Knowledge and agency in interprofessional care: How nurses contribute to the case-construction in an Intensive Care Unit

ABSTRACT

This paper focuses on the epistemic and interactional resources displayed by nurses participating in medical case construction and the ways through which they make a difference in the unfolding of this activity. This paper draws on an ethnographic research in an Italian Intensive Care Unit (ICU) selected according to a purposeful sampling approach out of a national sample of 40 ICUs participating in a larger research project. Our dataset, collected over a period of six months of ethnographic observations, consisted of the observers’ field notes and log-books, audio and video-recordings of morning briefings, in-depth interviews, informal conversations and shadowing of bedside practices. For the purpose of this article, we analyzed the video-recorded morning briefings, involving nine attending physicians and three specialized nurses. Adopting a conversational analysis approach, this paper identifies the epistemic activities through which the nurses orient the physicians’ ongoing reasoning. It illustrates how the nurses’ contributions display different degrees of agency depending on the type of activity, the turn taking and the turn design. We contend that the nurses’ interactional competence in managing their epistemic resources and rights related to their professional territory of knowledge makes their knowledge relevant and contributes in constituting the case construction as an interprofessional activity. Implications, limitations and suggestions for future research are discussed.

KEYWORDS:

• Conversational analysis
• intensive care unit
• interprofessional collaboration
• management of knowledge
• medical case construction
• nurses’ contributions

Acknowledgments

This article has been written within the framework of the national research project PHENICE (Phenomenology of infectious diseases in Intensive Care Units) financed by the Mario Negri Institute for Pharmacological Research (Milan, Italy) and coordinated by Doctor Guido Bertolini, MD. The ethnographic study has been coordinated by Letizia Caronia (University of Bologna) and Luigina Mortari (University of Verona). Giuseppina Messetti and Roberta Silva (University of Verona) and Marco Pino (Loughborough University) participated in the data collection and analysis. We wish to thank all ethnographic team members for their collaboration in data collection and analysis. We also wish to thank the medical and nursing staffs of the ICUs where we conducted the fieldwork for their essential collaboration in data collection and interpretation. We are most grateful to Kathy Metzger for revising our English text. We wish to thank Scott Reeves and the anonymous reviewers for their extremely valuable suggestions and accurate editing of our manuscript.

Declaration of interest

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental data

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Notes

1. By signaling the trouble and correcting it, participants break the “progressivity of the interaction” (i.e. its unproblematic and unnoticed flow, see Stivers & Robinson, 2006, p. 367) to restore mutual understanding or negotiate a commonly accepted version of what they are talking about (i.e. they engage in defending intersubjectivity, Schegloff, 1992). Depending on who repairs what and how, “some repair sequences often serve as vehicles for the expression of disagreement, or for introducing its relevance” (Schegloff, 2007, p. 151) and open up a sequence of conflict talk (Schegloff, Jefferson, & Sacks, 1977).

2. From a strictly interactional point of view, a question is a strong move (Bolden, 2009; Boyd & Heritage, 2006). However, from an epistemic point of view and with the exception of questions checking the addressee’s possession of information (e.g. the didactic question), asking displays the speaker’s lower knowledgeable position (Heritage, 2012) relative to the addressee who is – by definition - assumed to be in K+ position (Heritage, 2012). Thanks to their different work on the interactive and epistemic sides of interaction, questions (and answers) are among the major tools for the management of knowledge in conversation and the consequent (re)distribution of power (Tracy & Robels, 2009).