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BMJ. Apr 15, 2000; 320(7241): 1022–1023.
PMCID: PMC1117929

What's so great about collaboration?

We need more evidence and less rhetoric
Merrick Zwarenstein, healthcare researcher
Health Systems Research Unit, Medical Research Council, PO Box 19070, South Africa 7505 ; az.ca.crm@nietsnerawz.kcirrem
Scott Reeves, researcher

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.911 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.

Notes

General practice pp 1038, 1043, 1048, 1053

References

1. Department of Health. A first class service. Quality in the new NHS. London: Stationery Office; 1998.
2. Stein L. The doctor-nurse game. Arch Gen Psychiatry. 1967;16:699–703. [PubMed]
3. National Joint Practice Commission. Guidelines for establishing joint or collaborative practice in hospitals. Chicago: Neely; 1981.
4. Baggs JG, Schmitt MH, Mushlin AI, Mitchell PH, Eldredge DH, Oakes D, et al. Association between nurse-physician collaboration and patient outcomes in three intensive care units. Crit Care Med. 1999;27:1991–1998. [PubMed]
5. Hughes D. When nurse knows best: some aspects of nurse/doctor interaction in a casualty department. Sociol Health Illness. 1988;10:1–22.
6. Walby S, Greenwell J, Mackay L, Soothill K. Medicine and nursing: professions in a changing health service. London: Sage; 1994.
7. Larson E. The impact of physician-nurse interaction on patient care. Holistic Nurs. 1999;13:38–47. [PubMed]
8. Porter S. Nursing's relationship with medicine. Avershot: Avebury; 1995.
9. Jitapunkul S, Nuchprayoon C, Aksaranugraha S, Chalwanichsiri D, Leenawat B, Kotepong W. A controlled clinical trial of multidisciplinary team approach in the general medical wards of Chulalongkorn Hospital. J Med Assoc Thai. 1995;78:618–623. [PubMed]
10. Curley C, McEachern JE, Speroff T. A firm trial of interdisciplinary rounds on the inpatient medical wards. Med Care. 1998;36(suppl):AS4-12. [PubMed]
11. Zwarenstein M, Bryant W. Interventions to improve collaboration between nurses and doctors. In: Bero L, Grilli R, Grimshaw J, Oxman A, Zwarenstein M, eds. Cochrane Collaboration on effective professional practice module of the Cochrane database of systematic reviews. In: Cochrane Collaboration. Cochrane Library. Issue 2. Oxford: Update Software, 2000.

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