Understanding Collaboration Between Nurses and Physicians as Knowledge at Work

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Conclusion

Collaboration requires recognition that knowledge and work are intimately related. A smooth, effortless flow of work gives the impression that knowledge bases are shared between nurses and physicians and that the work is mutually understood and supported. The clinical situation of ICU patients with confusion is a good illustration of how knowledge and work are not exchanged or mutually understood. The model of case, patient, and person knowledge illuminates how physicians and nurses operate by using different types of knowledge, partly because the 2 groups are engaged in different kinds of work. When knowledge bases are not understood, are dismissed, or cannot be communicated, professional boundaries are reinforced and management of a patient is relegated solely to nurses.

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A problem that initially appeared as a problem in patients that called for interdisciplinary collaboration became solely the nurses’ problem. In the absence of a way to communicate knowledge other than case knowledge, the nurses and physicians’ mutually shared ground from which to work disintegrated. When the physicians exhausted their case knowledge about how to solve the problem, they felt they had nothing else to offer and left the management to the nurses. Sadly, the walking away was often accompanied by a devaluation of nurses’ work. Relational work is often confused with sentimentality and attributed to nurses’ meeting their own needs rather than the needs of a patient.

Collaboration between nurses and physicians involves the seamless flow of work when the collaboration is based on case knowledge or when patient knowledge is not contested. Case knowledge provides a false sense of certainty or, at least, minimal ambiguity. We have proposed a way of conceptualizing collaboration that includes the kinds of knowledge used in the care of patients and the factors that influence the kind of knowledge brought to bear. Circumstance shapes the use of knowledge and location binds knowledge in particular ways, thus relegating some knowledge to the foreground and some to the background, while other knowledge is rendered invisible.

In the circumstances of ICU patients with confusion, collaboration became problematic because case knowledge was not sufficient in doing the work of diagnosing the condition and managing the patients. When nurses explicitly sought help from their medical colleagues in these less-than-ideal circumstances, the nurses often felt abandoned, rejected, or ignored.

nurse

Employing a model of the different types of knowledge used in different kinds of work provides a valuable schema for extending the view of nurse-physician collaboration. The lack of valuing patient knowledge, and an unwillingness to understand this type of knowledge, is historically rooted in hierarchies of knowledge, gendered work, and protocols of behavior between nurses and physicians that remain relevant today. Collaboration remains a problematic and serious issue because the stakes are high not only for patients’ outcomes but also for professional identity. Collaboration is a matter of knowledge and a matter of morality.⁵⁴

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ACKNOWLEDGMENTS

We thank Dr Kim Walker, who provided useful comments on an earlier draft of this article. Also, we thank the journal reviewers whose constructive comments were valuable in the preparation of an improved manuscript. The research described was undertaken while Dr Stein-Parbury was a PhD student at the University of Adelaide. The location of the site where the research was done remains confidential because of research ethics.