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Doctors and nurses: new game, same result

BMJ 2000; 320 doi: (Published 15 April 2000) Cite this as: BMJ 2000;320:1085
  1. Mark Radcliffe, deputy features editor
  1. Nursing Times, London

    In the beginning the relationship between doctors and nurses was clear and simple. Doctors were superior. They had the hard knowledge that made ill people better. The nurses, usually women, were good but not necessarily very knowledgeable. They were in charge of folding pillow cases and mopping brows. Nurses didn't cure patients; on the whole they still don't. They were just nice to them while they waited to get better.

    In 1967 Dr Leonard Stein first outlined the doctor-nurse game. He said that the interactions between the two were carefully managed so as not to disturb the fixed hierarchy. Nurses were bold, had initiative, and were responsible for important recommendations. While being bold, however, they had to appear passive. In short, nurses were able to make recommendations as long as they made it look as if they were initiated by doctors. So the nurse was responsible for the wellbeing of her patients and the nourishment of the doctors' sense of professional self.

    A missed opportunity for nursing and a bit of a bore for doctors

    In 1990 Stein revisited the game and found that the nurses weren't playing any more. It seems they had unilaterally decided to change the way that they related to other health professionals. Nurses were tired of the handmaiden image and sought to invest their existence with a professionalism and value that they had previously been denied. Being a nurse was more than being a good woman; it was about being a well educated practitioner with independent duties, skills, and responsibilities.

    After the 1970s nursing reconstructed itself as an independent profession which sometimes stood up to doctors. They did this in various ways, an example being the investment in university education and the social affirmation that went with it. Nursing was reinvented, increasingly as an associate science to medicine. But, why didn't these quasimedical nurses simply train as doctors? Is it because they believed in the distinguishing nature of nursing? Or because they didn't have enough A levels? Was the pursuit of equality motivated by a belief in the value of nursing or an inferiority complex?

    For all the jostling for position over the past 20 years little has changed. This is primarily because the power in the relationship is mediated by the patient. If in doubt ask the patient who is in control. The public may love its angels but it holds its medics in awe.

    In the struggle with doctors, nursing has made a fundamental error. It has mistaken equality for uniformity.

    The frailty of nursing in the modern world is born of its intangibility. Nursing is more than treating ill people. It's about nourishment, problem solving, and easing a patient's experience of suffering, medical invasion, or death. It's always been hard to pin down, so it's not surprising that nurses have turned to the material world of postgraduate recognition, evidence based practice, expanded roles, and mimicking the medical career structure—nurse consultants, nurse practitioners, etc—in order to redesign their sense of self. The doctors, however, are still having their needs met by nurses.

    Surely doctors are more than happy to see nurses do tasks that usually take up time and quite frankly bore them. Nurses are taking over tasks from junior doctors—administering intravenous drugs, doing endoscopies, preoperative assessment, and some prescribing.

    Doctors are a simpler breed than nurses. Everyone knows what the doctor's job is. Doctors are the conduits of medical knowledge. They don't have to constantly redefine themselves. Doctors are little more than what science allows them to be. They are a totem. They don't rethink themselves, they don't need to. This gives them plenty of time and opportunity to redefine nursing.

    Medicine remains in the ascendancy. The capacity to cure has greater market value than dealing with distress. And frankly so it should. But in the face of that might not nursing have done better than “if you can't beat them join them”?

    In a short time nursing has built up an infrastructure of credibility from the wards to the universities, stopping off on trust boards and policy groups along the way. Nursing has garnered more governmental respect than ever. Unfortunately, this has been achieved by moving nursing towards convention, and the opportunity to move convention and credibility towards the core strengths of nursing has been missed. Nurses now have more power but arguably this has done little for nursing.

    What feminism has done for nursing is to make young women choose to be doctors. As for the game, it doesn't matter. It is an irrelevant unsophisticated squabble. The key to the success or failure of the doctor-nurse relationship is the patient experience. Unfortunately, in the past the relationship has often been motivated by jealousy, self doubt, insecurity, and arrogance. You cannot help believing that this has been a missed opportunity for nursing and a bit of a bore for doctors.