Education and debate

Doctors and nurses should monitor each other's performance

FOR

AGAINST

Doctors and nurses should monitor each other's performance

FOR

Tim Crossley, general practitioner. 

Thornley Street Surgery, Wolverhampton WV1 1JP

"You used to work on ward 3. Do you remember me? I was on nights." The nurse approached me at the end of year house officers' party; it was 1981.

"I used to hate you," she added. She poured a pint of beer over me. I was too startled by this informal appraisal method to reply suitably. Later, I learnt I had incurred her wrath by reacting to the incessant inhuman bleep by arrogantly snapping at her part in my misery.

Only the minds, not the hearts, of the professions are behind being appraised. I am a general practitioner, and most of us cling on to "independent status," best viewed as a kind of complex performance related pay, with certain small freedoms and certain obligations. Senior hospital doctors have different obligations and less freedom but still have the privileges of rank. Not, perhaps, a free car parking space but certainly team leadership, care of employees, and involvement in hospital developments.

This aloof position that we hold permits serious appraisals to be seen as something to be done to others, not oneself. Indeed, status is a barrier behind which we cower.

That the threat is perceived so deeply shows how unconfident we are as doctors. Yet what aspects of our work are important to appraise? We leap to thinking of technical skills, diagnostic ability, prescribing effectiveness, and manual wizardry, and how could anyone but peers test that? (Actually, anyone with an objective testing tool coulda nurse, for example, or perhaps a manager.) But what of communication skills and teamwork attitudes, those education-speak phrases of the 1980s and 1990s?

Doctors can be evil, incompetent rogues and yet charm their way up the ladder to invincibility. So can nurses. Away from the Shipmans and the Allitts, we all know of generally well meaning and competent clinicians facing complaints in which a failure to communicate with patients and each other is a factor. The other clinicians, be they the same profession or not, will have valid experience and views on what might have gone better. But in our culture blame is passed around until the music stops and someone has to face it. Maybe feedback from a different profession would feel a bit less like criticism.

To expect a peer, a person of equal standing who purportedly knows what is involved in the job, to be the only source of feedback is like asking for forgiveness. As if my rudeness at dawn to the nurse whose name, if I ever knew it, I have forgotten is allowable because I was soaked in fatigue. It isn'tand neither was her lack of knowledge of my circumstances.

The roles of doctor and nurse are blurring. My practice nurse gave the doctors a tutorial on asthma last week, and is our team's expert. I fancy I might be skilled at serious mental illness, but we all do hypertension, immunisations, listening, terminal care, and much else. The nurse's view on me is as important as my partner's view on me, and mine on her. The issue is whether any of this will result in change. Let's hope so.

AGAINST

Lynda Abedin, nurse practitioner. 

Walsall West Primary Care Group, Kingfisher Medical Practice, Willenhall, West Midlands WV12 5RZ

It is undesirable and impractical for doctors and nurses to monitor each other's performance. It would undermine effective team working, leading to mistrust and animosity, without any gain for patients.

The recent high profile cases involving doctorsthe Bristol case, where nurses felt unable to voice their concerns, and the Shipman case, where suspicions were aroused by a relativehave very little to do with the need for nurses to assume responsibility for monitoring medical practice. The problem lies with professional socialisation and the belief that whistleblowers will be treated unfairly, particularly when they challenge the professional practice of someone who holds a position of authority.

Current changes in nursing and medical education reflect the need to train a workforce that is able to meet the demands of the modern NHS. For example, the mentoring of nurse practitioners by doctors, to facilitate the acquisition of physical examination skills, enables these nurses to extend their practice to benefit patients. However, this does not change their fundamental nursing role. The mentoring doctors have a very different educational background, and this background does not equip them to monitor or assess nursing practice, except within the scope of taught skills such as physical examination.

Similarly, nurses who mentor doctorsfor example, newly qualified doctors acquiring clinical skills in a ward setting or doctors undertaking multidisciplinary advanced educational courses such as an MSc in pain managementdo not have the training to monitor doctors' performance except within the limits of the course. Registering bodies and employers require doctors and nurses to be monitored. How, and by whom, is a matter for the professions.

The apparent inability of the medical profession to regulate themselves has resulted in the introduction of reaccreditation. The demise of the current system means that doctors will be expected to produce documentary evidence of how their learning has changed their practice; doctors' performance will be subject to peer review, and poorly performing doctors will be brought into a system of support and educational updating. This has caused some discontent among the medical profession, but it would be totally unacceptable for both doctors and nurses if nurses were involved in the process.

The nursing profession has successfully maintained self regulation. The protection of the public is central to the process, as is evident when nurses who are subjected to disciplinary hearings by the United Kingdom Central Council for Nursing, Midwifery, and Health Visiting are removed from the register, but doctors disciplined in similar incidents are reprimanded and left to practice. Clearly there is a need for equity, and both professions need to audit their regulations. Both professions are accountable for their actions, by act or omission. Both are required to recognise limitations in knowledge and skills when treating patients and to seek advice and support. Both doctors and nurses are required to undertake training to fill gaps in knowledge and skills and to be lifelong learners.

Although it is necessary and desirable for any failure of nursing or medical care to be brought to the attention of staff and management, it is the responsibility of each profession to monitor its own members.

Patients will be best served by teams of doctors and nurses with the necessary skills and training to provide the relevant care at the point of contact. They need to have full confidence that the practice of these doctors and nurses has been subject to scrutiny, measured against best practice within their individual professions.

Footnotes

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