Intended for healthcare professionals


Bringing nurses and doctors closer together

BMJ 1997; 314 doi: (Published 01 March 1997) Cite this as: BMJ 1997;314:617

Greater cooperation will benefit patients

  1. Norah Casey, Editora,
  2. Richard Smith, Editorb
  1. a Nursing Standard, Harrow HA1 2AX
  2. b BMJ, London WC1H 9JR

    High quality health care depends crucially on doctors and nurses working well together.1 And every day throughout the world they do. Yet centuries after the professions of nursing and medicine were founded they remain curiously apart.1 2 3 Doctors and nurses train separately, keep separate patient records,4 report to different hierarchies, read different journals, and use different jargon. Sometimes these differences result in misery and conflict.1 2 3 4 5 6 The BMJ and the Nursing Standard, for instance, recently described the sad case of a nurse who was suspended after cooperating with a doctor over the management of a disturbed elderly patient.6 7 The professions and, most importantly, patients stand to benefit from closer cooperation,1 3 8 particularly as nurses take on more work that has traditionally been undertaken by doctors.

    Nursing is currently experiencing an intense debate over its future.9 Throughout this century first doctors and then strong nursing theorists and leaders have shaped professional and public thinking about nursing. Now nurses agree that the art of nursing needs to be underpinned by a foundation in science. That scientific foundation is being built, and nursing is emerging as a scientific discipline that is distinct from but complementary to medicine. Politicians, however, increasingly see nurses as the lower part of a medical pyramid of knowledge and skills. This is unhelpful and wrong. If we treat nurses as “minidoctors” then patients will lose the enormous benefits that only nurses can offer.

    There are, of course, important areas of overlap between the professions, and Terence English, a former president of the Royal College of Surgeons, delivered the Dame Kathleen Raven lecture on this subject at the Royal College of Nursing.10 On page 661 he describes how nurses have taken on some tasks previously done by doctors.11 His experience with the team in Cambridge performing heart transplantation taught him how important it is for nurses, doctors, and other health professionals to work still more closely together. But it also taught him the difficulties. He warns that “unless there is dialogue and trust between the groups, one or more of them are likely to feel threatened as their roles are changed.” One way in which doctors and nurses will come to understand each other is through receiving some of their training together and understanding more of each others' roles from the start of professional training. On page 682 two medical students describe how much they learnt from a week working as nurses.12

    As a contribution to encouraging closer cooperation among nurses and doctors, the Royal College of Nursing and the BMJ Publishing Group are this week publishing a mini-issue of a new journal, Evidence-Based Nursing. The first full issue will be published in November 1997. The mini-issue will be launched at a conference on evidence based nursing organised by Nursing Standard and the Royal College of Nursing. The BMJ Publishing Group and the Royal College of Nursing have already cooperated over the journal Quality in Health Care, and those who seek to improve quality in health care learn quickly that little can be achieved unless all parts of the healthcare team work together.8 13 They also learn that making that happen can be hard.

    Those who shudder at the mention of evidence based medicine may feel still more threatened by evidence based nursing. Florence Nightingale complained in 1860 that “No man, not even a doctor, ever gives any other definition of what a nurse should be than this–‘devoted and obedient.’”14 Although this view is still heard today, it is hopelessly outdated. The editors of Evidence-Based Nursing–Nicky Cullum, Alba DiCenso, and Donna Chiliska–describe in the mini-issue how they perceive the nurse of the next millennium15: “We expect nurses to care with their hearts and minds; identify patients' actual and potential health problems; and develop research based strategies to prevent, ameliorate, and comfort. We increasingly expect them to undertake work historically done by doctors; we also expect them to be empathic communicators who are highly educated, critical thinkers, and abreast of all the important research findings.”

    Evidence based nursing, just like evidence based medicine, is about combining clinical skills and experience with the best research evidence.16 Much of what doctors do is not supported by good evidence, medical evidence is disorganised, and many doctors have difficulties finding and critically appraising research. For nurses, the problems are worse. Little evaluative research has been done on the outcomes of nursing care, and nurses experience many problems in accessing and appraising published research.17 Yet a meta-analysis has shown that patients who receive research based nursing care have much better outcomes than those who receive routine nursing care.18

    Evidence-Based Nursing will encourage research based practice. The journal will systematically screen nursing and medical journals to identify original papers and systematic reviews that are scientifically sound and carry a message that is important to nursing practice. The journal will then publish an enhanced structured abstract of the paper together with a commentary that will appraise the new evidence and draw out its importance for practice. In addition, the journal will publish educational articles that will help nurses develop the skills necessary to practice evidence based nursing. We hope too that this joint publishing exercise will foster still greater cooperation between nurses and doctors, and better outcomes for patients.


    • See advertisement for Evidence-Based Nursing in this issue, opposite p 642 in Clinical Research, p 644 in General Practice, p 628 in Compact, and International editions.


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