Doctors and nurses: doing it differently

The time is ripe for a major reconstruction

The relationship between doctors and nurses has never been straightforward. The differences of power, perspective, education, pay, status, class, and - perhaps above all - gender have led to tribal warfare as often as peaceful coexistence. Nurses' readiness to be slighted and doctors' reluctance to be challenged create an undercurrent of tension. This may be masked in practice settings by the pressing need to get the work done, but it is there.

The newly arrived interplanetary traveller might find this puzzling. Two groups of people sharing an apparently identical goal, to serve patients, might be assumed to get along well. They might also be assumed to have some interest in exploring the relationship if it needs maintenance. But in reality, although a major reconstruction is now required, sensible debate between doctors and nurses is scarce.

The actors positions were reversed on the two journals

The prime minister, determined to convert the NHS from a liability to an election winner, is not only overseeing the reform process personally but intends to bang heads together in his "dialogue with the professions".¹ Longstanding boundary disputes about roles and responsibilities, more recently thrust into the foreground by the reduction of junior doctors' hours and its impact on nursing, are hot political issues.^2-4

Research evidence

How are the professions responding? The research shows that nurses can do some of what doctors do, usually to the greater satisfaction of patients.^5-8 The research also shows that nurse consultation over the phone can safely reduce hospital admissions for both adults and children and save NHS costs and that there seem to be high levels of satisfaction with NHS Direct, a system of nurse run telephone triage.^9,10 Some of the commentators think medicine is not changing, or only reluctantly, or that change is being imposed from outside by political expediency. Others argue that nursing has changed substantially in the past 20 years and, sacrificing many of its best values and practices, has lost its way. There seems to be a sense that the core dynamic is the same: nursing, for all its new independence and expertise, is still dancing around the medical maypole.

These are complex issues, too often reduced to crude simplification because the relationship is so emotionally charged. Nurses, more assertive, educated, and competent than ever before, resent what they see as continuing put downs by a profession holding all the cards. Doctors, puzzled and unaccustomed to being challenged, are themselves resentful at the apparent undervaluing of their competence, knowledge, and skill by nurses, the public, and policymakers. Everyone is confused.

For decades we understood the professions as a conventional nuclear family, with doctor-father, nurse-mother, and patient-child. But our hope for total wisdom and protection from father is forlorn, our wish for total comfort and protection from mother unachievable, and the patient has grown up. A new three way partnership should displace this vanishing family.

Changes in relationships within health services are, of course, being driven by broader changes. Women are increasingly powerful in most sectors, and the medical profession now includes many more women. At each level of the medical hierarchy women now make up a higher proportion than they did a decade ago, and this trend will probably accelerate. This offers the potential for different kinds of relationship and practice and starts to undermine the equation of female sex with low status.

How can the professions forge good working relationships in a context where an opportunity for one becomes a threat to the other? Commitment to open minded dialogue from both professions' leaders would be a good starting point. They need to understand how the past is shaping the present and tackle the inequalities that still mediate the relationship.

Letting go of the resentment

Only by letting go of the resentments can we start a dialogue on how the talents and commitment of doctors and nurses can be harnessed to improve services for patients. Such a dialogue would have far reaching implications. We need to rethink training, regulation, and pay. Perhaps the starting assumption should be that one system applies to all, with variation only where necessary. It would clarify how everyone today, irrespective of background, needs new skills. It would stimulate overdue reform of hidebound in stitutions, whether regulatory bodies or royal colleges.

Perhaps most importantly, it would refocus the debate about what doctors and nurses do. Instead of boundary disputes and substitution squabbles effort could be directed towards capitalising on the wealth of skills that all professionals can bring to bear on solving health problems. This fresh approach to the division of labour puts the patient at the centre for the first time.

Jane Salvage, nursing director, Emap Healthcare, Nursing Times, London NW1 7EJ

Richard Smith, editor, BMJ


studentBMJ 2000;08:175-216 June ISSN 0966-6494

1. Prime Minister. House of Commons official report (Hansard) 2000 March 22:cols 981-4. (www.publications.parliament.uk/pa/cm199900/cmhansrd/cm000322/debtext/00322-04.htm#00322-04_spm)
2. Beecham L. UK health secretary wants to liberate nurses' talents. BMJ 2000;320:1025.
3. Beecham L. NHS workforce planning must be integrated. BMJ 2000;320:1025.
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5. Shum CM, Humphreys A, Wheeler D, Cochrane MA, Skoda S, Clement S. Practice nurse-led management of patients with minor medical conditions: a randomised controlled trial. BMJ 2000;320:1038-43.
6. Kinnersley P, Anderson E, Parry K, Clement J, Archard L, Turton P, et al. Who should see the extras? A randomised controlled trial of nurse practitioner versus general practitioner care for patients requesting "sameday" consultations in primary care: process and outcomes. BMJ 2000;320:1043-8.
7. Venning P, Durie A, Roland M, Roberts C, Leese B. Randomised controlled trial comparing cost effectiveness of general practitioners and nurse practitioners in primary care. BMJ 2000;320:1048-53.
8. Iliffe S. Nursing and the future of primary care. BMJ 2000;320:1021-1.
9. Lattimer V, Sassi F, George S, Moore M, Turnbull J, Mullee M, et al. Cost analysis of nurse telephone consultation in out of hours primary care: evidence from a randomised controlled trial. BMJ 2000;320:1053-7.
10. O'Cathain A, Munro JF, Nicholl JP, Knowles E. How helpful is NHS Direct? Postal survey of callers. BMJ 2000;320:1035.