The literature on physician–nurse collaboration often laments the poor relationship between the professions, emphasizing anger, conflict,20,35,36
and differences in attitudes towards collaboration.16–19,37–40
By contrast, this study focused on successful physician–nurse interactions, illuminating the synergistic, positive, affective dimensions of successful collaboration.
The power of affect seen in these narratives suggests two concepts. First, successful collaboration may have transformative potential, especially for early collaborators. An episode that begins with the professional entering a patient care situation feeling worried, insecure or inadequate is transformed, ending with the professional feeling gratitude, often combined with relief and pleasure, for a job well-done.
Second, some narratives recalled events from training and early practice that continued to affect current practice, suggesting that early collaboration experiences may be formative, producing life-long collaboration expectations, attitudes and behaviors.
The nurses who participated in this study were predominantly US born and educated, and had years of experience, while the physicians were primarily international medical graduates in residency training. The differences in worldview that one might have expected from these discrepancies in age, experience, gender, ethnicity and profession16–19
make this study’s discovery of overlapping affective themes surprising, as many qualities of the affective experience were actually shared across the professions. What might account for this finding?
First, the results of any study are shaped by the methods chosen for exploration. Many studies of collaboration have used pre-determined surveys, while others have used ethnographic approaches. By virtue of their design, they may be more likely to amplify differences or uncover areas of conflict. Conversely, this study using Appreciative Inquiry solicited only success stories, making negative or discrepant experiences less likely to surface.
Second, although there were some differences in the narratives, many writers reported strong affective experiences, with uncertainty and vulnerability as central themes. Given an open-ended opportunity to share these experiences, it is not so surprising that physicians and nurses, entering into an interaction with similar feelings, would, on reflection, produce narrative coherence in terms of created and shared meaning.
Most importantly, based on gender and professional stereotypes and preconceptions, one might anticipate that affective experiences would be more common among the nurses than the physicians, but this was not the case. Despite the fact that the residents were 50% male and nearly 100% IMGs, the affective component was apparent more often in their narratives than in those of nurses, 98% of whom were female. The affective trigger for the residents was most often a sense of vulnerability and inadequacy. This theme of vulnerability and fear of making mistakes with dire personal consequences also appeared in a previous qualitative study involving IMGs, and it may be an implicit theme common in their early professional lives in the US.41
One might also expect that affective dimensions of collaboration would differ between seasoned professionals and novices of either profession, with affect diminishing as experience grows. In this study group, nurses could be categorized more often than residents as “seasoned.” However, the most important components influencing the affective dimensions of collaboration were not found in the age, gender, profession or ethnicity of the participants. Instead, they resided in the individual’s personal sense of competence and confidence or, conversely, uncertainty and vulnerability, and the extent to which a professional identity had been formed. Taken together, these two factors may account for the convergence in the experiences described.
Another aspect of the affective dimension of collaboration may have stemmed from the narrative setting most common in the residents’ stories, the ICU. The literature on physician–nurse collaboration in the ICU is one of inter-professional conflicts.37–40
Yet 60% of resident stories about successful collaboration took place in the ICU setting, paradoxically suggesting that the tensions particular to the ICU may represent fertile ground for teaching and modeling effective, successful collaboration. Evening and night duty for nurses, and night float experiences for residents may be of similar importance.
The formative nature of early collaboration coupled with the settings most often cited in the narratives (ICU and off-hour shifts) have educational and practice implications. Since high stress, high stakes environments appear to offer unique opportunities for cross-disciplinary support, education and cooperation, interventions could be profitably focused in those arenas. Combined ICU nurse–physician patient care rounds could create opportunities to teach and model collaboration, and to do both formative and summative evaluations of these skills for physicians and nurses. Creating the systemic expectation that nurses be included in ICU family meetings could facilitate development of collaboration skills. Routinely integrating physicians and MD-RN collaboration assessment into near-miss conferences, root cause analyses and case conferences could create opportunities to operationalize the principles of collaboration and to review and improve team functioning. Integrated MD-RN evening and night sign-out rounds could represent another high-yield opportunity.
Lastly, gratitude or thanks for the collaborating colleague appears in many of the narratives. Experience would suggest that gratitude is rarely expressed. Based on the findings of this study and the intensity of this dimension of the affective experience, encouragement of its expression would be appropriate.
Collaborative competence was another critical theme identified in our analysis. Collaboration has been defined as “nurses and physicians cooperatively working together, sharing responsibilities for solving problems, and making decisions to formulate and carry out plans for patient care.”15
Elsewhere in the nursing literature, collaboration, coordination, cooperation and mentoring are all considered as separate behaviors. Our analysis suggests that these might be best recognized as collaborative behaviors along a developmental continuum. Viewing collaboration in this way, relational skills between professionals play a seminal role and can, at times, trump clinical skills, placing an interaction into the “high order” collaboration category. Conceptualizing high level collaboration as “high order” characterizes the interaction in the language of energy and kinetics, in this instance, with fluidity, flexibility, synchronicity and intuition simultaneously operative on both clinical and relational levels.
Collaboration can be conceptualized as a series of graduated skills on a developmental continuum, which also suggests the notion of collaborative competence. Our data suggest that collaboration is not the exclusive province of the seasoned professional who is clinically sophisticated, but also happens at the novice level. Collaboration is not specifically addressed by most curricula. Instead nurse–physician collaboration attitudes and skills are deeply imbedded in the hidden curriculum of medical education and practice.49
If the concept of collaborative competence were generally accepted, the educational focus would shift from high level clinical skills to include equally important relational skills.42,43
This comes at a time when the relationship-centered care model44,45
and Watson’s “caring theory46
are gaining increasing recognition in medicine and nursing. Extending the focus on relationship to the nurse–physician dyad suggests a parallel process47
between successful collegial relationships and successful patient care.
We propose, as have others,48
that collaboration be considered a competency area, with attendant implications for nursing, medical education and staff development. We have observed that collaboration takes place in two principal domains, clinical and relational, which are known to be teachable and learnable. Given the fact that ours was a small study in an unrepresentative sample, additional confirmatory research will be needed to make this concept viable on a wider scale.