurses struggled to achieve professional independence from other professional groups (Goulter et al., 2015). Although the nurses in this study had responsibilities across several different health domains, they lacked professional confidence as well as the authority to make decisions regarding overall care plans. The authors argued that the key focus of inpatient mental health nursing remains largely unestablished. A possible consequence is structures failing to align with the direct care that the nurses are expected to provide.
Research has suggested that professional autonomy, selfleadership as well as opportunities to participate in knowledge sharing facilitate novel and innovative practices among nurses (Kim & Park, 2015). Although professional autonomy may be an important precursor of nurses' abilities to accommodate patient needs, nurses in both the mental health and SUD sectors are usually part of a broad health team consisting of personnel such as medical doctors, physiologists, psychologists and social workers. The collaboration and interaction between nurses and these groups may be critical for providing adequate care (Manojlovich and DeCicco, 2007).
Interdisciplinary work and collaboration, such as experience and competence sharing across professional groups at a treatment unit, are closely linked to the organizational domain of the ward climate in a health treatment unit (Gausvik et al., 2015;Moos, 2018). This domain focuses on factors such as the opportunity of different professional groups to alter the course of treatment or amend regulations and rules underlying treatment procedures and the level of control interdisciplinarity and nursing responsibilities have mainly focused on outcomes such as patient safety, job satisfaction and organizational factors, and included relatively small samples. The studies have also mainly been conducted in other sectors than the mental health and SUD nursing sectors.
Aim/Question: The aim of this study is to examine the associations between nurses' roles, interdisciplinarity and their perceived opportunities to accommodate patients' psychosocial, somatic and economic/legal needs.

Method:
A cross-sectional web-based questionnaire survey was conducted in a nationwide sample of Norwegian nurses in the mental health, SUD treatment and combined mental health and SUD treatment sectors. Of 5,501 contactable nurses (74% of the population), 1918 (35%) responded.

Results:
The results revealed that interdisciplinarity was significantly associated with greater perceived opportunity to accommodate patient needs, whereas strictly defined nursing roles/responsibilities were associated with less opportunity to accommodate these needs.
Discussion/Implication for practice: Facilitation of interdisciplinary collaboration may improve quality of care for patients in mental health and SUD treatment services.

K E Y W O R D S
communication, competence, interdisciplinary collaboration, Nursing role, responsibility exerted by professional groups over their working environment (Harvey & Jason, 2011). Interdisciplinarity has become an increasingly important aspect of healthcare systems, and it has been shown to improve system-and patient-level outcomes (Al Sayah et al., 2014;Gausvik et al., 2015;Van Bogaert et al., 2014). Meanwhile, interdisciplinary work can also generate substantial challenges because workers from different disciplines may disagree substantially over the purpose or type of treatment and patient needs (Bowers, 2009).
Previous studies have often focused on the multitude and complexity of nurses' roles in mental health and SUD services. However, few have investigated whether nurses' different roles are related to the accommodation of patients' needs. This study draws on a nationwide sample of Norwegian nurses in the mental health, SUD treatment, and combined mental health and SUD sectors. The study aims to investigate the extent to which a strongly defined nursing role with clear responsibilities and strong interdisciplinarity at the treatment unit is associated with nurses' perceived opportunities to accommodate patients' needs, adjusted for nurses' demographics and formal competence factors.

| Procedure
A self-administered web-based questionnaire survey was conducted with a sample of 5,800 nurses working in the mental health, SUD, or combined mental health and SUD sectors. The nurses were recruited from the member registry of the Norwegian Nurses' Organisation (NNO). The registry covers about 78% of nurses employed in the specialist mental health services (n = 6,300) and SUD (n = 1,100) sectors. Inclusion criteria were that the NNO members were registered as employed in one of the three sectors of interest, had the position of 'psychiatric nurse' or were registered as working in the psychiatry/ substance abuse area and working in specialized services for mental health or SUD. The study was independently reviewed and approved by the Norwegian Centre for Research Data, reference number 49,074.
The research was carried out in accordance with the ethical principles outlined in the World Medical Association Declaration of Helsinki.
The data were collected in the period from August through November 2016. All invited respondents received an invitation with a link to access the questionnaire via email and Short Message Service. Of the 5,800 nurses invited, 230 could not be reached or reported that they were not in the target group of the study. A further 69 nurses reported that they worked in other health sectors and were excluded from further analyses. A total of 1918 nurses responded to the enquiry (a response rate of 35% from the 5,501 contactable nurses). Web surveys generally obtain lower response rates than postal or face-to-face interview surveys. In a meta-study, the mean response rate across a wide range of web surveys was 34% (SD = 22%) (Shih & Fan, 2008). Because the current study focused on perceived accommodation of patient needs, nurses who reported 0%-19% of their work time being spent on patient contact (n = 267) were excluded. This left a total of 1,651 nurses, who constituted the analytical sample.

| Measurement instruments
The aim of this study was to examine the associations between nurses' roles, interdisciplinarity and their perceived opportunities to accommodate a variety of patient needs. To address this aim, a questionnaire was developed based on analyses of three semi-structured focus group interviews conducted among nurses (n = 10-15 in each group) working in the mental health, SUD, or combined mental health and SUD sectors. The interviews focused on identifying important themes in nursing roles as well as their responsibilities and clinical practice. In addition, based on the results of the focus group interviews, an expert group of experienced researchers and nurses contributed in devising the questionnaire.

| Demographic and formal competence factors
Demographic characteristics included the gender and age of the nurses. Formal competence variables included years of work experience in the mental health or SUD sectors and current health sector of employment (mental health sector, SUD sector, combined mental health and SUD sector). Work experience of 6 or more years has been suggested to distinguish inexperienced and experienced nurses (e.g., Saksvik-Lehouillier et al., 2013) and was used in the current study. The nurses also reported whether they held the position of specialist nurse. Furthermore, they reported whether they were continuing training as a psychiatric nurse or in multidisciplinary training in mental health work (which replaced the previous psychiatric nurse training from 1998), continuing training in psychotherapies for psychosis, combined substance misuse and mental health work, substance misuse problems, network education meetings and relational competence or other forms of continuing education. Moreover, the nurses reported the type of unit in which they were currently employed (outpatient unit, inpatient unit, and ambulatory team).

| Nurses' responsibilities and interdisciplinarity
Nurses' responsibilities and interdisciplinarity at the treatment unit were measured by seven items (Table 1). The nurses reported the extent to which such statements were true for their current workplace on a four-point scale, from (1) not at all to (4) to a large extent.

| Nurses' perceived opportunities to accommodate patients' needs
Nurses' perceptions of their opportunities to accommodate patients' various needs were recorded using a 13-item measure (Table 2).
Nurses reported the extent to which they believed they had the opportunity to accommodate the needs of patients in different health domains. The instrument was scored on a four-point scale, from (1) not at all to (4) to a large extent. The scale also included a not applicable response anchor. Responses to this anchor item were set to system missing values.

| Statistical procedures
Descriptive statistics were used to describe the sample. Principal component analyses (PCA) with iteration (i.e., items which failed to meet the criteria were excluded one by one until the criteria were met) were used to investigate the dimensionality in the measurement instruments. The criteria were that items which failed to load above 0.30 on its main dimension and cross-loading items with values above 0.40 were excluded (Hair et al., 2009).
Clinical interpretability of the dimensions was also a critical criterion for dimension extraction. Kaiser criterion and varimax rotation were performed to investigate the underlying dimensionality in the measurement instruments. Cronbach's alpha and average corrected inter-item-total correlations were calculated as reliability indices. Nunnally (1978) postulated that the alpha coefficient should be above 0.70 to reflect a coherent scale. However, more recently, TA B L E 1 Descriptives of responsibility and interdisciplinarity items 'To what extent do you agree with the following statements about nurses' responsibilities at your workplace?' Item 1. Not at all % (n)

To a low extent % (n)
3. To some extent % (n)
To investigate factors associated with nurses' perceived opportunities to accommodate patients' needs, three hierarchical linear block regression analyses were carried out. Nurses' demographics and formal competence factors were entered into the first block.
Dimensions of nurses' responsibility and interdisciplinarity were added in the second block to examine whether these factors ex- Collinearity is likely present when the VIF values exceed 4.00 by a tolerance less than 0.20 (Hair et al., 2009). A conventional significance level of .05 was used in all analyses.

| Sample characteristics
The average age of the nurses was 45.28 years (SD = 11.55, range = 21-69 years), and most were women (78%). As shown in Table 3, the majority worked in the mental health sector (77%) and 71% in inpatient units. A total of 75% of the sample had more than six years of work experience, while 72% were specialist nurses. The most common form of continuing education was in general mental health work (53%) and training as a psychiatric nurse (30%).
Descriptive statistics on interdisciplinarity and perceived opportunity to accommodate patients' needs.
Single-item distributions for nurses' responsibility and interdisciplinarity are shown in Table 1. As shown, the majority of nurses reported rather strong interdisciplinary collaboration, experience and competence exchange at their workplace. Most nurses also reported relatively clear-cut general work responsibilities/nursing roles and responsibilities in relation to other disciplinary groups.  Table A1 shows the results of a PCA for the 13-item instrument of perceived opportunity to accommodate patients' needs. As displayed, the instrument is segmented into three dimensions that explain about 54% of the total variance. Two items ("existential/spiritual needs" and "work and activity") were excluded from the analysis because they failed to load consistently. The first dimension included four items and was termed "somatic health care needs" (α = 0.735). The items in this dimension mainly covered patient care regarding physiological domains, such as nutrition and physical activity. The second dimension covered five items and was termed "psychosocial care needs" (α = 0.661). This dimension included items related to substance use, mental health and social interaction. The final dimension included two items and was termed "economic and legal supervision" (α = 0.624). These items covered supervision in terms of patients' legal rights and economic issues.

| Dimensional structure and reliability of the instruments
Higher scores on the instrument reflect greater opportunity to accommodate patient needs in the respective domains. Table A2 shows a PCA for the seven-item instrument of interdisciplinarity. The measure is divided into two dimensions that explain about 73% of the total variance. The first dimension, "Interdisciplinary interaction" (α = 0.726), included three items related to interdisciplinary competence exchange and collaboration.
The second dimension, "Nursing responsibilities" (α = 0.812) covers two items regarding how strictly the nursing roles in the units were defined. Two items ("Nurses at my workplace are heard and respected" and "I am given work tasks that do not belong to my responsibility domain") were excluded because they failed to load.
As shown in Table 3, consistent with the single-item analyses, the most seldom reported opportunities to accommodate patient needs were related to economic and legal supervision, whereas the opportunities to accommodate somatic and psychosocial care were more common. The nurses reported rather high interdisciplinarity, so their overall nursing responsibilities were reported to be less strictly defined. However, when demographic and formal competence variables were adjusted for, the most substantial contribution to the explained variance was the nurses' responsibility and interdisciplinarity block.

| Opportunity to accommodate patients' needs
Within this block, interdisciplinary interaction was strongly associated with higher scores in all three dimensions of perceived opportunity to accommodate patients' needs. Strictly defined responsibility for the nurses was systematically associated with fewer perceived opportunities across the three domains.

| D ISCUSS I ON
Previous studies of interdisciplinarity and nursing responsibilities have mainly focused on outcomes such as patient safety, job satisfaction and organizational factors (Al Sayah et al., 2014;Gausvik et al., 2015;Goulter et al., 2015;Kim & Park, 2015) and  (Omer et al., 2015), and across the primary and secondary care levels (Nicaise et al., 2020). It is possible that the current results reflect that inpatient treatment generally has a main focus on somatic care, whereas psychosocial care may be a stronger focus in outpatient settings and ambulatory teams. More research is needed to disentangle such potential tendencies. There is a great need to ensure safe transition from inpatient to community settings through clarifying the patient's situation and needs regarding housing, work and further follow-up (Xiao et al., 2019).
The finding indicating that interdisciplinarity in the treatment unit Mental health sector and Works in inpatient treatment excluded due to redundancy (serve as reference categories).
Adjusted B = Unstandardized coefficient adjusted for all remaining factors in the model. ****p < .001, *** p < .005, ** p < .01, * p < .05. Manojlovich & DeCicco, 2007). There may be several explanations for this association. It is possible that working in a multidisciplinary team or workplace together with professionals and leadership with complementary skills may positively influence nurses' perceptions of accommodating patients' needs, as opposed to a stricter and individual approach where they have to rely more on their own competence. The results also indicated that the contribution of strong interdisciplinary work exceeded formal competence such as level of education and work experience. A possible explanation is that interdisciplinary interaction is more important for nursing health care in the specific units than individual demographics and education among nurses.
Strictly defined nursing responsibilities were systematically associated with fewer perceived opportunities to accommodate patient needs across the three health domains. The existing literature is somewhat ambiguous regarding the role of nurses and the best ways to structure nurses' responsibility domains in relation to their clinical tasks (e.g., Bowers, 2009;Gausvik et al., 2015). The results of the current study support the assumption that professional autonomy and freedom are important in enabling nurses in the mental health and SUD sectors to accommodate patient needs. The distribution of responsibility also seems to be more critical than demographic characteristics among nurses for the accommodation of patients' needs.
Thus, patients may benefit from an improved collaboration climate in these treatment sectors. When the role of nurses is strictly defined, it is possible that nurses find themselves subordinates of medical doctors and clinical psychologists in relation to somatic issues and mental health.
The most frequently reported unmet patient needs among nurses in the present study were related to economic supervision, sexuality and intimate relationships. This concurs with previous research indicating that the effort for preparing nurses to work in these domains is poorly developed (Kong et al., 2009). The associations in the current study may also be bidirectional. Unmet patient needs could be influenced by patient factors, for instance, patients not wanting nurses to intervene across all domains. This could be particularly relevant to problem domains, such as intimate relationships, economy and work/activity, which to a certain extent could be perceived by the patients and nurses as private matters.

| Limitations and strengths of the study
The study has some limitations that need consideration when the findings are interpreted. The cross-sectional design does not allow for causal inferences, and self-reported data may be susceptible to socially desirable responses. Common method bias may also partially explain associations between variables when the independent and dependent variables are obtained by the same method and from similar information sources. Further research could also seek to triangulate respondents (e.g., by including both patients and nurses) because the current research focused solely on the nurses and system factors. It should also be pointed out that the explained variance in the models was relatively low (range = 10% -20%). However, the aim of the study was to investigate the associations between nurses' roles, interdisciplinarity and their perceived opportunities to accommodate a variety of patient needs, and not to maximize explained variance in perceived opportu-

| RELE VAN CE S TATEMENT
The current study features a nationwide sample of 1,918 nurses from mental health, SUD treatment and combined mental health and SUD treatment sectors in Norway. The findings highlight the need to address how mental health and SUD nurses organize practice to meet patients' needs. Interdisciplinary teamwork could strengthen nurses' ability to provide follow-up of patient needs. Discussions among staff on the nursing role and responsibility would be beneficial. There are overlapping competences held by many professional groups. Finding a balance of providing service in teams or individually could improve resource utilization at the same time as strengthening patient care.

CO N FLI C T O F I NTE R E S T
The authors have no conflicts of interest to declare.

AUTH O R CO NTR I B UTI O N S
LM and MÅ conceptualized and designed the study. TN analysed the data, and all authors contributed to interpretations of the findings.
TN, LM, JK and MÅ drafted the manuscript and revised it critically for important intellectual content. All authors approved the final version submitted for publication.

E TH I C A L S TATEM ENT
The study was independently reviewed and approved by the Norwegian Centre for Research Data, reference number 49074. The research was carried out in accordance with the ethical principles outlined in the World Medical Association Declaration of Helsinki.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request. TA B L E A 2 Dimensionality of nurses' responsibility and interdisciplinarity