“What do you want to do?”: expertise tension and authority negotiation in emergency nurse–physician interactions

Collaborative work represents a communicative context in which organizational actors navigate the blurring of knowledge and authority boundaries as they address complex problems. This article theorizes about expertise tension that arises when individuals with valuable insights lack corresponding authority to act, or vice versa. Using observations and interviews, we studied how physicians and nurses navigated this tension in problem-solving situations in a hospital emergency department. We found that nurses, who identified emergent problems, simultaneously asserted their situational authority and displayed a veneer of deference by asking physicians, “What do you want to do [in this situation]?” The question prompted one of three problem-solving activities (i.e., instruction by demand, reversed instruction, and collaborative improvisation) depending on the situation’s urgency and ambiguity. We discuss how nurses and physicians managed expertise tension without undermining their different claims to expertise and authority, highlighting the value of a communication-centered view in examining such dynamics.