The Open Nursing Journal




ISSN: 1874-4346 ― Volume 13, 2019
RESEARCH ARTICLE

Barriers of Nurse Collaboration for the Care of Acute Coronary Syndrome Patients in Emergency Departments: A Pilot Study



Titin Andri Wihastuti1, Ida Rahmawati1, Septi Dewi Rachmawati1, Yulia Candra Lestari2, Kumboyono Kumboyono1, *
1 School of Nursing, Medical Faculty, Brawijaya University; Malang, East Java, Indonesia
2 School of Nursing, Kendedes Institute of Health Sciences; Malang, East Java, Indonesia

Abstract

Introduction:

Acute Coronary Syndrome (ACS) is a cardiovascular disease that is one of the main causes of death worldwide. Nurse collaboration in Indonesia is still very complex and inadequate. Positive collaboration in providing care for patients with ACS is essential in the practice of nursing services.

Objective:

This study aims to explore the barriers in the implementation of nurses-physicians collaboration for the care of patient with ACS in Emergency Departments (EDs).

Method:

This research is a qualitative survey using purposive sampling. It was conducted on 16 nurses who worked in emergency departments from four general hospitals in East Java, Indonesia. Research data were collected using open-ended questions in semi-structured interviews.

Results:

There were three themes obtained from the data analysis, which include the difference of confidence between senior and junior nurses in ACS actions, limitations in performing professional nursing, and unclear job responsibilities.

Conclusions:

Collaboration of nurses and physicians in emergency departments still faces many problems. It is important to carry out interprofessional education initiations for nursing and medical students, apply peer-mentoring to increase the self-confidence of junior nurse, develop and train the clinical pathway of collaboration between physicians and nurses for the care of ACS patients in EDs.

Keywords: Acute coronary syndrome, Collaboration, Emergency nursing, Interprofessional, Physician, Barriers.


Article Information


Identifiers and Pagination:

Year: 2019
Volume: 13
First Page: 60
Last Page: 65
Publisher Id: TONURSJ-13-60
DOI: 10.2174/1874434601913010060

Article History:

Received Date: 11/09/2018
Revision Received Date: 22/11/2018
Acceptance Date: 10/12/2018
Electronic publication date: 25/02/2019
Collection year: 2019

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© 2019 Wihastuti et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: (https://creativecommons.org/licenses/by/4.0/legalcode). This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the School of Nursing, Medical Faculty, Universitas Brawijaya, Indonesia; Tel: +6281805004106; Fax: +62 0341 564755; E-mails: abu_hilmi.fk@ub.ac.id, publikasikoe@gmail.com




1. INTRODUCTION

Collaboration among nurses, as well as between nurses and physicians is an important element of health care [1Souza GC, Peduzzi M, Silva JA, Carvalho BG. Teamwork in nursing: restricted to nursing professionals or an interprofessional collaboration? Rev Esc Enferm USP 2016; 50(4): 642-9.[http://dx.doi.org/10.1590/S0080-623420160000500015] [PMID: 27680051] ]. It is an essential method for improving the quality of health, safety, patient satisfaction and employment. Acute Coronary Syndrome (ACS) is a part of CHD (Chronic Heart Disease) which causes an increase of around 1.6% in morbidity and mortality [2Khoshchehreh M, Groves EM, Tehrani D, Amin A, Patel PM, Malik S. Changes in mortality on weekend versus weekday admissions for Acute Coronary Syndrome in the United States over the past decade. Int J Cardiol 2016; 210: 164-72.[http://dx.doi.org/10.1016/j.ijcard.2016.02.087] [PMID: 26950171] ]. Appropriate management based on guidelines is able to reduce death and morbidity related to ACS [3Mol KA, Rahel BM, Meeder JG, van Casteren BCAM, Doevendans PA, Cramer MJM. Delays in the treatment of patients with acute coronary syndrome: Focus on pre-hospital delays and non-ST-elevated myocardial infarction. Int J Cardiol 2016; 221: 1061-6.[http://dx.doi.org/10.1016/j.ijcard.2016.07.082] [PMID: 27448533] ]. ACS patients need quick and proper help when reaching to the Emergency Departments (EDs) due to the limitation of patients' golden period. Treatment of ACS patients in EDs should be based on collaboration because this is a complex case.

The nurse-physician collaboration system in Indonesian emergency room is very complicated. The system of collaboration consists of structure, process and results [4Siegler EL, Whitney FW, He Y, Guo Y. Nurse-physician Collaboration 2000.]. Structurally, nurses and doctors have agreed on the importance of collaborating in caring for ACS patients in EDs [5Liao C, Qin Y, He Y, Guo Y. The Nurse-Nurse Collaboration Behavior Scale: Development and psychometric testing. Int J Nurs Sci 2015; 2(4): 334-9., 6Smith A, Cone KJ. Triage decision-making skills: a necessity for all nurses. J Nurses Staff Dev 2010; 26(1): E14-9.[http://dx.doi.org/10.1097/NND.0b013e3181bec1e6] [PMID: 20098 163] ]. However, there are difficulties in carrying out the collaboration process. The collaboration process could be recognized by aspects of assertiveness, autonomy and cooperation [7Hudson PV, Marshall AP. Extending the nursing role in Emergency Departments: Challenges for Australia. Australas Emerg Nurs J 2008; 11(1): 39-48.[http://dx.doi.org/10.1016/j.aenj.2007.11.003] , 8Pfaff KA, Baxter PE, Jack SM, Ploeg J. Exploring new graduate nurse confidence in interprofessional collaboration: a mixed methods study. Int J Nurs Stud 2014; 51(8): 1142-52.[http://dx.doi.org/10.1016/j.ijnurstu.2014.01.001] [PMID: 24486164] ]. Indonesian nurses are only able to identify the signs and symptoms as well as the proper management of ACS. However, the nurses felt that autonomy was limited. A study conducted by Moore Weaver revealed that many nurses resigned because of the bad cooperation between nurses in the room as well as bad interpersonal relationships with medical teams [9Ortiz J. New graduate nurses’ experiences about lack of professional confidence. Nurse Educ Pract 2016; 19: 19-24.[http://dx.doi.org/10.1016/j.nepr.2016.04.001] [PMID: 27428687] , 10Yaman Aktas Y, Kucuk Alemdar D. Triage Decision-Making Levels of Healthcare Professionals Working in Emergency Departments. Eurasian J Emerg Med 2017; 16(3): 92-6.[http://dx.doi.org/10.5152/eajem.2017.96168] ]. This is in line with a literature review by Milton, which showed that the patterns of relationship and communication between nurses in the room are still lacking [11Moore LW, Leahy C, Sublett C, Lanig H. Understanding nurse-to-nurse relationships and their impact on work environments. Medsurg Nurs 2013; 22(3): 172-9.[PMID: 23865278] , 12Khademian Z, Sharif F, Tabei SZ, Bolandparvaz S, Abbaszadeh A, Abbasi HR. Teamwork improvement in emergency trauma departments. Iran J Nurs Midwifery Res 2013; 18(4): 333-9.[PMID: 24403932] ].

Collaboration between nurses and physicians has also attracted attention because physicians and nurses are essential in providing good quality health care. If there are problems related to the collaboration, they will affect the service performed [13Milton CL. Leadership and ethics in nurse-nurse relationships. Nurs Sci Q 2009; 22(2): 116-9.[http://dx.doi.org/10.1177/0894318409332569] [PMID: 19342708] , 14Almidani E, Khadawardi E, Alshareef T, Saadeh S. International Journal of Pediatrics and Departmentsal collaborative approach for improving in-patient clinical documentation (five years experiences) 2018; 1-6.]. Therefore, an evaluation of nursing management is needed in order to create a positive atmosphere. The purpose of this study is to explore the process barriers of nurses-physicians collaboration for the care of ACS patients in EDs. The novelty of the results of this study is expected to be able to answer the research question: “What are the obstacles to assertiveness, autonomy, and cooperation in the process of collaborating nurses-physicians for the care of ACS patients in EDs?

2. MATERIAL AND METHODS

This research used a qualitative survey. The design is used to establish the meaningful diversity of some topic of interest within a population [15Jansen H. The logic of qualitative survey research and its position in the field of social research methods [63 paragraphs]. Forum Qualitative Sozialforschung / Forum: Qualitative. Soc Res (New York) 2010; 11(2): 11.http://nbnresolving.de/urn:nbn:de:0114-fqs1002110]. In the context of this study, the topic of interest was exploring the barriers in the implementation of nurses-physicians collaboration for the care of the patients with ACS in Emergency Departments (EDs). The inductive analysis approach is applied to identify keywords, sub-themes and themes from the results of interviews with the participants. The research was conducted from September to December 2017 in emergency departments at four general hospitals, East Java, Indonesia. Sixteen nurse participants were recruited using purposive sampling. Purposive sampling is a selection participant technique based on predetermined criteria [16Wihastuti TA, Rachmawati SD, Kumboyono , Harista DR, Lestari YC, Rahmawati I, et al. Qualifications of Emergency Nurse in Caring the Acute Coronary Syndrome Patient: The Perspective of Rural Hospitals in Indonesia. Indian J Public Heal Res Dev 2017; 8(4)]. The recruited nurses as participants were those still actively providing services for ACS patients, having work experience in EDs for the last year, and having Basic Trauma and Cardiac Life Support (BTCLS) certificate. Participants who meet these criteria are selected until data saturation is reached.

2.1. Data Collection and Instrument

For collecting research data, the researcher used semi-structured interviews (Table 1). All interviews were audio-recorded using a smartphone. The researcher did not know the participants before. The selection of the participants was assisted by one of the nurses in the EDs. The interviews were conducted in the EDs based on the mutual agreement; the interview time was between 30 and 60 minutes. The ethical principle was applied in this study by ensuring confidentiality and providing equal opportunity as the study progresses.

2.2. Data Analysis

The researcher analyzed the data using the Van Kaam method to illustrate and interpret the meaning of process barriers experienced by nurses in collaborating with physicians for the care of ACS patients in EDs. The steps of Van Kaam data analysis are as follows: (a) create a list of participants' expressions or answers, (b) perform reduction and elimination of answers, (c) categorize and create sub-themes based on categories, (d) create validation and re-identifying sub-themes that have been determined, and ending with theme determination, (e) describe the text, which is the statement of each participant showing a phenomenon, (f) give a description of the structural meaning of how the phenomenon occurs, and (g) provide a narrative explanation of the essence of a phenomenon under study and gaining meanings of the participants' experience through the phenomenon. The results of the data analysis are presented in the form of charts and narratives [17Speziale HS, Streubert HJ, Carpenter DR. Qualitative Research in Nursing: Advancing the humnistic imperative 5th ed. 5th ed.2011; 470., 18Reiners GM. Nursing & Care Understanding the Differences between Husserl’s (Descriptive) and Heidegger’s (Interpretive). Phenomenological Research 2012; 1(5): 1-3.]. Keywords, sub-themes and themes of the meaning of participants' experience through the phenomenon are presented in tables and narratives to make them easier to understand.

3. RESULTS

The results of this study are answers to the research questions which are tied to the demographic characteristics of nurses as participants of the study. The characteristics of the participants who took part in this study were observed nurses who were aged from 25 years to 58 years; eight males and eight females; bachelor of science in nursing was five participants, and eleven participants had associate degree in nursing; five participants had worked in ED for less than or equal to ten years; eleven participants had worked greater than ten years, and all participants have a BTCLS certificate.

There are three themes in this research, which are (a) difference of confidence between senior and junior nurses in caring for ACS patients, (b) limitation for performing professional nursing practice, and (c) unclear nursing job description (Tables 2 to 4). The abbreviations (P1), (P2), (P3) in the text, represent Participant-1, 2, 3, etc.

3.1. Difference Of Confidence Between Senior And Junior Nurses In Caring For Acs Patients

The participants’ answers to the following questions demonstrated nurses’ assertiveness in their ability to care for ACS patients in EDs.

The question was, “What did you feel when handling ACS patients in EDs?”

The theme revealed the difference in readiness of the two groups namely senior and junior nurses in collaborating with physicians for the treatment of ACS patients in EDs. The results of interviews showed that Participant-4 and Participant-8 as senior nurses were assumed to make minimal mistakes in caring for ACS patients. The statements of Participant-4, Participant-9, Participant-11, and Participant-15 indicated that junior nurses were less confident and more confused when handling ACS patients (Table 2).

3.2. Limitation For Performing Professional Nursing Practice

Limitation for performing professional nursing practice illustrated the barriers innurse autonomy in collaboration with physicians for the care of ACS patients in EDs.

The question was, “What were the limitations of the authority that you experience in collaborating with physicians to treat with ACS patients in EDs?”

There were two subthemes of obstacles in the implementation of autonomy experienced by nurses for the care of ACS patients in EDs. First, the limited authority to address triage decision making was revealed by comment Participant-2 and Participant-7. Second, the limited chance of nursing documentation was shown by statement Participant-12 and Participant-15 (Table 3).

3.3. Unclear Nursing Job Description

The theme demonstrated the nurses' perceptions of the duty, which were formed after cooperating with health professionals in treating patients with ACS.

The question was, “How is the implementation of cooperation between health professionals for the care of ACS patients in EDs?”

The participant’s response to the question informed that nurses haven’t been able to cooperate with health professionals because of the obscurity of nurses’ job descriptions. The job duties among health workers remained overlapping and were stated by Participant-5, Participant-9, and Participant-11. The comments of Participant-4 and Participant-12 indicated that male nurses do more services than female nurses (Table 4).

Table 1
Themes, sub-themes, and participants’ statements.


Table 2
Themes, sub-themes, and participants’ statements about assertiveness barriers in collaboration implementation for the care of patient with ACS in emergency departments


Table 3
Themes, sub-themes, and participants’ statements about autonomy barriers in collaboration implementation for the care of patient with ACS in emergency departments


Table 4
Themes, sub-themes, and participants’ statements about cooperation barriers in collaboration implementation for the care of patient with ACS in emergency departments


4. DISCUSSION

4.1. Difference Of Confidence Between Senior And Junior Nurses In Caring For Acs Patients

Rapid response and responsiveness are important for helping patients in the ED. Therefore, it is important that nurses should be able to manage patients with ACS as well as to recognize the signs and symptoms [16Wihastuti TA, Rachmawati SD, Kumboyono , Harista DR, Lestari YC, Rahmawati I, et al. Qualifications of Emergency Nurse in Caring the Acute Coronary Syndrome Patient: The Perspective of Rural Hospitals in Indonesia. Indian J Public Heal Res Dev 2017; 8(4)]. This response can be done by senior and junior nurses. For senior nurses, this is not an obstacle because the nurses already have a longer clinical experience than the junior nurses. Agnew and Flin show that in difficult and emergency conditions, the role of senior nurses is needed to maintain patients’ safety and stability [19Joob B, Wiwanitkit V. Acute chest pain: what about the time before visiting to the physician? J Acute Dis 2013; 2(4): 330-1.[http://dx.doi.org/10.1016/S2221-6189(13)60154-7] ]. Unlike the newly enrolled registered nurses, although considered competent, they do not always feel confident to do so.

Professional confidence is very important for nurses in order to provide quality care for ACS patients at the emergency departments. Qualitative research conducted by Ortiz shows that the participants did not feel confident because they were unable to communicate well with the senior nurses, and made mistakes due to lack of experience. The support of managers in providing interpersonal collaboration opportunities and knowledge development opportunities can help increase nurses’ confidence in the collaboration [20Agnew C, Flin R. Senior charge nurses’ leadership behaviours in relation to hospital ward safety: a mixed method study. Int J Nurs Stud 2014; 51(5): 768-80.[http://dx.doi.org/10.1016/j.ijnurstu.2013.10.001] [PMID: 24200223] ].

4.2. Limitation For Performing Professional Nursing Practice

According to Souza et al., collaboration is an essential way of organizational practice to improve the quality of health, safety, patients’ satisfaction and employment [1Souza GC, Peduzzi M, Silva JA, Carvalho BG. Teamwork in nursing: restricted to nursing professionals or an interprofessional collaboration? Rev Esc Enferm USP 2016; 50(4): 642-9.[http://dx.doi.org/10.1590/S0080-623420160000500015] [PMID: 27680051] ]. The intended collaboration consists of interdisciplinary collaboration i.e. physicians with nurses and among nurses. A study Khademian indicated that cooperation can be achieved if it provides effectiveness, clarity of roles, effective patient management, and the ability to resolve the problem to the team members [8Pfaff KA, Baxter PE, Jack SM, Ploeg J. Exploring new graduate nurse confidence in interprofessional collaboration: a mixed methods study. Int J Nurs Stud 2014; 51(8): 1142-52.[http://dx.doi.org/10.1016/j.ijnurstu.2014.01.001] [PMID: 24486164] ]. In the service process, the nurses have a limitation in performing medical measures, but they are allowed to provide inputs or suggestions. A nurse as a working partner is allowed to provide input based on evidence and their knowledge. The importance of cooperation between nurses and physicians should be widely recognized. Improved communication and good information delivery have been reported to reduce medical errors [12Khademian Z, Sharif F, Tabei SZ, Bolandparvaz S, Abbaszadeh A, Abbasi HR. Teamwork improvement in emergency trauma departments. Iran J Nurs Midwifery Res 2013; 18(4): 333-9.[PMID: 24403932] , 13Milton CL. Leadership and ethics in nurse-nurse relationships. Nurs Sci Q 2009; 22(2): 116-9.[http://dx.doi.org/10.1177/0894318409332569] [PMID: 19342708] ].

One of the limitations of nurses in collaboration is related to triage decision making. In some countries in the Americas and Europe, decision making for triage can be done by nurses and a team of health professionals including physicians and nurses [5Liao C, Qin Y, He Y, Guo Y. The Nurse-Nurse Collaboration Behavior Scale: Development and psychometric testing. Int J Nurs Sci 2015; 2(4): 334-9., 6Smith A, Cone KJ. Triage decision-making skills: a necessity for all nurses. J Nurses Staff Dev 2010; 26(1): E14-9.[http://dx.doi.org/10.1097/NND.0b013e3181bec1e6] [PMID: 20098 163] ]. The right of a physician is to determine the patient's priority in the triage, but there are some physicians who do not want to receive nurses’ feedback when they make wrong triage decisions. This can lead to misunderstandings between physicians and nurses.

Another limitation that the nurses perceived is the writing of nursing care documentation. Nursing documentation is a part of the patient's medical record which is an important communication tool for health care providers [10Yaman Aktas Y, Kucuk Alemdar D. Triage Decision-Making Levels of Healthcare Professionals Working in Emergency Departments. Eurasian J Emerg Med 2017; 16(3): 92-6.[http://dx.doi.org/10.5152/eajem.2017.96168] ]. This research reveals that the documents that should be filled by nurses are sometimes still filled by specialists, which makes it difficult for nurses to do further nursing care. Almidani, Khadawardi, Alshaaref and Saadeh in their research show the need for a change from the quality management team to improving compliance with the clinical documentation despite many challenges. Major improvements can be achieved when collaboration and efforts involving stakeholders are set as common goals.

4.3. Unclear Nursing Job Description

Unclear nursing job is a frequent phenomenon that requires immediate solutions. Lack of clarity about the role performed requires some nurses to perform the same activities every day. Nurses feel uncomfortable with the unclear job divisions. Research conducted by Standing and Anthony [2008] indicates that nurses want clear task regarding components; delegation structure, delegation process, and communication [4Siegler EL, Whitney FW, He Y, Guo Y. Nurse-physician Collaboration 2000.].

Effective communication and relationship patterns are very important to be created in the crowded condition of the EDs. Research conducted by Moore Weaver found that many nurses are out of work because the relationship between nurses in the room is not well [9Ortiz J. New graduate nurses’ experiences about lack of professional confidence. Nurse Educ Pract 2016; 19: 19-24.[http://dx.doi.org/10.1016/j.nepr.2016.04.001] [PMID: 27428687] ]. This is in line with the literature review by Milton which indicates that the relationships and communication between nurses in the room are still not as expected [11Moore LW, Leahy C, Sublett C, Lanig H. Understanding nurse-to-nurse relationships and their impact on work environments. Medsurg Nurs 2013; 22(3): 172-9.[PMID: 23865278] ]. This delegation is only verbal, not written or legalized. The same opinion was expressed by Mueller and Vogelsmeier [2013] that the delegation process from middle manager to nurses or from physicians to nurses should be based on the basic principle of public protection [14Almidani E, Khadawardi E, Alshareef T, Saadeh S. International Journal of Pediatrics and Departmentsal collaborative approach for improving in-patient clinical documentation (five years experiences) 2018; 1-6.]. When used effectively, delegates can lead to safer and longer-time patient care for a registered nurse to deal with more complex patient care.

The next factor is the unclear job description of nurses. This study found that male nurses work more than female nurses. Research conducted showed that differences in motivation and skills between male and female have long been considered as an important factor in the gender gap, but this factor is difficult to measure [21Mueller C, Vogelsmeier A. Effective Delegation: Understanding Responsibility, Authority, and Accountability. J Nurs Regul 2013; 4(3): 20-7.[http://dx.doi.org/10.1016/S2155-8256(15)30126-5] ]. Significant changes occur due to increased female's participation in the workforce, assuming that females are more capable of solving problems, analyzing, and providing competitive encouragement, motivation, and sociability in relation to performance [22Muench U, Dietrich H. The male-female earnings gap for nurses in Germany: A pooled cross-sectional study of the years 2006 and 2012. Int J Nurs Stud 2017; (July): 1-7.[PMID: 28716298] ].

CONCLUSION

The results of the study showed that there were obstacles in three aspects of the collaboration process namely assertiveness, autonomy and cooperation in treating ACS patients in the emergency departments. Nurses, especially junior, assertively acknowledge their lack of confidence. Also, nurses experience autonomy limitations in making triage decisions and difficulty in documenting nursing actions. Nurses also experience obstacles in cooperating with both physician and fellow nurses to treat patients with ACS in the EDs. Based on the results, it is important to carry out inter-professional education initiations for nursing and medical students, apply peer-mentoring to increase the self-confidence of junior nurse, develop and train the clinical pathway of collaboration between physicians and nurses for the care of ACS patients in EDs. Further research is needed to develop a model of nurse-physician collaboration based on work culture and regulations regarding their role in EDs.

AUTHORS CONTRIBUTION

All authors contributed to the concept of the study, design, collection data, analysis data, and manuscript preparation.

FUNDING

This research was funded by Medical Faculty, Universitas Brawijaya.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

Ethics approval for this research has been obtained from the Medical Research Ethics Committee of Medical Faculty, University of Brawijaya, Malang, Indonesia, with letter number: 216/EC/KEPK/06/2017.

HUMAN AND ANIMAL RIGHTS

No animals/humans were used for studies that are the basis of this research.

CONSENT FOR PUBLICATION

Not applicable.

CONFLICT OF INTEREST

The authors declare that they have no conflict of interests in this research and article writing.

ACKNOWLEDGEMENT

The authors would like to thank all parties who have assisted in the completion of this article, especially to the supervisor.

REFERENCES

[1] Souza GC, Peduzzi M, Silva JA, Carvalho BG. Teamwork in nursing: restricted to nursing professionals or an interprofessional collaboration? Rev Esc Enferm USP 2016; 50(4): 642-9.[http://dx.doi.org/10.1590/S0080-623420160000500015] [PMID: 27680051]
[2] Khoshchehreh M, Groves EM, Tehrani D, Amin A, Patel PM, Malik S. Changes in mortality on weekend versus weekday admissions for Acute Coronary Syndrome in the United States over the past decade. Int J Cardiol 2016; 210: 164-72.[http://dx.doi.org/10.1016/j.ijcard.2016.02.087] [PMID: 26950171]
[3] Mol KA, Rahel BM, Meeder JG, van Casteren BCAM, Doevendans PA, Cramer MJM. Delays in the treatment of patients with acute coronary syndrome: Focus on pre-hospital delays and non-ST-elevated myocardial infarction. Int J Cardiol 2016; 221: 1061-6.[http://dx.doi.org/10.1016/j.ijcard.2016.07.082] [PMID: 27448533]
[4] Siegler EL, Whitney FW, He Y, Guo Y. Nurse-physician Collaboration 2000.
[5] Liao C, Qin Y, He Y, Guo Y. The Nurse-Nurse Collaboration Behavior Scale: Development and psychometric testing. Int J Nurs Sci 2015; 2(4): 334-9.
[6] Smith A, Cone KJ. Triage decision-making skills: a necessity for all nurses. J Nurses Staff Dev 2010; 26(1): E14-9.[http://dx.doi.org/10.1097/NND.0b013e3181bec1e6] [PMID: 20098 163]
[7] Hudson PV, Marshall AP. Extending the nursing role in Emergency Departments: Challenges for Australia. Australas Emerg Nurs J 2008; 11(1): 39-48.[http://dx.doi.org/10.1016/j.aenj.2007.11.003]
[8] Pfaff KA, Baxter PE, Jack SM, Ploeg J. Exploring new graduate nurse confidence in interprofessional collaboration: a mixed methods study. Int J Nurs Stud 2014; 51(8): 1142-52.[http://dx.doi.org/10.1016/j.ijnurstu.2014.01.001] [PMID: 24486164]
[9] Ortiz J. New graduate nurses’ experiences about lack of professional confidence. Nurse Educ Pract 2016; 19: 19-24.[http://dx.doi.org/10.1016/j.nepr.2016.04.001] [PMID: 27428687]
[10] Yaman Aktas Y, Kucuk Alemdar D. Triage Decision-Making Levels of Healthcare Professionals Working in Emergency Departments. Eurasian J Emerg Med 2017; 16(3): 92-6.[http://dx.doi.org/10.5152/eajem.2017.96168]
[11] Moore LW, Leahy C, Sublett C, Lanig H. Understanding nurse-to-nurse relationships and their impact on work environments. Medsurg Nurs 2013; 22(3): 172-9.[PMID: 23865278]
[12] Khademian Z, Sharif F, Tabei SZ, Bolandparvaz S, Abbaszadeh A, Abbasi HR. Teamwork improvement in emergency trauma departments. Iran J Nurs Midwifery Res 2013; 18(4): 333-9.[PMID: 24403932]
[13] Milton CL. Leadership and ethics in nurse-nurse relationships. Nurs Sci Q 2009; 22(2): 116-9.[http://dx.doi.org/10.1177/0894318409332569] [PMID: 19342708]
[14] Almidani E, Khadawardi E, Alshareef T, Saadeh S. International Journal of Pediatrics and Departmentsal collaborative approach for improving in-patient clinical documentation (five years experiences) 2018; 1-6.
[15] Jansen H. The logic of qualitative survey research and its position in the field of social research methods [63 paragraphs]. Forum Qualitative Sozialforschung / Forum: Qualitative. Soc Res (New York) 2010; 11(2): 11.http://nbnresolving.de/urn:nbn:de:0114-fqs1002110
[16] Wihastuti TA, Rachmawati SD, Kumboyono , Harista DR, Lestari YC, Rahmawati I, et al. Qualifications of Emergency Nurse in Caring the Acute Coronary Syndrome Patient: The Perspective of Rural Hospitals in Indonesia. Indian J Public Heal Res Dev 2017; 8(4)
[17] Speziale HS, Streubert HJ, Carpenter DR. Qualitative Research in Nursing: Advancing the humnistic imperative 5th ed. 5th ed.2011; 470.
[18] Reiners GM. Nursing & Care Understanding the Differences between Husserl’s (Descriptive) and Heidegger’s (Interpretive). Phenomenological Research 2012; 1(5): 1-3.
[19] Joob B, Wiwanitkit V. Acute chest pain: what about the time before visiting to the physician? J Acute Dis 2013; 2(4): 330-1.[http://dx.doi.org/10.1016/S2221-6189(13)60154-7]
[20] Agnew C, Flin R. Senior charge nurses’ leadership behaviours in relation to hospital ward safety: a mixed method study. Int J Nurs Stud 2014; 51(5): 768-80.[http://dx.doi.org/10.1016/j.ijnurstu.2013.10.001] [PMID: 24200223]
[21] Mueller C, Vogelsmeier A. Effective Delegation: Understanding Responsibility, Authority, and Accountability. J Nurs Regul 2013; 4(3): 20-7.[http://dx.doi.org/10.1016/S2155-8256(15)30126-5]
[22] Muench U, Dietrich H. The male-female earnings gap for nurses in Germany: A pooled cross-sectional study of the years 2006 and 2012. Int J Nurs Stud 2017; (July): 1-7.[PMID: 28716298]

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Robert Looney
(Naval Postgraduate School, USA)

"Open access journals have transformed the way scientific data is published and disseminated: particularly, whilst ensuring a high quality standard and transparency in the editorial process, they have increased the access to the scientific literature by those researchers that have limited library support or that are working on small budgets."


Richard Reithinger
(Westat, USA)

"Not only do open access journals greatly improve the access to high quality information for scientists in the developing world, it also provides extra exposure for our papers."


J. Ferwerda
(University of Oxford, UK)

"Open Access 'Chemistry' Journals allow the dissemination of knowledge at your finger tips without paying for the scientific content."


Sean L. Kitson
(Almac Sciences, Northern Ireland)

"In principle, all scientific journals should have open access, as should be science itself. Open access journals are very helpful for students, researchers and the general public including people from institutions which do not have library or cannot afford to subscribe scientific journals. The articles are high standard and cover a wide area."


Hubert Wolterbeek
(Delft University of Technology, The Netherlands)

"The widest possible diffusion of information is critical for the advancement of science. In this perspective, open access journals are instrumental in fostering researches and achievements."


Alessandro Laviano
(Sapienza - University of Rome, Italy)

"Open access journals are very useful for all scientists as they can have quick information in the different fields of science."


Philippe Hernigou
(Paris University, France)

"There are many scientists who can not afford the rather expensive subscriptions to scientific journals. Open access journals offer a good alternative for free access to good quality scientific information."


Fidel Toldrá
(Instituto de Agroquimica y Tecnologia de Alimentos, Spain)

"Open access journals have become a fundamental tool for students, researchers, patients and the general public. Many people from institutions which do not have library or cannot afford to subscribe scientific journals benefit of them on a daily basis. The articles are among the best and cover most scientific areas."


M. Bendandi
(University Clinic of Navarre, Spain)

"These journals provide researchers with a platform for rapid, open access scientific communication. The articles are of high quality and broad scope."


Peter Chiba
(University of Vienna, Austria)

"Open access journals are probably one of the most important contributions to promote and diffuse science worldwide."


Jaime Sampaio
(University of Trás-os-Montes e Alto Douro, Portugal)

"Open access journals make up a new and rather revolutionary way to scientific publication. This option opens several quite interesting possibilities to disseminate openly and freely new knowledge and even to facilitate interpersonal communication among scientists."


Eduardo A. Castro
(INIFTA, Argentina)

"Open access journals are freely available online throughout the world, for you to read, download, copy, distribute, and use. The articles published in the open access journals are high quality and cover a wide range of fields."


Kenji Hashimoto
(Chiba University, Japan)

"Open Access journals offer an innovative and efficient way of publication for academics and professionals in a wide range of disciplines. The papers published are of high quality after rigorous peer review and they are Indexed in: major international databases. I read Open Access journals to keep abreast of the recent development in my field of study."


Daniel Shek
(Chinese University of Hong Kong, Hong Kong)

"It is a modern trend for publishers to establish open access journals. Researchers, faculty members, and students will be greatly benefited by the new journals of Bentham Science Publishers Ltd. in this category."


Jih Ru Hwu
(National Central University, Taiwan)


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