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“Nurses should defy the deeply embedded doctor-nurse game”

Nurses still need to push for equality with doctors

The “doctor-nurse game”, as described by Stein in 1967, was an oppressive tradition built on a long-standing historical relationship. Stein concluded that both professions would do well to eradicate this “transactional neurosis”.

The game he described was that nurses should be bold, have initiative and make recommendations to influence their patients’ care. At the same time, they must appear passive and make their recommendations appear to have been thought of by doctors.

Such communication strategies came from underlying social assumptions, in this case that doctors were masters and nurses servants. This communication game was just one example of the unjust inequality of professional hierarchy that assumed doctors were superior to nurses. This assumption came from several sources, mainly class and gender oppression.

You would think that these unfair games have been consigned to the dustbin of history. Nurses have been educated in universities since the mid-1990s. We now have nurse prescribers, nurse consultants and nurses with PhDs. Surely, this makes nurses part of the professional class?

Feminist theory and women’s liberation activism have removed the legal impediments to women (and men) joining whichever profession they can gain the qualifications for. Women now make up more than half of all medical students. Isn’t this evidence that the image of the female nurse being ordered about by the male doctor is a thing of the past?

Unfortunately, it would appear this professional imbalance continues. Doctors with equivalent experience and academic qualifications continue to demand much higher salaries than their nurse colleagues at all levels. Male doctors continue to hold the more prestigious and powerful jobs.

Examples of this unequal relationship continue at all levels. Indirect patient care tasks such as venepuncture, cannulation and prescribing are being handed over to nurses because they are too mundane for doctors. Major decisions in patient care tend to remain the responsibility of doctors. Resources for nurses to engage in professional education and research are far more limited than for physicians. Many interview panels for senior-level nurses at both universities and NHS institutions are chaired by doctors, while nurses rarely sit on medical interview panels.

If nursing aspires to be an equal but different profession to medicine, we must start challenging these deeply entrenched inequalities. It will not do for nurses to pretend this imbalance has gone away.

If we cannot fully use our education and experience to influence important parts of patients’ care, we are doing them a disservice.

The existing culture unjustly subordinates nursing to medicine. But culture is entirely constructed by humans so, with effort, it can be changed. Since the 1960s, there has been progress and degree-level registration will help to raise the status of the profession. Nurses must continue to push for equality for their sake and for that of their patients.

Bill Whitehead is senior lecturer, University of Derby

Readers' comments (69)

  • What a load of old tripe. Do nurses really want equality with doctors?
    "If we cannot fully use our education and experience to influence important parts of of patient care, we are doing them a disservice" Nurses carry out the most important and intimate part of a patients care. Doctors should be left to diagnose, manage and deliver the medical care plan - nurses should be left to nursing and prescribe, manage and deliver the nursing care plan. Taken wholly the care plan should be delivered as a team.
    "Indirect patient care tasks such as venepuncture, cannulation and prescribing are being handed over to nurses because they are too mundane for doctors. Major decisions in patient care tend to remain the responsibility of doctors" Are these really indirect patient care tasks? I would suggest that in modern nursing they are an important part of holistic nursing care and major decisions in care are, and always will be, the responsibility of doctors and perhaps the question should be why aren't the doctors and the medical team taking this responsibility?
    I could say more - but let's see what the reaction is first. I wonder whether this article is fishing?

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  • Anonymous | 28-Oct-2011 8:49 am you are absolutely wrong and views like yours are part of the problem that we still face in this profession.

    I think at the moment Nursing is still on the cusp of change (a slow burning one, I admit, but nevertheless), where on the one hand a single autonomous, powerful profession is emerging where Nurses are highly educated and are starting to demand and take charge more, but is still being held back by archaic views and practices (from both Nursing and medical staff), redundant stereotypes in the media and the public, and power imbalances in pay and status.

    At the end of the day, Nurses now are very highly educated, even in the case of Doctorates in Nursing going beyond that of some of our medical colleagues. This still needs to become much more the norm, with a distinct career path leading up to this however.

    We now perform a range of general and specialist skills, including diagnosing and prescribing. These are NOT just 'tasks the Doctors think are too mundane', these are highly skilled tasks that often complete the circle of care for our patients. There is very little a patient may need now that they cannot get from a Nurse. It is even increasingly normal for Nurses to teach Doctors in practice. What needs to happen however, just like in the example of education, is that these skills need to be consolidated and become more widespread throughout the profession.

    And Doctors take ultimate responsibility for patient choices? Do they? Really? In the past yes, and in some cases now, yes. But again, this is changing. It has always for as long as I have been a Nurse the case that if I felt a course of action was wrong, I would tell the Doctor and get it changed. But now there are Nurse practitioners, Nurse specialists, making these decisions too, and again, this is (extremely slowly) becoming more accepted.

    So on the whole, Nursing HAS changed, it IS the academic and professional EQUAL of the medical profession. It is simply that this view is yet to be commonly accepted by all, and that includes Nurses, Doctors, and the general public.

    And it is because of these remnants of an archaic past still dragging the profession down, and a lack of will by many within the profession to drive it forward, that we still do face vast inequalities in pay, working conditions and status, we are still seen by many as the lesser educated, poor handmaidens of the Doctors. This needs to change, and Nurses need to be the ones to stand up, fight, and remind people just who the hell they think they are dealing with?

    Nursing now faces an even greater challenge that threatens to kick the profession back to where it was 30 or 40 years ago, with the political machine taking the view that the only one's worth listening to or giving power to are the GP's, they are unwilling to give us power or say in the new 'consortium's' beyond a few token seats with no real power. They constantly attack our already pathetic pay, our increments, our pensions, we get constantly slandered and slated in the press with our so called professional bodies unwilling to defend or fight for us, etc etc etc. So it is little wonder that we are seen as a 'half' profession, sitting meekly in the corner and asking 'please sir' whilst the media, the public and the medical and political professions give us a kicking.

    At the end of the day, the Nursing profession IS equal to the Medical profession, we simply have different roles as part of the team as a whole, and it is only Nurses who can stand up and DEMAND equal pay, equal conditions, and equal status. But until we do, until those archaic remnants and viewpoints left in the profession are retired or gone, we will still suffer with this ridiculous power imbalance.

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  • Sorry Mike you want Nurses to have pay equal to that of Doctors? Very senior nurses can be paid more than junior doctors and maybe as much as a registrar (quite rightly). But at the end of the day a nursing degree is not the same as a medical school degree. Yes the lines are becoming ever more blurred in some roles but instead of those nurses moaning why dont they admit they wanted to be doctors and should have gone to medical school.

    And I never have any problems with Doctors treating me as a handmaiden, maybe because those days seem to have gone or maybe because i am a confident assertive knowledgeable nurse that they take seriously.

    The issue of pay and conditions for nurses is nothing to do with doctors.

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  • Mike - I wrote the first reply and, having spent my entire working life in care, starting as a Nursing Assistant and working my way up, realise that a medical degree cannot (and should not) be compared with a nursing degree. Yes, we have nurses who have Doctorates, Masters degrees (myself included) and whole range of post-graduate qualifications but nursing remains distinctly different philosophically and in function and as such will never, and should never, be equal to doctors. Do our patients really want this?

    At the end of the day, for the vast majority of patients the responsible Medical Officer has the ultimate responsibility for the patient.

    I agree completely with Sarah - confident assertive nursing is what's really needed. You have to earn power (not a word I would use as it has too many different connotations) and nursing has been gaining more respect as the profession matures, as more of the nurses with Doctorates and Masters degrees publish peer-reviwed nursing research.

    Challenges have been with us for a long time and I believe that the equality gap between all the professions has been narrowing (in both education and professional standards).

    Different roles will always mean different pay, different status and different perceptions.

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  • Sarah, not quite. You are right in that very senior nurses can be paid more than junior doctors. However, what I want is the OVERALL disparity to be addressed. Try comparing a very senior Nurses pay to a very senior Doctors pay, and my point becomes more apparent. The fact is that we are woefully underpaid, and I cannot believe anyone can argue against that.

    You are right in that a Nursing degree is not the same as a medical school degree, but a medical school degree is not the same as an academic degree in Nursing (or anything else for that matter). And despite what you say, the pay levels in Nursing DO NOT in any way reflect the level of qualifications we gain. Part of this problem is the lack of robust career pathways and roles in Nursing too.

    Robert, I think you may have misunderstood me somewhere along the way there. I in no way said that the Nursing profession and the Medical profession should be compared TO each other. What I have said (and repeated on many posts in this 'image' series, is that the Nursing and Medical professions are DIFFERENT, as you say with different paradigms and so on, but should be seen as EQUAL. That is not the same as comparing them. I am a Nurse, I will never be a Doctor, I don't want to be. But I will gain my Doctorate at some point in the future and strive for the echelons of my NURSING profession. As professions, we SHOULD be equal. That does not mean the same.

    I agree with you both about being assertive, but that does not mean I should accept my profession being viewed as inferior to any other, or the profession as a whole not being paid or getting the status we deserve.

    As for asking do our patients really want this? I don't know. I believe many do, or there would be no call at all for advanced Nurse practitioners, Nurse led walk in centres, community Matrons, etc. But there is still a LONG way to go before public perception of a Nurse as an independent practitioner, who can offer the same level of educated and skilled treatment and advice as a Doctor (albeit from a Nursing paradigm) becomes the norm.

    And I completely disagree that different roles will always mean different pay, etc. Perhaps they do NOW, but that does not mean they SHOULD.

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  • As a young adult, aspiring to be a nurse, with the potential of being a doctor yet choosing not too, I want to have my say on this article.

    From my own experience in hospitals, Doctors appear to think they have the upper hand becuase they are the ones with the "upperclass education and degree" yet I consider nurses to be at the frontline of the NHS. Nurses are the ones patients talk to, and trust. Nurses are the ones who help patients with the little things that make their stay in hospital as comfortable as possible, and this is what makes me want to be a nurse. Nurses are so much more hands on, and I for one wouldn't want to be on a par with Doctors because this may turn the profession to be associated with the stigmatism of being better than our peers, and this may then encourage patients to stop confiding in nurses, and nurses no longer helping, thus defeating the object of our role.

    Regarding this talk of pay, senior nurses are often paid more than junior doctors, but I think it quite right that a consultant is paid more than a senior nurse purely because of the effort and time taken to get to where they are, and the level of responsibility they have to endure every single day.

    Nurses can go and get postgraduate qualifications, and yes this is a path I might take, but this doesn't automatically entitle me to a better job or better pay, or put me on a par with Doctors. It simply means I want to reach my full potential which I assume all nurses want to do, and it is their choice how they achieve it.

    On a final note, a doctor is a doctor, and a nurse is a nurse. I know I am stating the obvious, and you may all deem me a young, inexperienced child, but they're completely different roles and I think it wrong that they should be compared with each other.

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  • This debate all hinges on power and who holds the reins to it and who doesn't. I agree it is based on a social construct which is becoming more outdated and yet in some ways more entrenched. Does venepuncture and cannulation represent some kind of emancipation or a weird twist of cloaked submission. If 'tasks' like these are to be empowering to the nursing care and and patient experience then thy must be integrated into a holistic care that is done by a named nurse or team, otherwise it is fragmentation by another name.
    The only way I can see to resolve this ping pong is to create a different ball park where power is shared and no one profession has power or authority over any other. No member of the team is deemed more important or indispensible than any other and therefore no-one gets paid vastly different from anyone else.

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  • George Kuchanny

    The only small thing I can add here is that a senior nurse is very likely to be far more aware of risks to her patient than a junior doctor. At no time should the nurse allow a junior doctor to put her charge at risk. Indeed, even consultants make mistakes that a senior ward sister can spot.

    Having said that, it makes clear sense to resist the rather silly notion that nurse should do whatever doctor decrees without demur.

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  • I would just be afraid that this 'equality' would come at the cost of numbers of trained nurses. Already trusts are trying to reduce the numbers of band 7's . If we are 'equal' the trained nurse will exist in numbers similar to those of doctors and our 'hand maidens' will be HCA's. Nothing will really change we will just continue to see only those with degrees as of any real worth. I do have a degree but I don't regard my colleagues who don't have one as inferior - in nursing experience does count and I know lots of brilliant nurses who don't have degrees.

    All this shows that we are not equal otherwise we would not see it as important to keep comparing ourselves. For me it is more often patients, not Doctors, who think that Doctors are my bosses and don't think that I can do anything without their say.

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  • Mike you are absolutely right on the money!

    Rebecca, just a few points: You say Doctors are the ones with the "upperclass education and degree", well so are we. Nurses are no longer academically inferior top Doctors. The one difference is that a newly qualified staff Nurse studies for post reg quals to gain the same level as a newly qualified Doctor.
    Second, you say , "but I think it quite right that a consultant is paid more than a senior nurse purely because of the effort and time taken to get to where they are," Do you not think it takes time and effort to study for a degree, then a Masters, then a Doctorate, and put in years of service as a Staff Nurse, Charge Nurse, Specialist Nurse, etc??? What a ridiculous statement, I'm sorry but it is.
    Finally, you talk about gaining extra quals and say "but this doesn't automatically entitle me to a better job or better pay, or put me on a par with Doctors" Yes it does!!!!! What other profession in the world would not expect higher pay and status that gaining a Masters or a Doctorate brings? Why should anyone move up that ladder if the professional or monetary rewards are not there to compensate them?

    At the end of the day, it is views like this that has kept our profession down. It is views like this that keeps us vastly underpaid (A staff nurse earns less than a damn tube driver) and allows constant attacks on our pensions and increments! As for the status and respect we have as a profession, again, Mike is right. As a degree profession, as autonomous professionals with Masters and Doctorate level qualifications, we do not have either the permanent career path, posts available or the status and respect that should come with those roles.

    That does not mean we are comparing ourselves to a Doctor on a professional level, of course we are different, but it does mean that we are (or should now be) demanding the same level of respect and status, as well as the pay levels that come with that.

    Anonymous | 29-Oct-2011 12:20 pm, first of all, those Nurses without degrees have the experience on top of the way they were trained, just because Degree Nurses are the future, does not mean we view our colleagues as any less because they were trained differently, even though they seem to think we do. You raise a very good point about staffing though, but if we had the status, respect and power that we should have as a profession, then that would not happen, cuts to staffing levels would not be happening at all because we would not let them! Do you see trusts and the goivernment going after Doctors the way they do us? No. That is because they have the status, respect and power.

    It is about time Nurses started demanding the same.

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  • Well said Kevin.

    I think we need to get away from this thinking that by demanding pay, status and respect as a profession on par with that which our medical colleagues enjoy, we are trying to BE or compare ourselves TO Doctors. That is a fallacy at best! We are an autonomous profession, and why should we NOT demand better pay that reflects our education, qualification, skill and training, why should we not argue for the status of highly educated and qualified professionals?

    Anonymous | 29-Oct-2011 12:20 pm, you argue that it is generally patients and the public which view us in this negative stereotype, I agree, our public perception is a huge, huge problem as I have argued on many threads. But how do you think this will change? It is certainly not be keeping the status quo. It will be by asserting our position as autonomous, highly skilled and qualified professionals! Then patients will see us in such a way, and not see us as inferior to Doctors. Then patients will access Nurse led services without thinking shouldn't you be checking with a Doctor? I could go on with many more examples here, but you get the point.

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  • Mike - I can now see where you are coming from more clearly - getting status and respect on a par with the medical profession is an aspiration I would agree with and fully support. Pay on the other hand is a far more political matter and there has always been, and always will be, a disparity.

    What I would reiterate is that progress over the last few years has been significant in that there is a Career Framework from entry to Consultant nurse status - when I started it was Nursing Assistant, student, Staff Nurse, Charge Nurse/Sister and very often it was dead men's boots for promotion opportunities. The other choice was that it was either stagnate in clinical practice or go into education - there were no Clinical Nurse Specialists, Advanced Practitioners or Consultant Nurses - if there were I may have stayed in clinical practice.

    I know it's not perfect and further walls need smashing down but the growing number of nurse-led services is testimony to progress.

    What I would also add is that nursing needs to progress in partnership with the other non-medical professions.

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  • NUrse are inferior to doctors. if I wanted to be a doctor then I would have gone to medical school , but instead I went to nursing school which did not require A levels. and I did a three year program of education not a 5 year degree. so it is totally inapropriate to to say that doctors and nurses are equal

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  • John Warwick, if you are a Nurse then you are a shame to the profession with views like that and extremely archaic in your information and opinion.

    Robert, Hmm, I see what you are saying about the career pathway, but I do not think the progress is as big as it seems, yes on the surface there are more pathways and roles open to Nurses, but these are disparate at best and often blocked with the dual demons of budget cuts and a postcode lottery of services. And there is still the serious issue of 'dead man's shoes' to progress, with job freezes and cuts. For example, how many newly qualified Nurses cannot find a job as a Nurse in the NHS? How many band 5's are in specialities they do not want to be in because that is all that was available and cannot move? How many Nurses cannot progress because the posts are not there? This should not be the case of course, and I think if Nurses had the status and respect we deserve, then it wouldn't be. We would be able to wield the professional power we have to demand that it didn't happen.

    As for pay, I again have to disagree. There is a disparity yes, doesn't mean there should be or always will be. I am a great advocate for strike action for a great range of issues within our profession, pay being but one of them. I know pay is very slightly off topic, but it does serve to portray the disparity between the respect and status our profession has, and the medical profession, or indeed many other educated professionals have.

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  • john warwick | 29-Oct-2011 8:48 pm

    "NUrse are inferior to doctors. if I wanted to be a doctor then I would have gone to medical school , but instead I went to nursing school which did not require A levels. and I did a three year program of education not a 5 year degree. so it is totally inapropriate to to say that doctors and nurses are equal"

    you are referring to your own experience here. Many nurses are higher up the academic ladder than doctors with higher degrees than them. Some have studied at degree level for five years or more to be awarded with a Masters or Doctorate which many doctors do not have. Both professions have entirely different roles which are essential to the healthcare system which would not function without them. It appears futile to determine equality between members of the professions and even more so to decide which one has superiority over the other.

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  • This is really interesting as you are just playing along with the game. Are we as good as doctors? This is not the point because we are different.
    From a personal view I have a sister who is a doctor. Her training was completely different to mine. She studied in more depth and for longer (6 years basic with an integrated masters in one year). It then took her 5 years and 23 letters after her name to become a GP. She has done something I could never do but that does not devalue my role as a nurse.
    The point is you have to have certain qualifications to be a doctor that are not expected for nurse training. That doesn't make nurses lesser beings, just different.

    Nurses may prescribe and diagnose but fundamentally what is important is our role in essential care and this arguement about being the best is a distraction at a time when nursing has some major problems to deal with as a profession.

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  • Of course there is always the media image, particularly in drama that portrays doctors as nurses bosses.

    Many nurses do follow doctors orders for a variety of interventions. Nurses at higher levels may be acting independently but that is not all nurses.

    I am not saying this a justification for not being seen as equal, just making the point that there are many factors that help perpetuate the image.

    I don't see that a comparison of a junior doctor and a senior nurse is valid. If we must compare then it needs to be junior against junior and senior against senior.

    For myself I don't care about whether or not we are seen as equal - we are different, I can't do what they do - they can't do what I do but we are just as valuable.

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  • bill whitehead

    The point of this as ever is for nurses to be able to provide the best care possible to our patients.

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  • compare apples and pears!

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  • bill whitehead

    oops "Indirect patient care tasks ..." in the article above was a mistype. It should read "Direct patient care tasks ..." sorry.

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