Interprofessional collaboration between nurses and doctors for treating patients in surgical wards

ABSTRACT

Interprofessional collaboration will be one of the main factors in the effort to increase patient safety in the coming years. Research has identified several challenges to interprofessional collaboration between nurses and doctors, where fragmentation of both education and clinical practice contributes to a strong affiliation to one’s own profession with little emphasis on collaboration. The aim of this study was to generate more knowledge about how nurses and doctors experience interprofessional collaboration in observation and treatment of patients on a surgical ward. The study was conducted in 2018 and used an explorative qualitative design that was based on four semi-structured focus group interviews. The respondents were 11 nurses and seven doctors with experience from different surgical specialties and employed in three different surgical wards in a Norwegian hospital. The data were analyzed using systematic text-condensation. The following three main categories, each with two subcategories, emerged: 1) Organization and culture: a lack of interprofessional meeting places and experience-based hierarchy; 2) Communication: use of communication tools and little room for professional discussions; and 3) Trust and respect: dependence and recognition and a blurred distribution of responsibility. Both nurses and doctors wished for closer interprofessional collaboration in observation and treatment in the surgical ward; however, organizational limitations with few interprofessional meeting places and time pressure made this difficult.

KEYWORDS:

• Communication
• doctor
• interprofessional collaboration
• nurse
• role clarity
• qualitative method

Introduction

Interprofessional collaboration is viewed as one of the main factors that could help increase patient safety in the coming years (Aase et al., 2016; Reeves et al., 2009). The World Health Organization (WHO) published the Framework for Action on Interprofessional Education and Collaborative Practice in 2010. This highlighted that the use of interprofessional teams in treatment can contribute to reducing mortality and reduce undesirable events and complications for patients (World Health Organization, 2010). The focus on patient safety has intensified in recent years. Through the national patient safety program, the Norwegian Health Directorate set a goal for reducing patient injuries using targeted measures throughout the health service (Health Directorate, 2017). Through a scheme requiring the notification of undesirable incidents to the Ministry of Health and Care Services, it is estimated that one in ten patients may experience one unwanted event in connection with hospitalization. The greatest risk factors associated with these events are ineffective care processes, poor communication and lack of documentation (Ministry of health and Care Services, 2015).

Interprofessional collaboration in healthcare is characterized as the process of different professional groups working together (on a common task or a joint project), to positively impact patientcare. This collaboration involves regular negotiation and interaction between professionals, valuing the expertise and contributions that various disciplines bring to patientcare (Reeves et al., 2017; Willumsen, 2016). Professionals view problems differently and from different perspectives because their professions are based on different knowledge traditions (Willumsen, 2016). In health institutions, interprofessional collaboration is a complex process. Reeves et al. (2010) studied interprofessional collaboration in primary care and highlighted four main theoretical factors that influence this complexity: relational, procedural, organizational and contextual. The relational factors address what directly affects the relationship between the professions, such as team processes, hierarchy and professional struggles. The procedural factors include the complexity of the working environment and the time allocated for cooperation. Organizational factors are important in rooting collaboration in management and common goals, whereas contextual factors address the influence of cooperation on, among other things, culture and gender role patterns.

In effective interprofessional teams, the professions have knowledge of each other’s roles and a common understanding of tasks and goals (Aase, 2017; Gordon & Walsh, 2005; MacDonald et al., 2010; Tan et al., 2017), while the ability to plan and reflect, communicate clearly and have effective routines in critical situations is also highlighted (Frankel et al., 2017). Effective interprofessional cooperation is closely linked to a working environment characterized by a flat structure, where the various professions can contribute their views on patient treatment equally without fear of criticism (Frankel et al., 2017; Tan et al., 2017; Tang et al., 2013).

However, research shows that health institutions are often hierarchically structured, with a traditional understanding of the role of medical doctors still prevailing among health personnel (Aase, 2017; Tang et al., 2013). Both the education system and medical institutions help maintain the hierarchy, with critics arguing that the fragmentation of both education and clinical practice contributes to a strong connection to one’s own profession with little focus on interprofessional collaboration (Aase et al., 2016; Almås et al., 2017). Such culture contributes to the major challenges that remain in creating good interprofessional teams (Aase, 2017).

In the spring of 2015, an improvement project began on surgical wards in a Norwegian hospital, with the aim of increasing the focus on patient safety by providing health personnel with a common framework for observing and reporting on patients’ clinical condition. In surgical wards, many of the hospitalized patients have multiple medical conditions and require close follow-up by several different practitioners, with nurses and doctors closest to the patient during treatment. Doctors on surgical wards have many duties outside the ward, including in the operating room and in the outpatient clinic. In addition, the wards have high patient turnover and are constantly under time pressure. Overall, these factors can help make interprofessional collaboration and communication between nurses and doctors extremely challenging. In order to structure and ensure the quality of both observations and communication in patient treatment, the observation tool NEWS (National Early Warning Score) (Royal College of Physicians, 2012) and the communication tool ISBAR (identification, situation, backround, analysis and recommendation) (Leonard et al., 2004) were implemented in the wards.

NEWS is an internationally well-known and validated observation tool, where vital parameters are measured through a risk chart. NEWS was developed to more easily identify patients in clinical deterioration (Royal College of Physicians, 2012, 2017; Smith et al., 2013). Through a risk chart, vital parameters are measured, and the patient is scored using a number system. If the score increases, the frequency of observations should be increased; for a total score above five, the nursing staff should seek the help of a doctor in assessing the patient (Royal College of Physicians, 2012, 2017; Smith et al., 2013). The use of ISBAR contributes to structured and clear communication between health professionals. It provides a common and predictable way of communicating, which in addition to potentially reducing misunderstandings, makes both the sender and receiver responsible through reflection on the patient’s situation (Leonard et al., 2004; De Meester et al., 2013). The purpose of the study was to generate knowledge about how nurses and doctors on surgical wards experience interprofessional collaboration in observation and treatment of patients. This knowledge is relevant to increasing the focus on and improving interprofessional collaboration in specialist health services and is transferable to other areas where interprofessional collaboration between nurses and doctors takes place.

Research question

How do nurses and doctors on surgical wards experience interprofessional collaboration in the observation and treatment of patients?

Methods

Research design

The study used an explorative qualitative design. This design is suitable for seeking new insight into research fields that are complex and relatively unknown (Malterud, 2012). The study was based on semi-structured focus group interviews of nurses and doctors employed on three different surgical wards at a Norwegian hospital. A focus group interview is an appropriate method for exploring phenomena that apply to common experiences, attitudes or views in an environment where many people interact. The collective verbal exchange can bring forth a wider range of views than in individual interviews (Malterud, 2012; Polit & Beck, 2017).

Data collection

The sampling was strategic and consisted of 11 nurses and seven doctors. The work experience of the nurses varied between zero and 30 years, with a mean of 6.7 years. The work experience of the doctors varied between zero and 30 years, with a mean of 11.7 years. Both genders were represented in both professions. The inclusion criteria were that the respondents had clinical experience in different surgical specialties such as urology, vascular surgery and gastroenterological surgery. These criteria were adopted with an eye toward obtaining rich data guided by the research question (Malterud, 2012; Polit & Beck, 2017). The participants were recruited in cooperation with the section leaders for both nurses and doctors. A notice was mailed to all employees with information about the study and a request for their participation. An additional selection was used to recruit doctors by asking some to participate directly, as their workdays were unpredictable, and several participants were unavailable on short notice. Four focus group interviews were carried out, two with each profession (Table 1). In the two nursing groups, there were five and six participants respectively, and three and four participants in the two doctor groups.

Table 1. Sample characteristics (n= 18)

Profession	Year of work experience	Code	Profession	Year of work experience	Code
Nurse	0– 2	N1	Junior doctor	5 −10	D1
Nurse	0– 2	N2	Senior doctor	15– 30	D2
Nurse	2– 4	N3	Senior doctor	15– 30	D3
Nurse	15– 30	N4	Junior doctor	5– 10	D4
Nurse	15– 30	N5	Senior doctor	15– 30	D5
Nurse	2– 4	N6	Junior doctor	0– 2	D6
Nurse	2– 4	N7	Junior doctor	0– 2	D7
Nurse	0– 2	N8
Nurse	0– 2	N9
Nurse	2– 4	N10
Nurse	2– 4	N11

The focus group interviews were performed during spring 2018. The interviews followed a thematic interview guide with open questions (Table 2). A moderator and a secretary conducted the interviews. The moderator was the first author of the study. The moderator was responsible for asking questions and managing the discussion and interaction flow of the group. The secretary wrote down the participants` statements based on their names, in addition to digital recording. This was done to ensure that the right participant was quoted correctly (Malterud, 2012). The length of each interview was approximately 60 minutes. The interviews were conducted in a meeting room separated from the daily activity of the hospital and were recorded on a digital audio recorder. The interviews were transcribed verbatim in anonymous form as soon as they were completed. The first author transcribed the data, and both authors read and developed the transcribed text. The authors` preunderstanding as nurses, contributed to an awareness of a continued need for revising, questioning and broadening the critical reflection during the analysis.

Table 2. Thematic interview guide

Interprofessional collaboration	What is your experience of interprofessional collaboration in your ward?
	What do you think promotes interprofessional collaboration?
	What do you think inhibits interprofessional collaboration?
	Does the ward culture encourage positive feedback? How?
	What significance do you think interprofessional collaboration has in patient safety work?
Observation and treatment of patients	What is your experience of support and help from those you collaborate with in situations with patients with clinical deterioration?
	What do you think could have helped identify and prevent clinical deterioration in patients?
	In relation to interprofessional reporting of patients with clinical deterioration, what is your experience of communication between the professions?
	What do you think are important issues to report regarding patients with clinical deterioration?
	Do other professions use terminology that can be difficult to understand?
Professional differences	Can you give concrete examples of how your professional knowledge is important in your interprofessional collaboration?
	What is your experience of sharing different opinions and views across the professions?
	When a conflict arises due to different professional backgrounds, how do you resolve this?
	How does the management in your department facilitate interprofessional collaboration?
	What is needed for interprofessional collaboration to develop in a good way?

Data analysis

The data were analyzed using systematic text-condensation (Malterud, 2012). The analysis was inspired by Giorgi’s psychological phenomenological analysis (Giorgi, 2012), particularly the analysis step and phenomenological method. In the STC, the phenomenology of the subjectivity context is important, but the emphasis is on the recognition and significance of the researcher’s point of view as a prerequisite for situational knowledge (Malterud, 2012b). The method is appropriate for thematic transverse analysis of qualitative data, as it can be used for different types of data with varying degrees of theoretical anchoring. The analysis is inductive and aims to develop knowledge based on the respondents’ experiences. The analysis was carried out in 4 steps: 1) obtaining an overall impression of the data, 2) identifying meaning-forming units, 3) abstracting the content of the meaning-forming units, and 4) summarizing the meaning of the content (Malterud, 2017). Table 3 gives an example of the steps of the analysis and a clarification of terms.

Table 3. Example of analyzing steps and clarification of terms

Meaning unit	Condensation – meaning unit	Subgroup	Main category
«Yes, it must be concrete. What is it about? No small talk, the doctors are in a hurry. They expect you to come quickly to the point. That is, at least my experience. If I start with too much explanation about a previous course, they become impatient».	Important to report the patient’s problem to the doctors in a structured and concrete fashion	Use of communication tools	Communication
«NEWS has made it easier to become more concrete and clearer in the messages to the doctors. It also makes us more aware of what can cause clinical deterioration; the NEWS score makes it easier for us “.	Use of ISBAR and NEWS has contributed to improvement in interprofessional communication
“It’s a hindrance to collaboration that the doctors often lack time. Before a doctor’s rounds, they flip through the patient’s medical papers in a hurry and say; next patient ».	The doctors’ rounds are so brief that the nurses often do not have time to ask their questions	Little room for professional discussions
«There may be a slightly higher threshold for some nurses, depending on previous experience, in relation to asking questions and increasing their own understanding in medical issues. Inexperienced nurses can be very reticent».	The doctors view the nurses’ level of experience as important in professional discussions

Ethical considerations

The Norwegian Social Science Data Services (NSD, No.57952) approved this study. Informed voluntary consent was ensured through written and oral information and a request for voluntary participation. The participants were informed that they could withdraw from the study at any time. The privacy of the participants was strictly protected, and all the information shared has been treated confidentially. The study investigated collaborative partners in clinical practice, and it was therefore important to use discretion and rigorous ethical standards with respondents who shared information on their knowledge and daily lives (Malterud, 2012).

Findings

The analysis resulted in the following three main categories, with two subcategories for each category: 1) Organization and culture: a lack of interprofessional meeting places and experienced-based hierarchy; 2) Communication: use of communication tools and little room for professional discussions; and 3) Trust and respect: dependence and recognition and a blurred distribution of responsibility.

Organization and culture

Lack of interprofessional meeting places

Nurses and doctors from the surgical wards reported that the doctors’ ward rounds were the only scheduled meeting points between the professions during the day. One senior doctor stated that only a few doctors were present in the rounds, while the others had work tasks outside the wards, in operating rooms and the outpatient clinic. The nurses experienced the rounds as short, often with several interruptions, and they felt a need for more time to thoroughly review the patients’ problems. Additionally, there was often only telephone contact between the professions throughout the day. The exception was that the doctors might be asked to supervise patients experiencing clinical deterioration during the day. Both professions stated that they felt that physical distance inhibited interprofessional cooperation. They felt that actively having to contact one another by telephone often made the contact feel formal.

Several nurses stated that establishing a routine where the doctors on evening and night shifts visited the wards to obtain an overview of the patients could help improve both collaboration and patient treatment. The nurses said they often had many questions that they did not ask because they did not feel the questions were serious enough to warrant a telephone call. One nurse said:

What you don’t need to know now, can always wait. However, perhaps it could still help patient treatment to get an answer? It could be easier to ask the small questions (N5).

The respondents said that there was no culture of common internal education, deviation or departmental meetings for nurses and doctors on the surgical wards. It was only the leaders of both professions on certain wards who had joint meetings on ward operations. Several of the nurses and doctors called for a common arena for professional development, with a senior doctor stating:

It is a little strange that we and the nurses have internal education on the same day, but no one has thought that we should have something in common (D3).

One nurse suggested that several interprofessional meetings could encourage more focus on working together toward a common goal.

Experience-based hierarchy

Several of the doctors felt there was a certain hierarchy within their own profession but that it varied and was more distinct on some surgical wards than on others. They did not describe this hierarchy as unilaterally negative but rather expressed the view that an experience-based hierarchy could be both natural and healthy. A junior doctor said:

Regardless of which profession you belong to, the views of a more experienced colleague should weigh more heavily than those of someone with less experience. Despite this, everyone should be able to express their opinion and question the patient treatment (D1).

Other junior doctors stated that creating a space for everyone to express their views was not always easy as it was often the doctor with the most experience who had the breakthrough in discussions. They felt it could be difficult to implement a treatment themselves and defend it when questioned.

The nurses stated that collaboration around patient treatment was easiest during the day when the regular doctors were at work. When there were unknown doctors on evening and night shifts, the nurses felt it could be difficult to obtain support for their concerns about patient observations. They believed that the doctors’ experience and knowledge of the patient group was important for patient treatment, especially in discussions about the need to transfer patients to a high dependency unit (HDU) or intensive care unit (ICU). One nurse said, “Whether or not a patient is transferred to the HDU or ICU often depends on who asks” (N5). Both senior and junior doctors confirmed that competence and experience level could be important in these transfers. A junior doctor stated:

It is quite clear that calling a friend who has a little more competence and rank helps. It helps to arrange space in the ICU (D6).

The doctors also believed that the nurses’ level of experience was important to patient treatment. One junior doctor said he believed inexperienced doctors received more pressure from experienced nurses than did senior doctors. He suggested that the reason for this was that the inexperienced doctors had less “influence and authority”. He said: ‘Experienced nurses don’t take no for an answer, if they feel confident in their observations’ (D4). Nevertheless, the doctors in this study agreed that they valued the expertise of the experienced nurses and that they often relied on them.

Communication

Use of communication tools

The nurses in the study noted the importance of reporting patients’ problems clearly and precisely to doctors. They found that the more specifically they were able to communicate a patient’s problems and changes in their clinical condition, the faster they received help for the patient. One nurse said: “Doctors are in a hurry, so they expect you to get quickly to the point” (N3). The doctors mentioned having to address constant simultaneous crises and said that they therefore had no opportunity to familiarize themselves with all the patients’ problems but could only attempt to pick out the patients with critical clinical deterioration. The quality of the communication between the two professions was critical for patient treatment, especially since priorities were often set over the telephone. One senior doctor said: “You must depend on the information you get” (D3). In some situations, a junior doctor said he received telephone calls where he did not understand what the nurse wanted. He stated: “I get phone calls where I wonder, what do you wish to achieve, what are you trying to say?” (D7).

Both nurses and doctors mentioned that the ISBAR communication tool had helped structure the interprofessional communication through telephone calls. The nurses said that although they did not completely follow the ISBAR procedure, they found that the tool could contribute to a more structured and thoughtful conversation, which in turn helped convey the core of the patient’s problem and its urgency. One nurse stated:

Take a moment and decide what to say before you call, do not just pick up the phone and figure out what to say, and you also will get better help (N8).

The nurses highlighted the implementation of NEWS and noted this tool also helped them report to doctors in a more structured and clear fashion about patients with clinical deterioration. Several doctors pointed out a positive change in nurses’ way of reporting vital parameters using NEWS. They felt the observation tool had contributed to a common language, which led to both professions gaining a more common understanding of the situation. The doctors perceived NEWS as a safer system, especially in communication with inexperienced nurses. They also reported that the use of NEWS had contributed to the nurses taking all the vital parameters before calling and having that data on hand when they presented patients’ problems. A senior doctor explained:

Now they know the values of the patient’s blood pressure, heart rate, respiration rate and saturation before they call. Parameters that are important for us to know, to decide the patient treatment (D5).

Little room for professional discussions

The nurses in the study said they thought it was important in interprofessional collaboration that they were heard and taken seriously when speaking to a doctor. If the doctors were open to questions, the nurses felt that the threshold for asking was lower. This could affect whether they asked questions. Several doctors said they wanted to be more available to answer nurses’ questions and thought it was important to have time to hear them and to learn the details of patient observations. The nurses felt they had the opportunity to ask questions about the doctors’ decisions and orders regarding patient treatment on their ward. In interprofessional discussions, the nurses felt they could influence patients’ treatments if they argued well for themselves, but to do so, they had to feel safe regarding the topic of discussion. Inexperienced nurses who felt insecure about their own competence said they often found it difficult to discuss patient treatment with the doctors. Inexperienced nurses were perceived as quiet and restrained; they also “retreated“ more often into discussions within their own discipline. A junior doctor said they would often ”throw out a few questions” to obtain a nurse’s response to help clarify the patient’s condition and the urgency of the issue. A senior doctor remarked:

I feel collaboration is easiest with independent and confident nurses who have strong opinions and come with them. I find it easier to discuss patients’ treatments then (D3).

Several nurses said that if they disagreed with a doctor’s decision, it helped if the doctor took the time to explain the decision and that this could prevent misunderstandings between nurses and doctors. A junior doctor pointed out that many aspects of medical treatment are complicated and not self-explanatory and that it is easier to understand and learn if one understands the reasons for decisions.

Trust and respect

Dependence and recognition

The doctors in the study agreed that they depended on the nurses’ observations to give patients the right treatment. One doctor said:

The nurses see the patients over time and have the continuity of the observations, while doctors are bedside for a moment (D1).

Therefore, the nurses’ perceptions of patients were considered important, and good information flow between the professions was viewed as crucial for capturing changes in patients’ clinical conditions. Several nurses said they often observed changes in patients’ conditions that were difficult to see and describe. Reporting on these patients was challenging for the nurses because the doctors often wanted specific data on changing vital parameters and not just a nurse’s gut feeling. A nurse said: “But if you have both, then you really have something” (N4).

Both nurses and doctors often perceived the limited number of available beds in the HDU and ICU units as problematic. This was stressful for both professions. Several nurses stated that they often felt they had an ICU unit on the wards. They experienced this situation as unsafe and frightening, and they sometimes felt they alone were responsible for critically ill patients. When nurses relayed their concerns to doctors, they were often told to simply wait and see. An experienced nurse said:

Doctors may realize that the patient has deteriorated, but they do not always realize how limited the resources are when we are two nurses on a night shift. It is often here the disagreement occurs, when you feel the patient is too unstable to be treated on a ward (N4).

The doctors had had discussions with nurses regarding patients’ conditions and the appropriate time to transfer patients to the HDU or ICU. A junior doctor said that due to a limited number of beds in these units, they had to distinguish between those who were acutely ill and those who were stable. A senior doctor said:

We often agree with the nurses about the monitoring level of the patients, but this can also lead to discontent and disagreement. The responsibility for these patients may lead to uncertainty and an increased workload for the nurses on the ward (D5).

Blurred distribution of responsibility

The nurses in the study found it challenging to reach the doctors who were responsible for their patients, especially during evening and night shifts. They often found that the doctors were busy with patients on other wards, in the operating room or in the emergency unit. Often, the nurses were passed on to other doctors. Nurses said they lacked guidelines regarding which doctors were responsible for what. An inexperienced nurse said:

I really don’t know who I should call, as I often get the answer no; then, call someone else … and then you spend a lot of unnecessary time (N2).

This lack of clear guidelines contributed to insecurity, and the nurses experienced stress when they had difficulty reaching the responsible doctor. The doctors mentioned having to address simultaneous crises but said that it should always be possible to contact a doctor on the telephone for assistance in assessing a patient’s condition.

Several nurses stated that sometimes they chose to call several doctors if they felt unsure of the answer they received from the first, to obtain a “second opinion”. The doctors were rarely informed of this practice. One nurse said:

This practice may not be okay with regard to the hospital system, but it is being done because of patient safety considerations, since the nurses on the wards often know both the patients and the procedures better than an unknown doctor on call (N9).

A senior doctor in the study felt this practice could affect cooperation with nurses negatively and that when nurses asked questions about patient treatment, they had to accept the answer and not ask another doctor the same questions. Several doctors had experienced this practice and found it problematic to learn that changes had been made to a treatment about which they had not been informed. This was experienced as a trust issue. They pointed out that medicine does not always have a single answer but there are often several ways to solve a problem. A doctor explained:

It’s better if the nurses are honest if they do not agree with the treatment, instead of appearing to agree and later asking another doctor (D3).

Discussion

The purpose of this study was to gain more knowledge about how nurses and doctors on surgical wards experience interprofessional collaboration in patient treatment. The findings of the study showed that interprofessional collaboration between the professions was characterized by few joint meeting places and little time for collaboration. Clear and structured communication between nurses and doctors had an impact on the quality of patient care, and mutual trust and respect in interprofessional collaboration was important for both professions.

This study found that interprofessional collaboration on the investigated surgical wards were affected by the fact that the doctors had many work tasks outside the wards, which means that the professions had few planned interprofessional meeting places during the workday. The professions worked together but with little integration. Heldal (2013) describes this organization of collaboration as working autonomously in a parallel manner and notes that it helps create parallel practice. Both nurses and doctors in the study found that lack of cooperation led to a feeling that it was “us and them“ and not a holistic team. Reeves et al. (2010) describe procedural factors, such as allocated time and space, as some of the main facilitators for creating interprofessional collaboration in a complex working environment. Interprofessional collaboration was perceived as most effective on a daily basis when the permanent staff was at work. The wards in the study organized pre-visit and doctors’ ward rounds jointly for both nurses and doctors, where they discussed treatment plans before visiting patients together. The ward round was considered the most important venue for information exchange about patients and ”face-to-face” communication between the professions. Collette et al. (2017) and Tang et al. (2013), who highlight the importance of involving both nurses and doctors, also note the importance of ward rounds. The nurses in this study recognized the importance of this common routine but found that it left little time to elaborate on patients’ problems and needs. In addition, the nurses experienced many interruptions, as well as having to wait for doctors. The doctors believed that having many simultaneous crises was the cause of interruptions and delays, and not unwillingness on their part. Reeves et al. (2009) note that doctors often prioritize their own profession’s specific activities over interprofessional rounds, which can mean that other colleagues must wait. Other interprofessional meeting places for nurses and doctors were limited. The respondents called for a common venue for professional development. Few common interprofessional arenas can make it difficult to develop knowledge of each other’s roles and a common understanding of tasks and goals (Aase, 2017; Collette et al., 2017; Tang et al., 2013). Relational factors such as role clarification are considered important in defining the different responsibilities of the professions and can help avoid issues such as transgressions of professional boundaries (Dahl & Crawford, 2018; Reeves et al., 2010).

Research describes health institutions as hierarchically structured (Aase, 2017; Heldal, 2013). This finding is consistent with those of this study, but our findings indicate that the hierarchy is not only professional but also experience-based. The positive side of this structure is that it can contribute to patient safety through the support of an experienced colleague, regardless of profession. Nevertheless, the respondents believed that the hierarchy could make it difficult to comment freely on patient treatment. Aase et al. (2016) and Leonard et al. (2004) write that hierarchical structure may cause health professionals to abstain from communicating their opinions, and this can limit valuable contributions to patient treatment. Reeves et al. (2010), who write that changes in organizational and contextual factors are necessary to create equal interprofessional teams, noted this risk as well. Such changes should be rooted in the organization’s leadership (Reeves et al., 2010).

Both nurses and doctors in this study agreed that clear and structured communication between the professions was essential in sharing information about patients. This finding is consistent with previous research. Reeves et al. (2010) write that open and clear communication between the professions is crucial to delivering patient care in a safe and effective manner. Research on interprofessional communication between nurses and doctors, on the other hand, shows challenges to such communication. Among other things, the professions’ different knowledge backgrounds contribute to different communication patterns. Nurses often communicate in an orderly and narrative manner, while doctors’ communication is characterized by being short and concise (Aase et al., 2016; Tan et al., 2017).

The findings in this study indicated that nurses and doctors experienced different patterns of communication between the professions. The doctors believed it could be challenging to gain clarity on what the nurses wanted to achieve in conversations and wanted clearer reporting on vital status to prioritize patients’ degree of urgency. The nurses were aware of the doctors’ need for concise reports but considered it difficult to report on patients exhibiting subtle changes that were difficult to describe specifically. Research shows that doctors’ response in acute situations largely depends on nurses’ communication being clear and based on concrete evidence (Guhde, 2014; Smith, 2010; Tan et al., 2017). Massey et al. (2009), on the other hand, claim that nurses’ communication is often based on emotions and is not sufficiently concrete in communicating physiological abnormalities.

Research shows that the use of communication tools can help balance the differences in the ways in which the professions communicate (Leonard et al., 2004; Lydon et al., 2016; World Health Organization, 2007). The findings in this study showed that both professions saw the value of using both ISBAR and NEWS and that use of these tools had contributed to improving interprofessional communication through a common language. The doctors believed that the use of NEWS in particular had improved communication with inexperienced nurses. The use of NEWS gives an increased focus on objective physiological observations and helps nurses routinely take multiple measurements of patients’ vital parameters (Royal College of Physicians, 2012, 2017). When nurses have a greater focus on physiological mechanisms and report more specifically about physiological abnormalities, professional discussions with doctors can become more equal (Leonard et al., 2004; De Meester et al., 2013). Several studies, on the other hand, show that many nurses refuse to converse with doctors and do not have the confidence to express their opinions, especially regarding theoretical knowledge (Aase et al., 2016; Massey et al., 2009). The nurses in this study reported that they could influence doctors’ decisions and orders but that to do so they must feel safe in their collaboration with the doctors and the topic of discussion. Inexperienced nurses often lack this security and have a greater need for doctors’ support and explanations of medical terminology. Collin et al. (2012), in contrast, maintain that doctors do not usually explain their orders if they are not asked directly. This contradiction can lead to important questions in medical treatment not being asked.

Findings in Aase et al. (2016) show that both nurses and doctors express the wish that nurses would be more active and directly involved in interprofessional discussions. This finding is consistent with the findings of this study, in which the doctors stated that they cooperated best with independent nurses who clearly conveyed their opinions. This finding may indicate that both doctors and nurses want more equal collaboration between the professions. This finding was somewhat surprising and contradicts several other studies, which show that doctors often do not value the independent opinions of nurses and consider nurses responsible only for carrying out doctors’ orders (Reeves et al., 2009; Tan et al., 2017; Tang et al., 2013). There are many indications that this culture is gradually changing and that the role of the nurse is developing toward more independence (Currie et al., 2010; Eriksson & Müllern, 2017; Niezen & Mathijssen, 2014).

One of the primary nursing tasks on surgical wards is observing patients. According to Massey et al. (2017), the first person to observe changes in a patient’s condition and the development of the course of a disease is usually a nurse. Nurses’ perceptions about patients were considered important information by the doctors in this study. Research shows that doctors’ interest in nurses’ opinions and suggestions for patient treatment is important for nurses to feel they have doctors’ confidence and respect (Tan et al., 2017; Tang et al., 2013). The nurses in this study reported that doctors had confidence in their assessments of patients’ conditions, but they also may disagree on patient treatment. Nurses do not have the authority to initiate treatment or request diagnostic examinations, so they depend on communicating a patient’s situation to the doctor responsible for treatment (Aase et al., 2016). The nurses experienced insecurity regarding their own expertise and lack of resources in relation to some patients and felt that doctors did not always understand this. This finding is consistent with previous research showing that nurses regularly experience lack of medical response even though they both make and share relevant observations (Martland et al., 2016; Tan et al., 2017; Tang et al., 2013). Doctors understood the nurses’ stressful situation but were also responsible for treating patients based on medical needs. These contradictions could lead to stress and challenge the trust between the professions, which is also confirmed in Martland et al. (2016).

Clarification of roles is important to define the tasks and responsibilities of the various professions, which can clarify their expectations of each other (Pullon, 2008; Reeves et al., 2010; Tan et al., 2017). The nurses in this study noted that they had trouble determining which doctors were responsible for their patients. Several nurses lacked clear guidelines on which doctor to call. The doctors believed, however, that the guidelines were clear and that the nurses could always contact a responsible doctor on the telephone. These findings may indicate that some responsibilities have not been clarified between the professions. Research shows that both doctors and nurses can be selective regarding colleagues with whom they want to communicate (Tan et al., 2017). Doctors often want to work with experienced nurses to obtain better-quality information about patients, and nurses prefer to communicate with doctors who know the patient group to obtain clear guidance on treatment (Martland et al., 2016; Tan et al., 2017). In this study, these findings were highlighted by the fact that nurses, in the face of unfamiliar doctors, often consulted several doctors about the same issue due to lack of confidence. Weller et al. (2011) also describe this practice. Pullon (2008) writes that trust and respect develop over time and are strongly connected to the perception of professional competence. The doctors believed that open and honest dialogue with the nurses about disagreements could contribute to strengthening the trust and collaboration between the professions and to more professional discussions.

Methodological considerations

Qualitative research methods are well-suited to providing knowledge of human characteristics and experiences and are appropriate in exploring dynamic processes, such as interaction and development (Malterud, 2017). Using Lincoln and Guba (1985) four evaluative criteria of trustworthiness, the rigor of these methods was confirmed. The sample in the study is strategic and represented by respondents who know the current topic. Their information strength is important for the study’s internal validity. Use of quotes and referrals to the respondents’ statements also helps strengthen the validity of the study (Malterud, 2017). In this study, both genders are represented in both professions. Differences in gender roles are not elucidated, as this is not the focus of the study; it could be a topic for a future study.

This study was conducted with the use of focus group interviews. The professions were interviewed separately, which is a strength as the respondents can freely express themselves without the influence of, for example, respect and hierarchy. Through individual interviews, other aspects of the topic could have emerged, as group dynamics can affect respondents’ statements (Malterud, 2017). This study was performed in surgical wards at a hospital and had a relatively small number of respondents, which may present challenges to the transferability of the findings. However, the findings may be transferable to other settings where interprofessional collaboration between nurses and doctors take place. The first author of this study knows the research field from her own clinical practice, and this proximity can contribute to a pre-understanding of the results. Reflectiveness is required in that one’s own point of view must be recognized and considered throughout the research process (Malterud, 2017). Transparency of the analysis has been attempted by explaining the steps in the analysis process (Lincoln & Guba, 1985).

Conclusion

Both the nurses and doctors in this study want closer interprofessional collaboration in observation and treatment of patients on surgical wards, and the importance of both professions’ input in patient treatment is recognized. Nevertheless, our findings indicate that traditional organization and culture contribute to the fact that nurses and doctors still work more in parallel than together, and few common meeting places and time pressure hinder collaboration. Professional discussions on patients’ conditions are often limited to short telephone calls, and the quality of the communication is considered crucial to prioritizing patient treatment. Combined, these factors contribute to nurses and doctors having little knowledge of each other’s competence and responsibility, which can challenge mutual trust and respect between the professions. The complexity of the activities, as well as a deep-rooted culture, make interprofessional collaboration difficult to achieve. Further research that focuses on how traditional organization and culture in hospitals affects interprofessional collaboration among nurses and doctors is therefore necessary to increase understanding in this area. This can help develop more theoretical models but also more practical models to improve conditions for collaboration among professionals.

Declaration of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

Acknowledgments

The authors would like to thank the participants of the study for sharing their experiences with us.

Additional information

Funding

We thank NTNU, Norway for their support.