What skills do doctors and nurses need?
BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a1722 (Published 18 September 2008) Cite this as: BMJ 2008;337:a1722All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Dear editor,
I read "What skills do doctors and nurses need?" and the responses with a
great interest as a medical educator of tomorrow's doctors. The "white
coats" of medicine seem not to be ready to abdicate their responsibility
and honor to another profession. Honestly, as a medical doctor I am not
ready to give up, but realistically when I thought about my education
years, practice years in different hospitals and health care units I must
say that I learnt a lot from nurse practitioners. While physician teachers
have no time, nurses were always there to ask, to learn and to teach. Does
it mean that they can be a doctor? No, but as a different profession of
the team I know that they are always nearby me. I believe that some
overlapping skills are well-done by nurses because they are always doing
it in daily practice in patient care. As Godlee pointed out doctors takes
risks, deals with uncertainty and this skill is neither easy to gain nor
easy to quit.
Competing interests:
None declared
Competing interests: No competing interests
One gets rather tired of seeing some themes recurring over time in
the literature. My first rapid response on the doctor-nurse issue was
published in April 2000 ["It is not the name, but the essence of the
profession that matters", http://bmj.com/cgi/eletters/320/7241/1083#7430],
and a letter of mine titled "Separate but complementary" appeared in the
Journal on 7 January 2006 [doi:10.1136/bmj.332.7532.52-a]. The text of the
latter is appended here:
"Editor— In my several years of postgraduate training I have
had the privilege to work with, and learn from, numerous nurses, male and
female. They never pretended to be anything else than their title implied,
and they expected me to authorise their suggestions about patient
management, even though their experience (particularly in specialist
units) was longer than my own. Through this collaboration I have come to
appreciate the complementary skills that diverse professions can bring
into the care (and occasionally the cure) of the whole person. Blurring
the roles can never accomplish as much as mutual respect and cooperation
between varied skills."
Having read the preceding correspondence I do not see any reason for
varying my opinion on the subject.
Competing interests:
None declared
Competing interests: No competing interests
I read with interest the editorial by Fiona Godlee about the skills
doctors and nurses need (1). Often, these skill sets are overlapping and
are not clearly defined. Godlee mentioned the standards for training and
experience of nurse practitioners in the UK. Nurse practitioners in the
United States play a significant role in health care.
Nurse practitioners are licensed, independent practitioners who have
completed advanced nursing education and training in diagnosing and
treating a broad range of illnesses (2, 3). They take health histories,
perform physical examinations, order and interpret diagnostic tests, and
prescribe medications. There are many more services nurse practitioners
provide (2-4). Nurse practitioners work in primary and acute care
settings, such as pediatric and adult health, school/college health,
geriatric health, and psychiatric/mental health, to name only a few (4).
The profession of the nurse practitioner evolved in the US in the mid
-1960s when there was a shortage of physicians (3). Since then, nurse
practitioners provide high-quality, individualized, and cost-effective
health care, but differ from physicians in that their primary focus is on
prevention, wellness, and education. They differ from nurses in that they
have advanced education and clinical training, as well as more
responsibilities (2-4).
Good health care depends on an optimal interaction between health
care providers. In this regard, I fully agree with Godlee (1) that "As
health care becomes more complex and fragmented, patient safety relies
more than ever on teams of people with a range of skills working
effectively together."
References
1. Godlee F. What skills do doctors and nurses need? BMJ
2008;337:a1722.
2. American Academy of Nurse Practitioners. Scope of practice for
nurse practitioners. Retrieved October 2, 2008, from www.aanp.org.
3. Mayo Clinic. Nurse practitioner career overview. Retrieved October
2, 2008, from http://www.mayo.edu/mshs/np-career.html.
4. Nurse Practitioner Central. About NPs. Retrieved October 2, 2008,
from http://www.npcentral.net/consumer/about.nps.shtml.
Competing interests:
None declared
Competing interests: No competing interests
The basic skills from all health care providers are dedication, hard
work & being a good listener.
Nurses are not inferior to doctors, they are simply different, their role
is essential in the medical care.
Basic human values, should be taught well in medical or nursing schools, a
reform is therefore needed in medical education.
Competing interests:
None declared
Competing interests: No competing interests
I agree with Suvira S Madan above. Who is going to do the nurse's
job? Talking with the nurses on the wards i have worked it is evident that
many went into nursing because they enjoy the 'traditional' roles that
nurses perform, that is the care of the patient as a whole and especially
their basic needs while they are ill. This is the basis of a humane and
safe environment in the hospital and an essential role and i feel the
current debate denigrates this a little, as if the job a 'nurse
practioner' or doctor does is more important or advanced than that a nurse
does.
I'm not implying that nurses should be confined to these
'traditional' roles, in fact it may help doctors to spend time doing jobs
only they can do if a nurse can do some of their duties, this has to be
balanced against de-skilling junior doctors however. Clearly there is alot
of crossover in what doctors and nurses do. But ultimately, as others have
said, they do different jobs for the majority of the time
When a nurse does mostly duties done by doctors and hardly any or no
jobs that a nurse normally does, it does beg the question, why don't they
just become doctors?
Competing interests:
None declared
Competing interests: No competing interests
I find it interesting and somewhat frustrating that these nurse
practitioners, presumably wearing a nurses uniform find themselves having
to stop patients from calling them 'Doctor', when for the last 22 years I
have been examining and treating patients only to hear 'Thank you nurse'
!!!
Competing interests:
None declared
Competing interests: No competing interests
my experience tells me there is a big difference between the
knowledge skills and abilities of doctors and nurses.
I trained as SRN/RSCN for 4 years and worked as staff nurse research
nurse and ward sister for the following 7 years. This gave me considerable
clinical experience and knowledge of nursing and some medical knowledge. I
then went to medical school and found I knew about 10% of the course
already The only exemption i was given was to not attend the 1 weeks
nursing experience.
The clinical interest i already possessed enhanced my training so i
got distinction especialy in physiology and pharmacology However anatomy ,
pathology and diagnostics were completely novel.
A a gp I still feel that the knowledge and diagnostic skills i have
now are not possessed by nurses. I do not find diagnostic agreement in
patients who have been to the walkin centre, with district nurses dressing
a wound for a week where angulation of colles fracture goes unoticed, or
the overall evaluation of patients by clinical specialist nurses too
influenced by an individual protocol.
Nurses I feel realise that they have not got this ability. This is
shown by the number of nurses who undergo clinician or prescribing
training then dont use it. Prescribing figures would show that they dont
prescribe much but otc medication and the large proportion trained who
then move to a management only role ( all the nurse clinicians in our pct)
Competing interests:
I am a GP , a state registered nurse and sick childrens nurse , a chronic patient
Competing interests: No competing interests
Although, as suggested by Dr Sambandan, managers loved the concept of
delegating to nurses some of the tasks traditionally performed by
doctors(1), the root cause of the consequent blurring of the boundaries
between doctor-led practice and nurse-led practice is that doctors
conspired with the managers to recruit and train nurse consultants and
nurse specialists. In a nutshell, without doctors to train them(or half-
train them, as the case may be), there would be no nurse specialists. In
some instances the motives were altruistic, if not questionable, as in the
instance of the doctor who said he could not cope if all he saw were
complex co-morbidities and undiagnosable problems(2). And yet, dealing
with complexity, even if one cannot put a conventional diagnostic label on
it, is just what doctors have been trained to do, down the ages, because,
like the poor, both the diagnosable and the undiagnosable, as well as the
complex and the straightforward, will always be with us. What is also
universal about the way medicine is taught is that it inculcates positive
attitudes towards complexity, given the fact that "complexity demands
attitudes quite different from those heretofore common in (for example)
physics"(3)(parentheses are mine).
Finally, "a clinician's personal
experience with the patient's complex behaviour observed during a long
period"(4) is probably what inspires confidence to a much greater extent
than a protocol-driven encounter with the diabetic nurse, heart failure
nurse, or rheumatology nurse. Accordingly, when we opt out of "complex co-morbidities and undiagnosable problems" we do so at our peril because, as
we become increasingly deskilled in the art and science of dealing with
complexity, patients will, sooner or later, realise that "the doctor-
emperor" neither has solid experience or, for that matter, "any clothes
on", and that recognition will hasten the demise of our credibility as a
profession.
References
(1) Sambandan S
Lt's return to the "Root cause"
Rapid response
British Medical Journal 25th September 2008
(2) Sharvill J
Protocols, case mix(and costs)
Rapid response
British Medical Journal 23 September 2008
(3) Goldenfeld N., Kadanoff LP
Simple lessons from complexity
Science 1999:284:87-89
(4)Frey U., Suki B
Complexity of chronic asthma and chronic obstructive pulmonary disease:
implications for risk assessment, and disease progression control
Lancet 2008:372:1088-99
Competing interests:
None declared
Competing interests: No competing interests
The current debate would not have risen, if not for the fact that the
workload of doctors had increased tremendously over the last decade, which
led to strategies to reduce this workload by delegating some of the
"lesser problems and technical taks" to Nurses. The Managers loved the
concept, as in their short sightedness, it was more "cost effective". A
Medical doctor has to go through 5 years at Medical School, followed by at
least 2 years thereafter, before spending another 5 years at least to
practice a specialist in Primary Care or Secondary care. None of the other
professions have such a degree of training with apprenticeships and life
long learning, to hone in the experience needed to manage the complex
human problems in a holistic way. Sadly, some Nurses trying to be doctors,
have lost the very essence of nursing - caring,compassionate role that a
nurse should have, which is as important if not more important than the
medical treatment for the patient who is ill. The "healing" of the patient
requires both the doctor and the nurse. Being a Nurse technician doing a
procedure is different from being a doctor. The knowledge and experience
at the other end of the Endoscope does matter.
Competing interests:
None declared
Competing interests: No competing interests
Re: What skills do doctors and nurses need?
I was interested in reading the responses to this article. I have nursed for over 25 years and now I am an Advanced Paediatric Nurse Practitioner in a District General Hospital after a 2+ year training programme.
It's disappointing to hear so many voices ascertaining to 'drs are best', my thoughts are we should be recognising the different attributes all health professionals bring as our job is to look after the patients surely, not our egos?
I'm very fortunate that locally I am not exposed to this frame of mind apart from the odd medical student. Here we very much work as a team, I work within the acceptance of my limitations but can work autonomously assessing, diagnosing, ordering tests and reading results whilst knowing when to refer on. If it wasn't for the role development of nurses we would not be able to sustain a 24 hr service with the reduction in trainee doctors filling posts. So in answer to the question what skills to we need...tolerance of each other, less ego stroking, acceptance of continual professional boundary changes and remembering the patient at the core of what we do!
Competing interests: No competing interests