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.

This has prompted Nursing Times and the BMJ to try to advance the discussions. When we conceived this project nearly 18 months ago, we had no inkling that it would be so topical. Now 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 contributions to both journals this week, ranging from research to analysis to opinion, display a multitude of perspectives. 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.

In preparing our joint issues we have had the invaluable help of a guest editor who belongs to neither tribe but who is a close observer and critical friend of both. Celia Davies, professor of health care at the Open University, argues that the stranglehold of gender thinking must be loosened and the old doctor-nurse stereotypes must go.¹¹

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.

As we asked in our joint editorial last August,¹² 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 which 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 institutions, 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.