What's happening to nursing?

The traditional division of labour between nurses and doctors is changing

British nursing has notched up many successes in the past decade. Nursing practice, underpinned by radical reform of nursing education, has shifted from a task centred approach towards personalised care; other innovations have improved the quality of care; and research and critical thinking are flourishing. It is an impressive record.

Against this backdrop, understanding why Christine Hancock, that most lucid and reasonable of union leaders, should find herself leading the Royal College of Nursing in an assault on the government may be difficult. Yet, far from feeling buoyed up by their recent achievements, nurses are experiencing what Carpenter calls “a much deeper sense of betrayal than the difference between 1% and 3% in pay (p 338).”1 Something has gone badly wrong. While nurses” concern over pay is real, it has also acted as a trigger for their discontent over the state of the profession and the state of the NHS itself.

This week's articles on nursing provide clues to understanding this paradox (pp 338, 303, 309).1 2 3 Many of the issues are not new: Davies's important new book4 (reviewed by Carpenter1 echoes some of the conclusions of earlier analyses.5 The central predicament of nursing as a woman's occupation in a man's world remains unresolved, while the traditional marginalisation of nursing by medicine and governments continues. These chronic problems have been compounded by the new market culture of the NHS, which leaves nurses wondering whether altruism, compassion, and social justice—the values nursing espouses at its best—have any place in the new world of balance sheets and short term contracts.

The marginalisation not only of nursing but of the values it traditionally represents underlies the confusion and grief felt by many doctors and nurses. Bradshaw and Short, from different perspectives, deplore the apparent demise of tender loving care.2 Their reasoning may be shaky and imbued with nostalgia for a mythical golden age, but many share their feelings. In particular, nurses are desperately trying to maintain their traditional values while finding a place in the new order, in which they are still relatively powerless. This struggle creates dilemmas that epitomise the tensions arising from unpopular NHS reforms.

Nursing work is undervalued partly because of doctors ‘ignorance about it.’ Twas ever thus, but the rules of the game are changing.6 Today's nurses are increasingly likely to be assertive and well educated, while the doctors who symbolise their traditional oppressors are less certain of their ground; consumerism, general management, and politicians have all undermined doctor's authority. This variant of the game adds a new dimension to the debate about the interface between medicine and nursing. Moreover, the distinction between “cure” and “care” seems increasingly simplistic in the light of new knowledge about what makes people better or more able to cope with long term disease or disability and about what protects them from illness. These challenges to the traditional division of labour are being reinforced by pragmatic considerations such as reducing junior doctor's hours. One outcome is the formalisation of what happens informally anyway: nurses doing doctor's work.3 But where will it all end?

The Bristol team's investigations of shifting role boundaries are timely. Based on research rather than reminiscence, their latest study highlights two main directions in which these developments could lead.3 The first, substitution of doctors by nurses,7 is a short term response to medical staffing problems but an undesirable alternative to putting medicine's own house in order. The second is far more promising: expert nurses complementing but not substituting for expert doctors, and together providing a better service to patients.

This was Lempp's experience as a primary health care nursing specialist,2 in a service based not on internecine squabbles over professional territory but on what patients, clients, and their families needed and wanted. It may be unfashionable, but Lempp's call for multidisciplinary training is crucial. Nursing and medicine share a common core of knowledge and skills: could these not be taught to medical and nursing students together, thus diminishing the professional barriers that are usually firmly erected by the time of graduation? Learning together enhances mutual understanding, based on knowledge of people rather than stereotypes. Token efforts that leave the structural inequalities of sex and hierarchy untouched will achieve little, but a radical approach could do much. The next step, involving patients and carers in the learning process, might help destroy those professional barriers for ever.