Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Health Care Practice, Policy and Change
- Marjorie Gott (19 April 2000)
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Doctors and nurses
- Iain Mackenzie (26 April 2000)
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Doctors and nurses: celebrate the difference
- Patrick T White (9 May 2000)
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Doctors and Nurses Working Together in the 21st Century
- Florence B K Mwando (19 May 2000)
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Marjorie Gott, MD, Gott Associates International Health Care Consultant
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The health policy environment is changing rapidly and new working practices are called for.Worldwide, using nurses as the first point of contact with the health service is the direction health care is taking, as policy makers seek better value for money. For a great deal of the last century the nursing contribution to health care was largely invisible. Part of the role of the nurse of the future will be to educate other key players about the value of nursing and the contribution that it can make. They can do this by showcasing good practice that is truly collaborative. If doctors and nurses jointly design, deliver and monitor services the impact on health and illness experiences can be significant. A recently published work; Nursing Practice, Policy and Change (Gott 2000) looks at health care and good practice case studies in the UK, US and Australia. Findings show: Better teamworking, lighter doctor surgeries, better use of each others expertise Better care management by use of jointly designed protocols Better response to community needs, especially underserved communities in the UK, US and Australia Greater cost effectiveness; one Australian practice now employs 4GPs, 2 NPs instead of 6 GPs. See Nursing Practice, Policy and Change, Gott M, Radcliffe Medical Press, Oxford, www.radcliffe-oxford.com |
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Iain Mackenzie, Specialist Registrar John Radcliffe Hospital, Oxford.
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The debate on the future role of doctors and nurses is minimally advanced by those who portray it in terms of male/female [1], strong/weak or oppressor/oppressed, and is too important for us (patients and carers alike) to allow it to be hijacked by the politicians [2, 3]. The provision of health care requires the services of a multitude of individuals ranging from the engineer who services the lift to the laboratory technician who analyses the blood samples, never mind the doctors and nurses. It is a team effort. It is obvious that any human endeavour that involves more tasks than can be accomplished by a single individual requires a team in which each member has a specific role. An orchestra composed entirely of conductors is likely to be as successful as an aeroplane with six pilots but no flight attendants, or a bus with two bus conductors but no driver. The four elements critical to the success of a team effort are that: (A) the team's goal is common to all its members, (B) every task required to reach the goal is allocated, (C) the tasks are allocated to team members who have the skills to perform them, and (D) someone is in charge. The current crisis stems from the fact that 'doctors' and 'nurses' in their present incarnation form a team which fails on all four counts, and the Government's response is to fuel the crisis by appealing to the ‘victims’ of the old stereotypes [2], which for the most part no longer hold true [4]. First, it is far from clear that medicine and nursing currently share a common goal (as anyone who has tried to do a ward round will know). Secondly, someone will have to see it as their responsibility to comfort the frightened, feed the week, dispense medication and clean blood, food, faeces and vomit from the beds and bodies of our sickest, because the people that used to don’t want to anymore [5,6,7,8,9,10,11]. Thirdly, we will need to make sure that those who take on particular tasks have the training appropriate to the job (not only phenomenology, ethnography and reductionism [6] but also physiology, pharmacology, biochemistry, anatomy, microbiology, pathology, clinical medicine and surgery) and are therefore both able and willing to take responsibility for their actions [2]. And lastly, it will need to be agreed who should lead the ward-based clinical team, and take responsibility when it all goes wrong. In order to create a successful health-care team those who currently profess some knowledge in the field (and that means doctors as well as nurses and professors of health care) will have to reach a consensus on what the goal is, how to reach it, who should do what, and who should be the team leader. This may even involve the complete disappearance of 'doctors' and 'nurses' as we now know them [12,13]. [1] Davies C. Getting health professionals to work together. BMJ 2000;320: 1021 - 1022. [2] Beecham L. UK health secretary wants to liberate nurses' talents BMJ 2000;320: 1025 [3] Hopkins D. Political rhetoric-the tip of the iceberg. http://www.bmj.com/cgi/eletters/320/7241/1025 [4] Vetter M. Gender difference, what gender difference? http://www.bmj.com/cgi/eletters/320/7241/1025 [5] Hamon C. Some NHS care is unacceptable. BMJ 1998;317:1463. [6] Phillips, M. How they teach nurses not to care. http://www.sunday-times.co.uk/news/pages/sti/2000/02 /27/stirevnws02013.html [7] Michaeli D. What skills are for nurses. http://www.bmj.com/cgi/eletters/320/7241/1025 [8] Roskell, D. Teamwork is not about everyone trying to do the same job. http://www.bmj.com/cgi/eletters/320/7241/1025 [9] Osborne R. What skills are for nurses. http://www.bmj.com/cgi/eletters/320/7241/1025 [10] Evans G. So who will do nurses' current tasks? http://www.bmj.com/cgi/eletters/320/7241/1025 [11] Fletcher M. Doctors have become more caring than nurses. BMJ 2000;320: 1083 [12] Salvage J, Smith R. Doctors and nurses: doing it differently. BMJ 2000;320:1019- 1020 [13] Doyal L, Cameron A. Reshaping the NHS workforce. BMJ 2000;320: 1023-1024. |
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Patrick T White, Clinical Senior Lecturer Department of General Practice and Primary Care, Guy's King's and St Thomas' School of Medicine
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Dear Sir The BMJ 'Doctors and Nurses' issue (15th April 2000) signally fails to define or describe nursing, but repeatedly talks about nurses doing doctors' jobs. The predominance of the theme of substitution of doctors' work by nurses undermines the ideas of multidisciplinary working, working together, cooperation and collaboration which 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 ignorant. The importance of difference stressed by Celia Davies frames the debate.1 This is an essential idea and one which is the foundation of the utility and pleasure of my relationship with my practice nurse colleagues. However, following Davies' 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 Mark Radcliffe which with admirable symmetry closes the debate opened by Davies.2 But between their two papers who is actually celebrating the difference? As a GP I do not look to nurses to do the things I dislike doing more cheaply and more efficiently. I do look to nurses to take on the tasks they do better than me and to share the tasks they do equally well. Primary care teams should be looking to employ nurses for the special skills they have and for the special roles they offer. Sometimes nurses are less costly because nurse training is shorter and the opportunity to specialise can therefore come earlier. And, yes, we should be thinking of the most cost effective services we can provide. The lack of clarity in the BMJ about what nursing is reminds me of the soul searching debate in general practice recorded in the 1950's and 1960's in which the discipline was asking itself if it was simply a hotch potch of the medical specialties or something essentially discrete or different. The BMJ seems to be having a similar debate about whether nursing is a less advanced form of medicine. I would be interested to see a nursing view of the nursing role. If the relationship between medicine and nursing is really to bear fruit then medicine will have to recognise more explicitly that nursing is a different profession and that nurse training prepares different professionals. In their final letter in the correspondence section Laurant and colleagues 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 ………".3 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 which celebrates the difference. Yours sincerely, Patrick White
1. Davies C. Getting health professionals to work together. BrMedJ
2000;320:1021-2.
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Florence B K Mwando, Clinical Nurse Practitioner Queen's Medical Centre
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Recent published literature reveals the importance of increased shared care between nurses and doctors1,4. It has also been demonstrated by the exchange visit of the ophthalmic doctors and nurses delivering primary eye care in the Republic of South Africa3. The overall goal is to alleviate suffering, reduce long waiting lists and appointment times. This clearly will enhance the health of the world population. Colleagues in the third world have been taking related histories, making diagnoses, treating patients and referring them to medical practitioners for some time now. With 75% of the increase of the world elderly population expected to be in the developing world2, team care between doctors and nurses is therefore of utmost importance (to achieve a healthy old age). Increased community nursing hours and reduced junior doctors hours have also contributed to nurses doing more expanded roles3. This means that nurses carry out roles which doctors would ordinarily do in the Western World. It is now finally in the Western World that previously known anecdotal evidence has confirmed that practice nurses also offer an effective service for patients with minor illnesses4. It must be encouraged for some of these practicalities to be published3. Priorities are different, in different parts of the world. It is appropriate to conduct controlled studies when finances are available in Western countries, whilst in the Third World priorities are to control for example malaria, immunisation programmes and family planning3. Other evidence looks at community eye nurses in the Republic of South Africa, the Gambia, Botswana and Malawi where nurses take histories, screen patients with cataracts and prepare them for operations, before the ophthalmologists even get involved. Also included in the nurses duties are operating on minor eyelid disorders such as skin tags and chalazia3. Most United Kingdom ophthalmic units have specialists and clinical nurse practitioners who are guided by local policies and scope to carry out fluorescein angiograms, slit lamp skills, tonometry, biometry and perimetry3. It is acknowledged that the medical services in the Third World are poor and nurses are highly competent and multi-skilled. They have many responsibilities and more practical experience. However gaining the underpinning knowledge is sometimes difficult to achieve due to the lack of resources, particularly specialist medical and nursing schools, and finance. For doctors and nurses, travelling abroad and working together, these are the best teaching experiences available. It maximises the contributions that both doctors and nurses make. Yours sincerely Florence BK Mwando
References 1 Josefson D. Unsupervised nurses may soon give anaesthetics in United States. BMJ, 2000; 320: 959. 2 Kalache A and Sen K. Ageing in Developing Countries. In: MSJ Pathy (Ed). Principles and Practice of Geriatric Medicine. 3rd Edition. 1998, pp 1561. 3 Mwando F. An overview of professional key issues and development in community eye health and to compare the Third World perspective with that of the Western World. Paper presented to the International Ophthalmic Nurses Association Conference, Nottingham, 7-9 April 2000. 4 Shum C, Humphreys A, Wheeler D, Cochrane M, Skoda S, Clement S. Practice nurse-led management of patients with minor medical conditions in general practice: multicentre, randomised controlled trial. BMJ, 2000; 320: 1038-1043. |
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