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Is the doctor-nurse game still being played?

The doctor-nurse game first described 40 years ago is still relevant to modern nursing, despite many changes to the profession. Is nursing partly to blame?

In this article…

  • How the doctor-nurse game was first described 40 years ago
  • Why some believe changes to the nursing profession have rendered the game obsolete
  • How the game between medicine and nursing may still be very much on

 

Author

Dean-David Holyoake is a senior lecturer in the School of Health, University of Wolverhampton

Abstract

Holyoake DD (2011) Is the doctor-nurse game still being played? Nursing Times; 107: 43, early online publication.
Forty years ago, Leonard Stein outlined his theory of the doctor-nurse game. In 1990, he revisited his theory and found that the game he had described no longer existed, mainly because nurses were no longer willing to play.
Since the publication of the original theory, attempts have been made to professionalise nursing and to negotiate a sense of identity within the somewhat patriarchal doctor-nurse relationship.
I believe, despite denials from the nursing establishment, the doctor-nurse game continues, and changes to the profession have not been as far-reaching in this respect as hoped.

Keywords: Professional relationships/Game theory/Multidisciplinary working

  • This article has been double-blind peer reviewed
  • Figures and tables can be seen in the attached print-friendly PDF file of the complete article

 

5 key points

  1. The doctor-nurse game says that doctors and nurses share a special relationship founded on role expectations based on power, influence and territory. The nursing role showed respect, acted passively and never disagreed with the doctor
  2. In recent years, nursing has aspired to be a profession and take on greater responsibilities
  3. By 1990, the author of the doctor-nurse game said it was no longer being played because nurses were no longer competing
  4. Yet many of those working on the front line believe the doctor-nurse game is still being played
  5. Nursing is more dependent on medicine than ever before and medicine still holds all the cards

 

In 1967, Leonard Stein wrote an article called “the doctor-nurse game” discussing the relationship between the professions (Box 1).
The notion of the game can be thought of as a metaphor for understanding the dynamics of how the two professions were expected to relate in everyday practice. As such, both doctors and nurses interacted with one another in pre-prescribed and historical ways in which the nurse was always aiming for approval. As noted by Keddy et al (1986) “worthiness was equated with helpfulness to the doctors”. These unspoken about and often-hidden traits, behaviours and expectations determined the nature of nursing identity. Likewise, the idea of a game illuminated the possibility that there are winners and losers.
The historical baggage implicates the fine balancing of the game and imagery from the times of Nightingale’s Victorian housewife through the house maiden in pre- and interwar periods to the sexually liberating 1960s. Thus, the space was set for Stein to think about the nature of the game.
In 1990, Stein and colleagues revisited their theory and concluded that the contest they had originally described had changed largely because, among other reasons, nurses had given up on it.
The nursing establishment also promotes the idea that “the game” is over and no longer relevant in modern clinical practice. Nursing has become more educationally focused, politically aware and eager to raise its perceived status.
According to Closs (2001), Stein et al’s revisiting of the doctor-nurse game in 1990 showed nursing had unilaterally given up the game in what is described as a “hostile” and “stubborn” manner. This suggests the nursing professional did some kind of Educating Rita rags-to-riches turnaround. Rita got educated and refused to play. Yet many patients and nurses I have spoken to do not feel this to be an accurate description. For them, the denial of multidisciplinary conflict conceals the true experience of many frontline nurses when it comes to the nature of the doctor-nurse relationship.

BOX 1. THE GAME CONDITIONS

  • It is against medicine that nursing is determined, objectified and always represented.
  • The game is about systems and discourses as well as the interpersonal. Boundaries and rules are tied up with roles and gatekeeping resources. It suits certain groups to maintain a particular status quo.
  • Ultimately, medicine holds all of the cards.

The history of relational games

During the 1960s, there was an increasing belief that social psychology could offer insights into the way human beings behave in groups.
Game theory is an approach used to try to understand how individuals and groups of people relate. Its principle facets are competition and cooperation. In game theory, participants or groups (called players) engage in some sort of theoretical conflict such as a shortage of resources or an ethical dilemma. This conflict sets up opportunities for chance occurrences, but mostly players make choices that then affect the outcome or payoff.
This sort of analysis has been used to explore aspects of nursing practice (Reeves, et al, 2008; Sweet and Norman, 1995). Game theory has also been used to explore how people are motivated to make moral choices (Axelrod, 2006), and communicate and signal understanding as in the work of Skyrms (1996) and Bicchieri (2006). Theorists such as Sober and Wilson (1998) and McKenzie (2000) have argued that the emergence of group norms or, in the case of nursing, professional standards, are founded on the bargaining and development of attitudes about morality.
These all too very human conditions make the issue of the doctor-nurse game a very real practical concern for discussion in the modern era of healthcare reforms. I believe that the game is far from over and that it is very much game on. In fact, it can be argued that the nursing profession is driven by a number of competing discourses and professional values that substantiate and perpetuate the game.

Knowing each other’s role does not end the game

As noted by Keddy et al (1986) “a look into nursing history confirms there has been an evolution of conflict between the medical and nursing professions”.
I see the present-day game as simply part of that evolution - just more sophisticated and hiding itself. In Stein’s 1967 study, the “culture” was always ordered and binary, black and white. The male doctor always knew best and the nice lady nurse (if she was any good) would follow orders.
Keddy et al cite Hoekelman (1975), himself a physician, who states “the key problem in the nurse-physician relationship is the basic lack of understanding each discipline has for the other’s role in the provision of healthcare”. Here we are 35 years later and this explanation appears to still be perfectly satisfactory.
When Stein (1967) intimated that doctors and nurses played a game that had the aim of maintaining a status quo in the perceived social relationships of both professions, he seemed to be suggesting that it was within the interests of both professional groups to perform in an expected fashion.
And all was well with the game until nursing, as Stein et al (1990) concludes, decided it did not want to play anymore. When they revisited the game, they found nurses had shed some of the handmaiden duties, improved their education and were in a process of redefining themselves. New nursing is too sophisticated to play games - or at least that is how it appears.
In short, nursing seemed to be in a type of identity crisis stemming from an inferiority complex and the illusion that equality was easily within their grasp (Department of Health, 2000a). Nursing extended, expanded and took on duties that previously would have been performed solely by junior doctors. Taking bloods, prescribing and consulting with clients signalled a redistribution of power, influence and game strategy.
But does this really show a reluctance to play the game or rather act as a reminder that medics have happily let go some of their grip in favour of taking a stronger hold of the more sophisticated issues of care - such as commissioning, research, and new technologies?
Manias and Street (2001) highlighted that nurses felt their medical counterparts did not listen to them during ward reviews. Bucknall and Thomas (1995) surveyed 230 Australian nurses and concluded the potential for conflict was due to the physical and cognitive closeness of nursing and medical spheres.
Others have pointed to the need to look at gender power relations (Gatens, 1996; Butler, 1990) to better understand the doctor-nurse relationship.
Sweet and Norman (1995) did a literature review of the doctor-nurse relationship and argued there is much “anecdote and opinion”, but not much empirical research to “establish an evidence base around the impact of patriarchy” on the doctor-nurse relationship (Goodman and Clemow, 1998).
This insistence on empirical truths and a belief that it is both possible and beneficial to establish correct questions is itself an example of patriarchy because it reinforces the larger discourses that promote role expectations and construct the game. If you were to ask nurses about their experiences, they would more than likely say - as they did in the work of Adamson et al (1995) - that they are more dissatisfied with their professional status than doctors.

The difference debate

Discussions of the doctor-nurse game may appear a fun distraction but it goes some way to show how nursing has squandered opportunities. For every nurse who has learnt to take bloods, prescribe medication, become a graduate or argued with colleagues to be called nurse consultant, there are 1,000 who simply see the profession as a practical hands-on affair concerned with care.
The opportunities and career ladders that replicate those of medicine are reminders that the didactic nature of the game is still very much ongoing.
The Wanless Review (Welsh Assembly Government, 2003) assumes that 20% of work undertaken by physicians will eventually be taken up as nursing duties. The nursing profession is still committed to emulating the medical profession by raising its status through the extension of role as opposed to an expansion of its caring definition. The need for association, even acceptance, is a marker of the fact that the game continues.
Who are the players? At the micro and interpersonal level is every nurse, healthcare professional and service user. As just discussed, these people compete against one another within a nursing establishment that includes the governing bodies, media, unions and collaborative organisations. These sectors are not neutral, but rather sustain the game through a process of naturalising, maintaining and manipulating the signs, apparatus and symbols of nursing.
Farrell (2001) describes how aggression and hostility between nurses have undermined their position in relation to other groups. For every nurse manager who argues the game is over, there will be a number of patients and an equal number of newly qualified nurses who will show you exactly how it is for them. According to Closs (2001), it should be possible in the present climate “for doctors and nurses (and other healthcare professionals) to collaborate in a range of activities more often and more successfully”. But any nurse who has waited patiently for the consultant to arrive will tell you that the notion of collaboration is patchy at best and about power.
Nursing has been so intent and fixated on mirroring medicine that it has turned itself into little more than a clone. Like a third-generation photocopy, nursing has strived to be accepted as equal but faded in the attempt. This is because, in the grand scheme of things and put bluntly, nursing is not medicine and, if it was, it just would not be as good.

The effects of redefining

It is true to say that perceptions of the nursing role have changed. There is much literature regarding the power dynamic debate and the assumption that interprofessional working is beneficial for the patient (Zwarenstein and Bryant, 2001; DH, 2000b).
This, of course, is part of the power dynamics that maintain the doctor-nurse game. Attempts to erase difference turn nurses into mini-doctors as opposed to developing nursing.
The game continues to project nursing as being clinically minded like medicine and inadvertently wanting to be more like medicine than medicine itself. It appears that nursing aims to achieve the same status by adopting and adapting to the same values, skill sets, education and career frameworks at the expense of more authentic nursing identities.

The end game

I believe, despite denials from the nursing profession, the doctor-nurse game continues. This is also despite the high-profile promotion of all things multidisciplinary and collaborative. The earlier work of Stein et al (1990) suggested that nursing had given up the game because it had become more educated and unwilling to maintain the status quo.
But I would argue that the game was not the nursing profession’s to give up. The gap between the nursing elite and the everyday majority is wider than ever.
Even though it is astute to think of nursing as too grown up to play games, it remains the case that, through a process of assimilation, adoption and extension of role, nursing is less “different” and therefore more dependent on medicine than ever before.

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