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Practice comment

‘Anger as medical and nursing boundaries blur is no surprise’

Imagine that the NHS has been transformed into a garage workshop, and assume that my car thinks I lead a double life as Top Gear’s The Stig, or has filled itself with the wrong fuel, albeit free at the point of delivery. I seek help.

Like doctors, highly trained mechanics know what’s going on under more bonnets than Jane Austen could have ever dreamed of. Turning back the clock would probably reveal an obedient nurse busily tidying a set of spanners or folding tow ropes. But this scenario has changed. I now have the choice of asking that my car is jacked up and repaired by the NHS garage nurse, who actually may not be the best person to deal with my car. If the task at hand is too difficult, further advice needs to be sought. And if all else fails, at least I would probably be supported in making healthy lifestyle choices such as “mobilising” to the bus stop.

The workings of the human body are far more intricate than those of the internal combustion engine. Many doctors, having undergone years of rigorous study followed by further professional development understandably feel threatened and angry that the line between medicine and nursing has blurred. How dare nurses encroach on their territory?

Yet despite this, the NHS Careers website describes medicine (and not nursing) as being about “helping people – treating illness, providing advice and reassurance, and seeing the effects of both ill health and good health from the patient’s point of view.”

In the cost-effectiveness versus quality debate, it is little wonder that some doctors may feel upset and fear for their patients’ wellbeing - just consider all the shroud-waving which accompanied the introduction of non-medical prescribing.

But then I wonder how I would feel if GP consortia were to decide on the basis of competitive commissioning that HCAs could emulate nurses? Throw in a couple of study days, and expect unregulated Band 3 HCAs to undertake travel consultations or diabetes reviews? I think I’d be shroud-waving, too.

Both nurses and doctors can have academic backgrounds. Post-qualifying, nurses often undertake further studies in their spare time, and these tend to be partly or wholly self-funded. Yet if asked, not one of these nurses would say that they are doing this because they want the kudos of becoming mini-doctors and looking cool in stethoscopes and scrubs. Instead, they talk in terms of patient outcomes and service improvement. In other words, they are nurses who are proud to continue being nurses.

Nurses and doctors hold the same core values, and there is more that unites us than divides us. Of course, there will always be gaps in knowledge and experience for all clinicians, as the preparation needed for our respective roles differs.

But if we are truly complementary, it seems puzzling that it is easier to have asked whether nurses should ever emulate doctors than whether doctors should ever emulate nurses.  

I’ll have to think long and hard about it – my bus isn’t due for a while…

Jane Warner is locum practice nurse in Somerset; and associate lecturer, General Practice Nursing Foundation Programme, University of Plymouth

Readers' comments (26)

  • The situation is very confused and we seem to have lost our respect for the provision of fundamental care somewhere along the way. I fear that we have also forgotten that is is only by being with the patient that we can ably determine if they are happy, safe, comfortable and responding to care and treatment. If I am ill in hospital I want the best informed person to spend enough time with me to be able to provide the right treatment and the right monitoring. In my opinion this means that I need much of my direct care provided by a well educated nurse ably assisted by a health care assistant. I also want a compassionate team including medical staff to include me in making decisions that affect me and working together as a team instead of in competition. It's okay for roles to be blurred but the false distinction between, and creation of a hierarchy in technical and fundamental care is leading to unecessary dissatisfaction in patients as well as staff. Be proud to care knowledgeably and lobby the Trusts to make it possible to do the work well.

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  • I think it is wholly unfair to compare the Nurse/Doctor debate to the HCA/Nurse debate. As the article states, 'Both nurses and doctors have academic backgrounds. Post-qualifying, nurses often undertake further studies', HCA's do not have this. A Nurse who prescribes for example is wholly skilled and fully academically qualified to do so, as much as any Doctor. 'A couple of study days for an unregulated level 3 HCA' simply does not in any way compare.

    Whilst a Doctor undertakes long and rigorous academic training to obtain their medical Degree, so too a Nurse goes through long and rigorous Degrees. Now a three year Degree does not equate to a five year medical Degree, BUT, the post qualifying Nurse then obtains specific post grad quals in Prescribing, Diagnosing, Specialisms, etc, many going through to obtain their Masters or Doctorates. This brings the Nurse up to the academic level of a Doctor and even surpasses it, as an academic Doctorate takes longer than a medical one (after all the term Doctor is still technically honorary for physicians). Many Nurses now have the academic Title of a Doctor and use that to work within their profession of Nursing to deliver highly qualified Nursing care.

    Now this does not make the Nurse better than a Doctor, but it certainly means that Doctors are no longer the only qualified medical staff able to deliver skilled medical care.

    The difference comes in with the paradigms of our respective professions. Both Doctors and Nurses deliver highly skilled and qualified medical care, but we do so from slightly different, albeit often intertwining, perspectives. We do different jobs all with the same goal in mind, to treat and care for the patient.

    It is about time the Medical and Nursing professions worked together as equals on every level to treat and care for our patients.

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  • Jane- it worries me you lecture with such views.

    The other person is dead right. How you acquire the knowledge that is required to become a 'clinician' can vary, but as stated after a diploma, degree, masters and prescribing I feel well placed to offer a medical component to care. If I didn't: I wouldn't.

    If I turned up to a department I would want the most qualified in the area of care to be dealing with me. Yes, major multiple trauma consultant- but they probably haven't stitched for a while. If it's a sprain I'll take the physio....

    So we need to think laterally as to whose best for what. The biggest criticisim levelled at ANPs is that of standardisation. We have none and we desperately need it.

    It's arrogant to assume that HCA's can't deliver nursing care, but equally too defensive and uniformed to say doctors are
    Medical automitons.... Nursing is an exciting, evolving profession. Not a has been programme about cars.

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  • There should be standardised further training courses for nurses so that it is clear to everybody what further duties they are qualified and competent to undertake. going off and indulging in a course in their free time at their own expense means little and does imply trust in their capabilities.

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  • Anonymous | 6-Mar-2011 8:57 am, I agree, but it isn't arrogant to assume that HCA's cannot deliver Nursing care, it is a fact that they have not obtained academic qualifications to deliver such care.

    Anonymous | 6-Mar-2011 9:15 am, I absolutely agree. The sooner we get standardised post reg qualifications the better.

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  • I am just completing my Nurse Practitioner degree, my husband is a Business Consultant, he can see quite clearly that the problem is "branding". When working at a higher level we need to ditch the "nurse" prefix. It is painful to do , but is the only way to avoid confusion & be taken seriously....but what should we be called?

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  • I really like the idea of nurse physician-this is a good re -branding for me.
    I love being able to take the best from nursing and medicine and put them into the patient care bowl to be mixed and taken as necessary-we are lucky and the patients are too -doctors do not have that luxury of knowing what we do-we know what they do-and take the best bits of that.

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  • Gemma Watford

    Nurses and doctors need to have clear boundaries on their roles as practitioners, in their clinical field. They should not be enroaching onto doctor's territory, and have their clinical duties verified, such as venepuncture, intravenous fluids administration of,wound care, clinical leadership etc. To put it simply nurses should be nurses, and doctors should be doctors, as in the olden days so to speak.

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  • Great points from Mike - the first 'advanced nurse practitioner', the nurse that started to taken on doctors roles was arguably Mary Secole: she was 'qualified' to do so because of how she wad trained by her doctoress mother. The ebb and flow of roles is governed by competency to do the role ie the Bolam test, not by the title of who dies it. Re garages - the last time I put my car into a garage I didn't ask if it was a doctor mechanic or a nurse mechanic, I just wanted to know were they competent. Branding!!! shame on nurses considering dropping the title just for a brand - we're either competent nurse or not, but we're still nurses.
    Lecturer - poor students if that the alleged contemporary views they are being encouraged to consider.

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  • Interesting debate, I'm on a nurse practitioner course and have been encouraged to think that I and my colleagues are leaving nursing behind in recognition of this new role. Shocking to begin with but having been on it a while now I actually agree to some extent.
    Being a nurse practitioner does not equate to a better nurse as it is profoundly different. It does require a very different modus operandi whilst retaining all nursing experience as well (as a goldmine), something like being bilingual.
    It also depends on the context you are practicing in as to how this is weighted.
    I like the nurse physician, having just read that, as a title and indication of skills and role.
    For those that would prefer the traditional boundaries and glass ceiling approach I'm afraid your days of your comfort zone are very numbered. We are here and things are changing, in this in my opinion for the better.

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  • so where do the poor patients fit into this tug of war? what they need is decent bed side nurses looking after them properly and employers want nurses who accept reasonable salaries and pension schemes. the nhs cannot afford the luxury of these pretentious nurse-doctors.

    or if you want it all your own way, get more pay but then expect you and everybody else to pay for their own health care. the very concept of paying for healthcare makes all brits up in arms but there are ways of supporting this without leaving them worse off if it is properly managed as in europe then we could afford more of these nurse-doctors or doctor-nurses, but I suspect it is more of an ego trip for a fancy title than anything else and will add even more to the confusion of other healthcare workers, their patients and the general public!

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  • Anonymous | 10-Mar-2011 2:58 pm
    Wow! You don't get it do you? And so rude as well.
    Second thoughts I'm not going to respond to such ignorance and determination to offend.

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  • Anonymous | 10-Mar-2011 4:00 pm

    patients and colleagues can do without this attitude. the central focus is quality nursing care not collecting accolades and titles.

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  • µ | 10-Mar-2011 5:15 pm
    I agree and neither is about 'collecting mere titles'. Its all about care of people and how to do that to the best of our ability with humanity. Your attitude does no-one any credit.

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  • it would good if these comments could be used as an opportunity for intelligent and objective debate otherwise it is a waste of time reading them!

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  • I feel Janes comments are a little narrow minded. I agree that as a profession we should continue to provide "nursing care", but what that involves should match care delivered care to the patients needs. Why should a nurse not diagnose and treat there and then rather than delaying and waiting for a doctor?

    The important factor is about competency and recognising your personal limits regardless of whether you are a doctor, nurse or health care assistant. We are moving towards an age where we have more elderly people and more people with long term health problems than ever before. The landscape of nursing and healthcare has to evolve to meet the demand.

    I have a Masters degree in Clinical Nursing, a non medical prescribing qualification and have been practising at an advanced level for 10 years. I can clearly understand the difference between my role, that of the doctor and that of advanced health care assitant roles (such as assisitant practitioners).

    Furthermore, Jane's arguement is a little confused due to her job title. Where did Practice Nursing orginate from? Didn't GP's do long term condition management prior to training up nurses to do the job?

    Enjoy the autonomy and the collaboration. I for one do not wish to return to the days when nurses career progression and role definition was dictated by medical "superiority"

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  • Anonymous | 10-Mar-2011 2:35 pm and Anonymous | 11-Mar-2011 4:55 pm Well said!!! I completely agree!

    To all the others who would rather a Nurse be barely more than a HCA, and say those of us who improve our practice are simply 'collecting titles' instead of caring for our patients, then you should seriously take a look at your own practice. To me, caring for a patient means a lot more than simply 'being at the bedside'. It is about delivering highly effective and skilled clinical and medical care too. The ONLY way to do that IS by gaining extra qualifications, Degrees, and yes, those aforementioned titles. If I simply wanted to be at the bedside and deliver no medical/clinical care, I would have remained a HCA.

    The glass ceiling in Nursing is finally being broken, and I for one will not allow old fashioned attitudes drag me back down to the handmaiden status of yore. If those of you who want to remain down there in your comfort zones, then I suggest retiring and allowing those of us who want to be a modern NURSE (and I like the term Nurse physician too for higher bands) with all the new connotations that advanced practice, degrees/Doctorates and so on bring with it, to get on with our careers and bring our profession up to the level it should be at.

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  • mike | 13-Mar-2011 12:18 pm

    making assumptions again about individuals you know nothing about or what experience or qualifications they hold! Some may not even be nurses but these pages are open for all readers to contribute comment and it is also valuable to hear about nursing from other perspectives. this is what advances debate and drives change instead of the narrow views often displayed here.

    this comments area is designed to be a platform for this debate and not for making childish judgements and attacks on others which do not uphold the values of the nursing profession!

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  • male nurses cannot even aspire to being 'handmaidens' perhaps there is a substitute
    title for them! In fact during this era there weren't even male nurses although there were male orderlies at some stage, probably mostly in the military. Who was the very first qualified male nurse to come onto the wards?

    handmaid (also handmaiden)
    n noun
    1 archaic a female servant.
    2 a subservient partner or element.

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  • "To all the others who would rather a Nurse be barely more than a HCA,..."

    this is offensive to both registered nurses and to HCAs both working in the own right. and professional nurses have an obligation to keep their practice up to date!

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