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. 2000 Sep 16;321(7262):698.

Doctors and nurses

Let's celebrate the difference between doctors and nurses

Patrick White 1
PMCID: PMC1118566  PMID: 10987782

Editor—The BMJ issue on doctors and nurses does not define or describe nursing but repeatedly talks about nurses doing doctors' jobs.1 The predominance of the theme of substitution of doctors' work by nurses undermines the ideas of multidisciplinary working, cooperation, and collaboration that also feature in this issue. Unless doctors are clearer about the role of nurses in health care, discussions about their relationships with nurses will appear patronising and uninformed.

The importance of difference emphasised by Davies frames the debate.2 This idea should be the foundation of the utility of the relationship between doctors and nurses. But following Davies's paper, every article strives to seek common ground between medicine and nursing, with nurses seen primarily as an economic substitute. This continues until the final personal view by Radcliffe, which, with admirable symmetry, closes the debate opened by Davies.3 But, between their two papers, who is actually celebrating the difference?

As a general practitioner I do expect nurses to do the things I dislike doing more cheaply and more efficiently. I expect nurses to take on the tasks they do better than me and to share the tasks they do equally well. Sometimes nurses are less costly because nurse training is shorter and the opportunity to specialise can therefore come earlier. We should be thinking of the most cost effective services we can provide.

If the relation between medicine and nursing is really to bear fruit then medicine will have to recognise more explicitly that nurse training prepares different professionals. In their letter Laurent et al epitomise the need for a more penetrating conceptualisation of the nursing role in talking about substituting nurses for doctors to improve quality and optimise the (cost) effectiveness.4

Davies highlights the importance of difference—it is not what people have in common but their differences that make collaborative work more powerful. I look forward to a BMJ and Nursing Times collaboration that celebrates the difference.

References

  • 1.Doctors and nurses. Special joint issue with the Nursing Times. BMJ 2000;320 (7241). (15 April.)
  • 2.Davies C. Getting health professionals to work together. BMJ. 2000;320:1021–1022. doi: 10.1136/bmj.320.7241.1021. . (15 April.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Radcliffe M. Doctors and nurses: new game, same result. BMJ. 2000;320:1085. . (15 April.) [PMC free article] [PubMed] [Google Scholar]
  • 4.Laurent M, Sergison M, Halliwell S, Sibbald B. Evidence based substitution of doctors by nurses in primary care? BMJ. 2000;320:1078. . (15 April.) [PMC free article] [PubMed] [Google Scholar]
BMJ. 2000 Sep 16;321(7262):698.

Teamwork is not about everyone trying to do the same job

Derek Roskell 1

Editor—Beecham reports the government's 10 point challenge on nursing skills.1-1 Effective teamwork between doctors and nurses need not entail one group taking over the work of the other. Members of genuine teams have distinct roles and do not compete to do the same tasks. Not everyone working on an aeroplane participates in flying it. Bus conductors and drivers do not fight over who tings the bell and who holds the steering wheel.

Why, then, is it that the only way anyone seems able to perceive doctors and nurses working more closely is by nurses taking on the role of a doctor? Anyone who has been in hospital knows that good nursing is priceless, promoting healing in its widest sense. The thrust of much of the debate, and the implication of the proposals put forward by the health secretary, Alan Milburn, is that “traditional” nursing cannot be a rewarding career. No wonder recruitment is difficult. I find former nurses everywhere. Most are caring people who have left reluctantly because they feel their basic nursing is undervalued—by managers, by some doctors, but also by the nursing profession itself.

Mr Milburn has implied that nurses should not be seen as working for doctors. There is definitely a role for specialist nurses, and I would support a fast track for able nurses into and through medical school. But we are approaching a situation in some departments where a doctor cannot ask a nurse to do anything. Some new style nurses are more interested in listening to the patient's chest than making sure he or she has something to vomit into. Frequently, nursing observations are not followed through lack of staff or time. This is not teamwork: it is doctors and nurses unproductively duplicating work. Meanwhile we see junior doctors, who are temporary team members wherever they work, treated as unwelcome intruders into someone else's territory. I know of many doctors working long hours on units where they are not even provided with a stool to sit on, while other “team members” enjoy whole offices, sitting rooms, and a secure supply of chocolates.

I hope for three things to come from this debate.

Firstly, as it is no longer the role of nurses to work for doctors, we need to create another group of healthcare workers whose role this is. Perhaps this is a niche for (paid) medical students.

Secondly, we should value the different contributions of individuals within healthcare teams.

Thirdly, we all need to learn the true meaning of teamwork.

References

BMJ. 2000 Sep 16;321(7262):698.

Who will do nurses' current tasks?

Dave Anderson 1

Editor—It is all well and good for the government to say that new roles should be undertaken by nurses, but who is going to do the current jobs that nurses are required to do?2-1 Do we simply employ more care assistants, as they are cheaper than qualified staff, and return to the two tier system in nursing that the conversion of enrolled nurses was supposed to remove?

Junior doctors are stretched, and reallocating some of their roles will undoubtedly ease their workload. But what about the ward nurses? There can often be only one or two trained nurses caring for up to 40 patients at a time. Will more money be made available to increase these shortfalls before dumping others' workloads on an already overburdened service?

References

BMJ. 2000 Sep 16;321(7262):698.

Why liberation is necessary

Jayne Lunn 1

Editor—I should like to suggest a few answers to the questions posed in the Editor's choice of the special joint issue with the Nursing Times: “Why . . . is a government minister having to liberate nurses 52 years into the health service? What's he liberating them from?”3-1 Perhaps the minister recognises that nurses need to be freed from the white, male, middle class culture that has so dominated health care for the past century or more. The analogy drawn by the editor between nurses and prostitutes to illustrate the differing balance of responsibility and power—that nurses have the former but not the latter, the converse of what he perceives as the case for prostitutes—only confirms that he subscribes to this culture. The audience (“university educated”) would naturally realise that prostitutes have no power. It lies in the hands of the men that use them.

Smith then describes the divisions between doctors and nurses as including sex, background, philosophy, training, regulation, money, status, and intelligence. There is no doubt that doctors receive more money and have greater status, but where is the evidence that they come from different backgrounds, are less regulated, and (most insultingly) are of higher intelligence? These divisions are a product of the male dominated, paternalistic culture that has prevailed for the 52 years of the national health service.

If nurses increasingly take on the tasks that “bore doctors” this would be an inappropriate use of highly skilled healthcare staff. If, however, they become the initial point of contact in the majority of consultations it is likely that patients, as suggested by the papers in the joint issue, will enjoy increasing satisfaction. Should nurses eventually take over the 80% of first contacts that is projected, we can look forward to the end of the recruitment and retention crisis among general practitioners that we hear so much about.

The divisions that Smith lists only serve to reinforce stereotypical behaviour. As long as doctors persist in treating nurses as “B list” players in primary care such behavour will be perpetuated. It is time that doctors climbed down from their ivory towers and recognised their fellow professionals as integral team players.

References

  • 3-1.Editor's choice. Doctors and nurses: a new dance? BMJ 2000;320 (7241). (15 April.) [PMC free article] [PubMed]
BMJ. 2000 Sep 16;321(7262):698.

Intelligence is not in the eye of the beholder

Francine M Cheater 1

Editor—The editor seems to be confusing intelligence with an ability to pass science examinations.4-1 Scoring highly in science A levels, a prerequisite to getting into medical school, does not mean that you are intelligent. It means that you are good at passing exams. The intelligence required to be a competent and caring doctor (or nurse) encompasses much more, as indicated by the need to overhaul medical undergraduate programmes in the United Kingdom.

The editor also assumes that people who apply to do nursing are not also able to apply for medical school. I know of at least three nursing colleagues who chose nursing, not medicine, as a career, although they were all offered places in “top” medical schools. I maintain that it is not differing levels of intelligence that divide doctors and nurses; rather, it is the perception, held by some doctors, that nurses are intellectually inferior that is the real barrier.

References

  • 4-1.Editor's choice. Doctors and nurses: a new dance? BMJ 2000;320 (7241). (15 April.) [PMC free article] [PubMed]
BMJ. 2000 Sep 16;321(7262):698.

Sex difference? Is there one?

Norman Vetter 1

Editor—An important point that seems to have been missed in discussions of the roles of doctors and nurses and sex stereotypes is that medical students have been predominantly female for at least five years in this medical school and in most others that I have been in contact with.5-1 This trend shows no sign of abating. This is not to do with the medical school's admissions procedure—a similar proportion (about two thirds) of students applying from school are women. There seems to be a feeling in the schools and possibly society at large that a girl who is doing well in science based subjects would do well to go in for medicine rather than pure sciences or engineering. There is no longer a sex difference between junior doctors and nurses, and this will also soon be the case for specialist registrars and higher categories.

References

  • 5-1.Editor's choice. Doctors and nurses: a new dance? BMJ 2000;320 (7241). (15 April.) [PMC free article] [PubMed]
BMJ. 2000 Sep 16;321(7262):698.

Medical profession is no longer patriarch of professions

Anne Price 1

Editor—Alcolado in his personal view on nurse practitioners and the future of general practice does not credit colleagues in primary care with the ability to deliver services effectively.6-1 Many general practitioners provide care beyond that defined by the general medical services contract by working collaboratively with primary care teams that will increasingly include nurse practitioners in future. Advanced nursing roles are an important development in primary care, but the implications have yet to be fully appreciated. Only now, as changes affect the interface between primary and secondary care, do some doctors perceive a threat.

As a nurse practitioner I do not carry out “tasks” but can provide most people's primary care needs for most of the time. I am not a gatekeeper to the general practitioner but a clinician whose experience and degree level training have equipped me to distinguish serious illness when it occurs, to manage common chronic and self limiting illness, and to form long term relationships with patients and families. Although it may be difficult to distinguish my practice from that of a general practitioner, I am not a doctor substitute, and patients actively exercise their choice to see me. The assumption that everyone wants to see a doctor when they are ill is insupportable, and evidence is accumulating that they welcome the opportunity to consult a nurse.6-2,6-3

It is not inevitable that patients lose the choice of seeing a general practitioner. The medical profession must seek solutions to recruitment problems in unattractive areas, but not by expecting the nursing profession to step aside to preserve the status quo. Where is the evidence that a traditional medical degree followed by vocational training is the only adequate preparation for general practice, where, as Alcolado concedes, much morbidity has a social cause? There is scope for widening the entry gate to vocational education and valuing the interpersonal skills of nurses alongside the clinical skills of doctors, in a multidisciplinary educational model, to enable doctors and nurses to become primary care practitioners.

Nurse practitioners are aware of their obligation to address questions of external validation and professional regulation, and work is under way to resolve such issues. Primary care is fortunate to have nurses who are prepared to pioneer innovative roles alongside doctors who acknowledge that the medical profession is no longer the patriarch of professions. Such collegiate and collaborative relationships improve teamwork to the benefit of professionals and patients.

References

  • 6-1.Alcolado J. Nurse practitioners and the future of general practice. BMJ. 2000;320:1084. . (15 April.) [PMC free article] [PubMed] [Google Scholar]
  • 6-2.Reveley S. The role of the triage nurse in general medical practice: an analysis of the role. J Adv Nurs. 1998;28(3):584–591. doi: 10.1046/j.1365-2648.1998.00685.x. [DOI] [PubMed] [Google Scholar]
  • 6-3.Chapple A, Rogers A, Macdonald W, Sergison M. Patients' perceptions of changing professional boundaries and the future of ‘nurse-led’ services. Primary Health Care Res Dev. 2000;1:51–59. [Google Scholar]
BMJ. 2000 Sep 16;321(7262):698.

Length of consultation is important for patient satisfaction

Peter Brindle 1

Editor—The message from the three papers by Shum et al, Kinnersley et al, and Venning et al is the same.7-1–7-3 Patients express greater satisfaction with practitioners, whether nurses or doctors, who spend longer over their consultations and give them more information. The cost effectiveness of nurse practitioners seeing minor illness is yet to be established.

The real issue is the length of the consultation, not whether suitably trained nurses can identify minor and largely self limiting conditions as well as a general practitioner. This new work takes these scarce and highly skilled professionals away from other work that they are already good at and diverts them to something that general practitioners can do already. About 20% of cases seen by the nurses had to be seen by a general practitioner at the same visit anyway, so why not cut out the middle man? Keep the doctors seeing the acute illnesses, but use the resources that might be used on training these nurses to increase consultation time of general practitioners who have already been trained. It is, however, worth considering the related point that spending longer on minor illnesses at the expense of something else might not be an appropriate use of scarce resources anyway.

References

  • 7-1.Shum C, Humphreys A, Wheeler D, Cochrane M, Skoda S, Clement S. Nurse management of patients with minor illnesses in general practice: multicentre, randomised controlled trial. BMJ. 2000;320:1038–1043. doi: 10.1136/bmj.320.7241.1038. . (15 April.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7-2.Kinnersley P, Anderson E, Parry K, Clement J, Archard L, Turton P, et al. Randomised controlled trial of nurse practitioner versus general practitioner care for patients requesting “same day” consultations in primary care. BMJ. 2000;320:1043–1048. doi: 10.1136/bmj.320.7241.1043. . (15 April.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7-3.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;320:1048–1053. doi: 10.1136/bmj.320.7241.1048. . (15 April.) [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 2000 Sep 16;321(7262):698.

Data do not provide conclusions on nurse practitioners

Peter Leman 1, Jane Terris 1

Editor—We work alongside a large group of emergency nurse practitioners in a positive relationship and were interested in the paper by Shum et al on nurses treating minor illness.8-1 They concluded that practice nurses offer an effective service for minor illnesses, but the data provided do not support this.

Almost the entire effect seen (2.2/100) is a result of the greater length of time that the nurses spent with the patients. The multiple regression leaves an almost negligibly significant difference (P=0.047) once this is taken into account.

Shum et al state that they used an intention to treat analysis, but it does not include those patients who did not wish to see a nurse in the first place (n=206). This allows for selection bias, as the enrolled patients then formed a subset who may have preferred to see a nurse.

Despite their possible equal satisfaction with the consultation, only 7.5% of those that saw a nurse wanted to see a nurse again, and five times as many (31.5%) would rather see the doctor next time. In contrast, of those patients who saw the general practitioner half would still rather see the general practitioner, and only 2% wanted to see a nurse next time. These data sit uncomfortably with the satisfaction scale results, and the validity of the questionnaire is open to question, as it was originally developed to compare satisfaction with different general practitioners, not between different types of healthcare providers.8-2 “Comparison between health professional groups should be undertaken with caution.”8-3

Information bias distorts many of the findings of the study—the lack of blinding of the intervention style (doctor or nurse) to the observer (patient). We should also consider that the number of subjects in the study was in fact just the 24 individuals being assessed (five nurses and 19 general practitioners), each intervention was by an individual practitioner, and outcome was satisfaction with that individual's style of consultation, thus the true sample size was only 24.

Shum et al should take into account that the “clinically effective service” they conclude is offered by nurses also needs to detect rare illnesses as well as generate satisfaction with outcome in self limiting illness. The future care pathway for minor illness is uncertain and may include nurse practitioners, but this paper has contributed little evidence to support such a change in practice.

References

  • 8-1.Shum C, Humphreys A, Wheeler D, Cochrane M, Skoda S, Clement S. Nurse management of patients with minor illnesses in general practice: multicentre, randomised controlled trial. BMJ. 2000;320:1038–1043. doi: 10.1136/bmj.320.7241.1038. . (15 April.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8-2.Baker R. Consultation satisfaction questionnaire: development of a questionnaire to assess patients' satisfaction with consultations in general practice. Br J Gen Pract. 1990;40:487–490. [PMC free article] [PubMed] [Google Scholar]
  • 8-3.Poulton B. Use of the consultation satisfaction questionnaire to examine patients' satisfaction with general practitioners and community nurses: reliability, replicability, and discriminant validity. Br J Gen Pract. 1996;46:26–31. [PMC free article] [PubMed] [Google Scholar]
BMJ. 2000 Sep 16;321(7262):698.

Author's reply to Brindle and Leman and Terris

Chau Shum 1

Editor—Much but not all of the greater satisfaction with nurses was related to longer consultation times. Our data imply that this satisfaction is at least as high as that with general practitioners and would probably remain comparable even with shorter consultations. Although the consultation satisfaction questionnaire was originally devised for doctors, its use for nurse consultations has been validated,9-1 and it seemed to be the most appropriate of the currently available tools when selecting outcome measures.

Bias could be introduced when a large proportion of eligible patients decline to participate in a trial—the 206 who declined were only 10% of all eligible patients. We could not have included them in the intention to treat analysis because in a standard clinical trial design those who decline do not have outcome data collected on them.

The satisfaction ratings and the patients' indications of which type of professional they would prefer to see in the future are two different issues. With the satisfaction scale, patients were rating their satisfaction with the consultation they had just had, whereas in answering the question about future preference, patients in the doctors' group were expressing a view about a form of care that they probably had not experienced. Patients tend to like existing services.9-2 The fact that more patients in the nurses' group (69%) than the doctors' group (53%) would be happy to see a nurse in future shows that experience of a new form of care can alter perceptions of it. Furthermore, the question of future preference may be affected by factors such as continuity of carer and the expectation of seeing a doctor when ill.

Clinical effectiveness is difficult to measure, particularly for management issues in general practice. We discussed various study limitations, including the issue of rare events. However, our data suggest that the nurse service is clinically effective.

Service provision is different from showing that a type of service is potentially effective. We found that nearly 20% of patients seen by the nurse had to be seen by a general practitioner as well. Whether this is sustainable in terms of cost effectiveness is still not clear. Our data suggest that referral rates may fall as nurses become more experienced: in the second half of the trial only 17.7% of nurses' patients had to be seen by the doctor, compared with 21.3% in the first half.

Cost effectiveness goes beyond the immediate cost of a nurse or general practitioner. We should take into account factors such as the improvements that could be made by changing the way current services are provided. For example, in minor illness there might be little to choose in terms of cost between a nurse and a general practitioner, but doctors' time might be better used in seeing patients with more complex problems or extending other services.

References

  • 9-1.Poulton B. Use of the consultation satisfaction questionnaire to examine patients' satisfaction with general practitioners and community nurses: reliability, replicability, and discriminant validity. Br J Gen Pract. 1996;46:26–31. [PMC free article] [PubMed] [Google Scholar]
  • 9-2.Porter M, Macintyre S. What is, must be best: a research note on conservative or deferential responses to antenatal care provision. Soc Sci Med. 1984;19:1197–1200. doi: 10.1016/0277-9536(84)90370-8. [DOI] [PubMed] [Google Scholar]
BMJ. 2000 Sep 16;321(7262):698.

Doctors and nurses need to collaborate

Elaine Gill 1

Editor—On completing reading the special issue on doctors and nurses I came away with these messages: doctors and nurses are different, working together is difficult, nobody really knows how to do it anyway, and we need more research.10-1 There is not much to argue with there.

What can be done? We have introduced shared learning for medical and nursing students in years one and two of their training (with the Florence Nightingale School of Nursing).

It may be too late to put postgraduate programmes in operation if undergraduate education is not responding likewise by providing opportunities for interprofessional learning. It may be more important that undergraduate changes are appreciable and valued. We then have a chance of success on the grounds of a diminishing return of undesirable attitudes, which are difficult to change.

Our approach has been to focus on communication and basic clinical skills for medical and nursing students. Mixed groups of students learn and work collaboratively on patient centred tasks and present work together at the end of sessions. So this is not about a medical student “sitting in” with nurses or vice versa.

What students, clinicians, and lecturers think so far is difficult to tell at this stage. But reluctance, resistance, guarded interest, and perceived low value are being replaced by cautious acceptance and continuing support for further developments.

How have we done it? Initially a joint research project concentrated on communication skills and effective team working. Clinical skills needed for infection control were introduced in year 2. We gained support after two years to timetable the course centrally. We model good practice by cofacilitating where possible. We responded to feedback from students and facilitators.

What did we need? Support from our bosses and deans; a commitment to work together and respect for each other's difficulties; only slightly less than missionary zeal and will; and the ability to deal with criticism from people with personal agendas and barely hidden prejudices.

Why are we doing it? Doctors and nurses are the predominent groups in professional health care. They spend most of their time working together in clinical settings. This is not about nurses learning to do doctors' tasks for them. We aim for learners to come away with increased understanding of each other, patients' needs, and shared clinical problems. It is still early days.

References

  • 10-1.Doctors and nurses. Special joint issue with the Nursing Times. BMJ 2000;320 (7241). (15 April.)
BMJ. 2000 Sep 16;321(7262):698.

Doing it together with PAMs

Nina Bunce 1,2, Gill Cunningham 1,2, Alison Davies 1,2, Cynthia Nemeth 1,2, Mary Styles 1,2, Arun Kundu 1,2, Melanie Munn 1,2, Angela Scrase 1,2, Rowena Vincent 1,2, David C A Candy 1,2

Editor—We welcomed the joint edition of the BMJ and Nursing Times.11-1 Here we describe how delivery of care in paediatric gastroenterology has been enhanced by cooperative care in which doctors, nurses, and “PAMs” (professionals allied to medicine) have become equal partners.

We have established a multidisciplinary service for children with elimination disorders called “the Pro-Motion team.” Children with severe constipation are admitted under the care of the ward sister (MM) and play specialist (AS) for disimpaction with polyethylene glycol (Movicol) and behaviour modification. School age children are visited and supported by a specialist school nurse (NB) and preschool children by a health visitor (CN). A clinical nurse specialist in child and family psychiatry (AD) sees children with emotional problems. When parents are able to take part in the behaviour modification programme the children are discharged to the care of a community children's nurse (GC), with visits from NB and CN. Consultants—a paediatric gastroenterologist (DCAC), specialist registrars (AK, RV), and staff grade (MS)—are increasingly involved in a consultative role rather than driving the service. The level of support and expertise provided by professionals, including nurses and a play specialist, from a variety of backgrounds and different NHS trusts has been directly responsible for attracting competitive research funding.

An alternative model of service delivery, provided by AD and DCAC in the Holistic Paediatric Gastro-Enterology Clinic, is in keeping with the spirit of the special NT/BMJ joint issue. Children with gastrointestinal symptoms in whom there is thought to be a major psychological component are seen by the clinical nurse specialist and the gastroenterologist together. A medical examination is followed by a detailed psychological history as well as the medical history. A joint diagnostic formulation and management plan is developed with the family, which may include diet, pharmacological therapy, and stress management. A joint letter is sent to the referring doctor. Depending on the outcome, follow up may be with one specialist but is usually with both. They have seen about 50 families in this way. Formal audit of the service will be required, but the initial experience of the professionals involved is that substantial progress has been made with families who were “challenging” or difficult to help.

The bringing together of biomedical and nursing expertise with PAMs in a “one stop” consultation, without stigmatisation of the family, may be one area in which the nurse consultant role proves its worth.

References

  • 11-1.Doctors and nurses. Special joint issue with the Nursing Times. BMJ 2000;320 (7241). (15 April.)

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