ACEN - the Australian College Of Emergency Nursing provides trauma and paediatric training courses for nurses

Doctor-Nurse Relationship - A general discussion and review Dr Mwaura

Mt Gambier Emergency Department. Printed in ACEN Express June 2007
Francis Kimani Mwaura was born and brought up in Kenya in a small country town at the foot of the Aberdare Ranges – best known for its Wildlife Safari and as the place where Princess Elizabeth inherited the throne of England in 1952. He graduated from the University of Nairobi in the year 2000 and subsequently worked in primary healthcare in both rural and urban Kenya. He migrated to Australia in January 2006 with a view to serving as the first point of patient contact in a world class health system. Currently he is working in South Australia at the blue lake city’s Mt. Gambier Hospital emergency department. He is married to Dr. Judy Kimani, who shares his vocational interest. Their future hope is to also share the fulfilment of family life and the intellectual and emotional satisfaction of serving as doctors in rural Australia. His favourite pastime is enjoying Aussie slang, jokes and etiquette.

In the beginning, the relationship between doctors and nurses was simple and clear. Doctors were superior; they had the ability to make sick people recover. Nurses (usually a female), on the other hand, supported the patients as they recovered. Nurses did not cure patients. They looked after the patient as they waited for them to get better. They were trained, not educated.

Florence Nightingale: ‘No man, not even a doctor, ever gives any other definition of what a nurse should be than these – devoted and obedient.’

Times have since changed with the introduction of University degree courses (including post graduate degrees) in Nursing. Nurses are therefore now more knowledgeable in their area of specialty. Nurses have become more educated and confident in their work and knowledge and may even stand on equal footing with doctors in some areas. The input of nurses in the general management and decision making in patient care has increased, and so has their ability and power to make suggestions and influence decision making in patient management. Nurses have since been bolder, had more initiative and are responsible for important recommendations.

Currently, being a nurse is more than being a good woman. It is about being a well educated practitioner with independent duties, skills, and responsibilities. With the University degree in nursing, the profession has not only reinvented itself as an associate science to medicine, but has also added an aspect of social affirmation.

Looking back, in 1902, McGregor-Robertson defined the doctor-nurse relationship: ‘A nurse must begin her work with the idea firmly implanted in her mind that she is only the instrument by whom the doctor gets his instructions carried out; she occupies no independent portion in the treatment of the sick’.

In 1917, Sarah Dock was once told by a doctor that as a nurse she was merely an intelligent machine meant to carry out doctors’ orders.

Florence Nightingale: ‘No man, not even a doctor, ever gives any other definition of what a nurse should be than these – devoted and obedient.’ This definition would do just well for a porter. It might do for a horse!

The relationship between doctors and nurses has never been straight forward. The differences of power, perspective, education, pay, status, class, gender, cultural background and perception is a potential for conflicts as often as peaceful existence.

The Australian health system significantly relies on Overseas Trained Doctors (OTDs). What is their experience as far as the doctor-nurse working relationship is concerned? Are there any potential areas of conflict and harmony? Do the nurses view them differently depending on gender and country of origin?

The doctor-nurse relationship has traditionally been a man-woman relationship. It has been a dominant subservient relationship. The two professions were understood as a conventional nuclear family, with doctor-father, nurse-mother and patient-child. Things have obviously changed from this old thinking but none the less, many issues that affect how doctors and nurses work alongside each other stem from that traditional association.

In psychiatry, patients project their fantasies and view the doctor-nurse relationship as that of father-mother, and they expect the two to offer total, unconditional care they expect from their real parents.

In sociology, this sexual stereotype is seen as gender assignation of nurturance and passivity of the female role and decisiveness and competitiveness to the male role (Savage, 1987). Drawing parallels with family roles, doctors assumed positions of head of family, deciding where and how the important work had to be done, while nurses (their ‘wives’) looked after their physical and emotional needs of those dependant on them, whether they be patients, junior nurses or inexperienced doctors (Oakly 1984, Willis and Parish 1997, Gaze 2001).

These gender roles too have since changed with there being more female doctors, male nurses, nurse consultants, nurse practitioners, and clinical nurse specialists.

Experienced nurses are now the ones who initially indict and guide inexperienced junior doctors with the essential aspects of the disciplines (Stein 1967).

In earlier times, nurses used subtle techniques to guide doctors into a decision. In order not to undermine their authority and to avoid inter-professional conflict, this was done in a way that it appeared as if it were the doctors who came up with the decision.

Novice doctors learn to play the game as they progress in their careers. Nurses are taught it even before they graduate. Playing the game successfully has rewards such as good teamwork and mutual respect. Failure to do so results in penalties like conflicts and loss of career prospects.

When Grafti (1974) revisited this issue, he discovered that nurses were either not willing to play ‘the game’ or have even in fact stopped playing. Some ward managers even prefer doctors to be ‘incompetent zombies’ so that they can run the ward in their own way (Grafti 1974).

When the doctor-nurse working relationship is strained, behind the doctors’ backs, nurses can express resentment and act out their feelings (Kalisch and Kalisch 1977).  Some become ‘silent saboteurs’, undermining or sabotaging, in a passive-aggressive way, decisions made by the team (Warelow 1996). Not surprising, some doctors perceive this game as an elaborate charade, in which they feel manipulated by the nurses.

There is a potential for verbal (and perhaps even physical) abuse by nurses, particularly if the doctors’ status for some reason is perceived low, owing to inexperience, youth, gender or cultural background. The ensuing cycle of abuse resembles that seen in families. (Hughes 1988, Marsden 1990).

In the past, (Barbara Zelek and Susan P. Phillips 2003), persistent sex-role stereotypes influenced the doctor-nurse relationship. Nurses were more willing to serve and defer to male doctors. They approached female doctors on a more egalitarian basis, were more comfortable communicating with them, yet more hostile towards them. When nurses and doctors are female, traditional power imbalances in their relationship diminishes, suggesting that these imbalances are based as much in gender as on professional hierarchy. The effect of this change on authority of the medical profession, the role of nurses and on patient care merit further exploration.

Female nurses sometimes describe female doctors as ‘demanding, domineering and bitchy’. Female doctors on the other hand, resent both having to make extra efforts to be nice to nurses, and devising conscious strategies to cultivate egalitarianism and friendship. Female OTDs may experience unequal treatment, more intense scrutiny and lack of respect from nurses. Female OTDs also face a further unique experience with nurses in that they are likely to be met with less confidence and perhaps likely be given less help than their male counterparts. Occasionally there is an unconscious ‘erotic game’ taking place between male doctors and female nurses, making it easier for the male doctor to get along with female nurses.

Do nurses view OTDs as powerful professionals or do they view through the lens of country of origin, religion, social class, and cultural background? Has the traditional authority of doctors over nurses been eroded when that authority arises solely not from professional, but from gender or training status? Furthermore, potential sources of conflicts may be due to jealousy, gender chauvinism, self doubt, insecurity, inferiority complex, arrogance, stereotypes cultural misunderstandings and suspicions, and ignorance on both parties.

Other factors likely not only to interfere with smooth working relationships between doctors and nurses but also have management implications, are poor after-work social interactions, staff shortages, hospital management policies and perceived cultural and gender stereotypes.

Further, factors likely to affect the doctor-nurse relationship in as far as OTDs workplace conflict are concerned might be, multi-disciplinary relationships, status and experience of the doctor and nurse, patient expectations, training and education level, institutional norms, professional norms, risk management and defensive practices by both doctors and nurses.
Whereas the doctor may not be used to being openly challenged by nurses, the latter may be more assertive, educated, and even quite competent than ever before. The nurses may resent the continuous put down and are not ready to be slighted. The doctors, puzzled and unaccustomed to being challenged are themselves resentful at the apparent (or real) undervaluing of their competence, knowledge and skill by nurses. Clearly, a new partnership needs to be forged in this case.

Further, existing facilities need to be strengthened to allow and integrate OTDs into the system, for example by allowing them to observe educational seminars. The observer position helps introduce the OTD to local practice and protocols. Existing team building and other interactive seminars need also to be strengthened and built upon. Female OTDs also need more specific ways of integrating them into the system not only as OTDs, but also as female physicians, thereby bringing into harmony the two professions.

Commitment to open minded dialogue from both professions and letting go of resentment would be a good starting point. This will help to harness talents and commitment and hence improve patient care and satisfaction. We need to rethink and redefine recruitment processes, integration processes and workplace regulations. Perhaps, we all need new communication skills and conflict resolution skill irrespective of background.

From a doctor’s point of view, the OTDs can take several steps to improve the doctor-nurse relationship at their workplace:

• Make sure you know the names of the nurses on the unit, and introduce yourself to new arrivals; involve yourself in the orientation of new staff
• Seek informal opportunities to meet with nurses; spend time in informal chat in the nurses’ office, hearing the issues of the day
• Familiarize yourself with evolving nursing skills and changes to their roles and responsibilities
• Ever considered spending some time with the night staff?
• Make sure that your clinical decisions are well understood by others and that you have covered all contingency plans and set review dates
• When giving instructions make sure that you address them to the senior nurse, who will delegate to other nurses if necessary
• Do not volunteer nurses to carry out a task without asking them first
• If you pick up early signs of disgruntlement, particularly with any decisions that you have made, don’t let things fester, thinking that the problem will go away: be prepared to be criticized and to make changes to your clinical judgments when appropriate
• When delegating, do not presume that nurses are there to carry out menial tasks or that they are less busy than you are: it might take the same time to explain what you want done, as to do it yourself.
• Create a culture in which all team members are encouraged to contribute and air their views
• Discuss with nurses how they can take a leading role in ward reviews, organizing priorities for discussion Be prepared to muck in when there is a crisis: this may involve wheeling a patient to X-ray

When serious incidents occur, such as failed resuscitation, attend and lend support at the debriefing session, share feelings openly with staff involved and present a united front when having to address these issues with managers, patients and carers

• Acknowledge and give recognition to nurses’ skills when the opportunity arises,
• Emphasize the team approach, the need for collaboration and mutual dependency on each other’s skills; refer to yourself as a member of the team
• Be prepared to support nurses when they have arrived at decisions and independent judgments in your absence, even if you have reservations about them or they have had negative consequences; review judgments fairly in open, frank discussion in circumstances where all staff can feel comfortable
• Have regular staff meetings, preferably chaired by nurses, and be prepared to take action when required; meet with the nurse manager and other senior staff to discuss policy, philosophy of care and management issues
• If possible, organise away-days with the team, with workshops and interactive sessions, attended when appropriate by an external facilitator; this will give everyone time to think about topics that you do not have time to deal with during everyday practice
• Be aware that your main role is to contain anxiety in a very stressful environment and one that exerts a considerable emotional strain on the nursing staff; it is expected that senior doctors will ‘sort it out’.

References

1. Questionnaire survey of working relationships between nurses and doctors in University Teaching Hospital in Southern Nigeria. Roseline I Ogbimi and Clement A. Adibamowo 2006.
2. Gender and power: Nurses and doctors in Canada. Barbara Zelek and Susan P Phillips 2003
3. The doctor-nurse relationship. Leonard Fagin and Antony Garelick. 2004
4. The nurse-doctor relationship: a selective literature review. Sarah J. Sweet and Ian J. Norman 1995.
5. The doctor-nurse relationship: how easy is it to be a female doctor co-operating with a female nurse? Gjerberg E and Kjolsrod L. 2001
6. Doctors and nurses: new game same results. BMJ 2000; 320:1085(15 APRIL)
7. Overseas trained doctors. What’s in a name? Ranjana Srivastava and Declan J.Green 2004
8. Doctors and nurses: doing it differently studentBMJ 2000; 08:175-216 June 0966-6494