Editorials

Doctors and nurses: changing family values?

We want to hear about how doctors and nurses work together

Next April Nursing Times and the BMJ will publish special joint issues on doctors and nurses working together. Both publications have explored the relationship before. Both are again keen to understand when the partnership works well, where it fails, and how it can be improved. As such, we are collaborating in assessing and editing articles for this joint theme issue. We welcome original research on doctors and nurses working together in different healthcare settings, highlighting how, where, and why good practice develops. We want to encourage reflections on bringing down barriers: What needs to change to make partnership a reality? Or is partnership itself a misguided goal in the healthcare field?

Doctor, nurse, patientthese three roles have always been at the heart of effective health care. Understand them as a household, 19th century nurses were often told. The husband-doctor was to be wise, firm, yet kindly; the wife-nurse was to stay in the background, dutiful, keeping order among the servants and ever watchful of her husband's needs; and the child-patient was to be respectful and obedient, just that little bit in awe of father. Respect for father was probably at its peak at the point of the mid-century creation of the NHS. Governments listened to the medical profession and, reflecting the balance of power within it, focused aspirations on creating better access to acute medical care. Nurses remained in the background, both in policy debates and in practice. Patients kept quiet; they wanted medical care and were prepared to put up with the discomforts of waiting and the lack of amenities of the surgery and hospital. Today we talk of partnerships in care delivery, of teamwork and collaboration, of user focused quality systems and clinical governance. So what has changed?

Patients have changed. They are better educated, they want information, and are ready to complain. Yet they are often also vulnerable and afraid, wanting to look up to the old style doctor and to hear talk of the miracle cure. Nurses have changed. There are protests from many quarters about the upstart university nurse. Doctors have changed too: over half of all medical school entrants are women and there are more doctors from ethnic minorities. The two professions disagree about whether the doctor-nurse game (he will pretend omnipotence, she will collude with this) is dead and buried or alive and well. Government attitudes have certainly changed. In education, law, and policing, as well as in health care, there has been a withdrawal of trust from professions. This did not go away with a change of government. In 1997 it just took a new form, with markets transmuting into monitoring and efficiency and effectiveness still centre stage.

All this makes for confusing times for professions locked together in the way nurses and doctors are. Both have faced trial by media over disciplinary cases before their regulatory bodies and questioning of their right to self regulation. Both have faced demands for new levels of accountability in their daily work. But there are important differences. Nursing saw developments of its role on the back of a campaign to reduce junior hospital doctors' hours. Nurse practitioners, nurse prescribers, and NHS Direct, we might say, are less a vote of confidence in nursing than a vote of no confidence in medicine. Can the professions forge good working relationships in a context where an opportunity for one becomes a threat to the other? And what are we to make of the emergence of medical directors on the scene at the point where nurse managers have made an exit?

There are many more key questions. Are new guidelines emerging that facilitate team working? Are the barriers at the point of practice set up by nurses who are reluctant to take responsibility and doctors who are reluctant to share itor are they in another place, in the lack of adaptation of structures and processes in the regulatory bodies, perhaps, or in the policy framework of the new NHS? Our joint issues next spring will explore just how well new doctors and nurses are working together in the new NHS. Why not follow this crucial debateor even better, contribute to it.

Celia Davies, professor of health care. 

Open University, Milton Keynes MK7 6AA

Jane Salvage, editor in chief. 

Nursing Times, London NW1 7EJ

Richard Smith, editor. 

BMJ