A recent white paper on the NHS strongly recommended improved teamwork between professionals.1 On what basis? How well do nurses and doctors collaborate? Does it matter to anyone? And if it matters, can it be improved? The short answer to all of these questions is: We don't know.
The modern concern with interactions between doctors and nurses began with an opinion piece in a psychiatric journal in 1967. It likened the relationship to a game, a power struggle. The two professions were occupying the same patient care “space,” but they communicated indirectly and manipulatively, with little warmth or mutual support—like a bad marriage.2
One response has been to reallocate tasks between the professions, and this week's journal reports several studies of such substitution. They contribute to the growing literature on the success of specialisation and delegation as strategies for avoiding the problems of collaboration.
The other response has emphasised joint decision making as the route to better patient care and professional relationships. This idea of nurse-doctor teamwork last received serious attention in the report of the US National Joint Practice Commission, published 20 years ago.3 Little has been heard of either the report or nurse-doctor collaboration since then. Undoubtedly, many reasons exist for this, but one is surely the absence of empirical research on the effects of interventions aimed at achieving teamwork.
A Medline search on the MESH term “interprofessional collaboration,” including the terms “doctor” and “nurse,” produced more than 1000 articles. Almost all were rhetorical or editorial, with some offering explanatory hypotheses or sociological theories. There were few empirical studies of the nature of the interactions, conflicts, and collaborations between nurses and doctors.
Two studies, by the same author, have reported an association between poor collaboration in intensive care units and poor patient outcome.4 Turning to cause, some studies have reported power differentials and uncoordinated or interrupted communication of patient care information as problems.5,6 Despite the paucity of evidence, two narrative reviews of the literature have concluded that problems with collaboration are common and widespread.7,8
With regard to improvements, two trials and a systematic review have evaluated the impact of joint nurse-doctor ward rounds on patient outcomes.9–11 Tantalisingly, these two trials hint that working more closely together may be worth while, but we know too little to glibly assert that collaboration has a positive value. To develop and evaluate interventions aimed at improving nurse-doctor collaboration, we will, as ever, need more research.
References
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