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OPINION

Bill Whitehead: 'Why do nurses feel unable to challenge doctors’ decisions?'

  • 9 Comments

Employers must have supportive structures that encourage nurses to be assertive, says Bill Whitehead

In recent months, nurses have, in some instances, been criticised for failing to challenge medical and managerial decisions where they knew them to be wrong. In a few high-profile cases this has led to patients dying or suffering to such an extent that they have been forced to pursue the healthcare providers through the courts.

Why is still happening? The universities and schools of nursing that preceded them have been advising their students that they are autonomous professionals for decades. That was certainly the case when I registered in the 1980s. Equally, nursing’s professional regulator has long made this clear in its code of conduct.

‘This stems from the long-standing position of nursing as an oppressed profession. Nurses are oppressed by forces that continue to permeate the whole of society, such as gender and economic class’

Something deeper than the educational and legislative process must be going on.

Let’s look at the facts. Nurses and doctors are part of the same multidisciplinary team, striving towards the same goals of providing excellent patient care, diagnosis, treatment and cure. They each seek to have therapeutic relationships with their clients. Both professions have a range of specialisms and roles that encompass the care of the whole person from cradle to grave. What is the difference?

Both professions gain their registered status with bachelor’s degree level academic achievement as a minimum. Nurses generally have one degree after a three-year course and doctors usually have two after a five years, but they are of
equal academic status. Both have a professional regulator with legal power to admit and remove the ability of people
to practise.

Even if this professional equivalency were not the case, academic and professional achievement cannot make a person right when they are clearly wrong.

If we are focusing on the wellbeing of the people in our care, we must be prepared to accept the collective wisdom of the team, rather than rely on the ability of one member of it, no matter how prestigious their qualifications.

In the majority of cases (but not all), the doctor will have lead responsibility for the patient’s treatment. Similarly, the administrators of the organisation may often have a legitimate managerial responsibility to lead nurses. Neither of these positions of power negate the responsibility of nurses to raise their concerns. They are required to do so legally and ethically.

Why is it then that many nurses still feel that they are unable to question the word of medical professionals and corporate managers, even when this is to the detriment of their patients?

This stems from the long-standing position of nursing as an oppressed profession. Nurses are oppressed by forces that continue to permeate the whole of society, such as gender and economic class. Nurses are mainly women and from working-class backgrounds. Therefore, despite our achievement of legal and academic equality, nurses continue to be unfairly oppressed in the same way as other women and working-class people. This position is to the disadvantage of nurses and the people we care for.

To challenge this situation requires courage from us as individuals and collectively via our trade unions and nurse leaders. We also need supportive workplace organisations where we are encouraged to challenge decisions we believe to be wrong, even when they are made by doctors and managers. This requires employers to have supportive structures that encourage nurses to be assertive in their everyday professional lives. Only then will we have a safe environment for patients and a truly professional role for nurses.

Bill Whitehead is assistant subject head for nursing at the University of Derby

  • 9 Comments

Readers' comments (9)

  • bill whitehead

    For some academic support to my comments see my article
    "Will graduate entry free nursing from the shackles of class and gender oppression?" Nursing Times [2010, 106(21):19-22]

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  • Julie Bernstein

    I wonder if there is a cultural difference in this area between hospital and community settings and also between general and mental health nursing. As you say, it has been highlighted as a serious issue through recent high profile cases, but my experience in community mental health has been somewhat different. I have observed many nurses disagreeing with medics, working autonomously and taking a high level of responsibility for leading decision-making about service users in their care.

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  • tinkerbell

    My experience of challenging a doctor, or as I would prefer to call it, having a collaborative chat, has gone one of 2 ways They have either got all defensive and tried to put me in my place (which doesn't work for me) or they have thanked me for bringing it to their attention. As a newly qualified staff nurse we were treating a young mother with supposedly severe post natal depression. She was not responding to any treatment. I asked the ward doctor to do a neurological examination and check the fundus for papilledema. He gave me a withering look but complied and called the medics who later confirmed she had a brain tumour. One of the medics later returned to our ward and asked me 'how did you know she had a brain tumour? I said 'I didn't, it was just a guess'. He said 'well I would like to shake your hand. We shook hands and he left.

    I would like to have been wrong because they informed me there was nothing that could be done to save her, so her baby would be without its mum and her young husband without his wife.

    It took a few moments of consideration & struggling for me to speak up to our ward doctor that day in the office and voice my concerns as he seemed to me a bit of a misery, I remember thinking to myself 'just tell him, go on' and then I blurted it.

    Our consultant always drummed it into us 'the first rule of psychiatry is to eliminate a physical cause'.

    As I have personal, tragic knowledge of brain tumours I couldn't stand back and say nothing.

    I look forward to the day when all nurses feel unhindered to just say what's on their mind regardless of whether they are right or wrong without feeling they are any less entitled or unequal or subservient. Nobody can make you feel that way unless you give them permission. We are there to make a difference, let's make it. I am proud to be a nurse, nothing subservient going on here. I am working class, so what?

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  • The way I look at it, it is my professional responsibility to speak up if I am not in agreement with a doctor's decision.
    I try to do this in a respectful way, as I am well aware that it may be my own deficit in understanding but equally it may be that the doctor has not taken into account all of the factors when reaching a decision.
    I can honestly say there have been very few occasions when a doctor has not responded positively to my query.
    I have been a nurse for 20 years, and I do worry when I see younger/less experienced nurses just accepting decisions when they don't understand the rationale. I try to encourage them to ask questions, and emphasize that it is their professional responsibility to do so.

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  • michael stone

    I think Bill is right about this, in 'general terms'.

    I 'challenge' all manner of NHS-related people, in connection with my end-of-life issues, and in my experience the people who 'engage most' tend to be academic medics, or sometimes academic nurses, followed in descending order by normal medics, and least of all normal nurses.

    I agree with Bill about this:

    'If we are focusing on the wellbeing of the people in our care, we must be prepared to accept the collective wisdom of the team, rather than rely on the ability of one member of it, no matter how prestigious their qualifications.'

    but for my end-of-life at home issues, I want that extending to include relatives living-with the patient (the 'team' becomes GP, live-with relatives and DNs), and that approach depends on a 'yes' answer to this question, which I'm currently using:

    'Should lay and professional carers during EoL, be regarded as in equal possession of non-technical qualities ? So, while things such as clinical expertise should be recognised as varying between lay and professionals, and from clinician to clinician, should qualities such as honesty and the vaguer ‘good intentions’ be assumed [by guidance and protocols] present in everyone involved, unless there is some [clear] proof of ‘wrong doing’ ?

    And I mean proof of wrong doing – not simply ‘confusion’.'


    So far, that question is proving quite challenging, to both nurses and doctors.

    But there does need to be some method of reaching a decision, when people don't agree (although, as it happens, my analysis does settle for opposing legitimate decisions as being equally legally valid: that seems logically true for my EoL stuff, but it doesn't work very well for simpler situations). The NHS, irrespective of who is an independent professional, does LIKE a clinical hierarchy, with a specific clinician (usually a medic) 'being in overall charge of the treatment/case'.

    But if I was ill with malaria, and could take the opinion of a nurse just returned to England after 10 years in Africa, where she had treated hundreds of malaria patients, or of an F1 doctor who had never actually seen a case of malaria, I think I'd go with the nurse !

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  • After 34 years of nursing and now working in a very senior hands on position and teaching others I feel able to speak out but this has often been regarded as 'out of order', stroppy, feminist'- so these days I equip myself with all the facts so that I have an unsinkable rationale - this works for me but it drives me nuts when I hear that behind my back people think I am too stroppy for my own good!! There is one thing for sure you cannot please everybody all of the time - when I am stroppy for this person who cusses me they may one day realise that I am doing it for their own good and as their advocate-c'est la vie!!

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  • tinkerbell

    Kirsty they're possibly jealous, take no notice. Women have a bad press and get labelled 'stroppy' or some such when they are just being confident because they are competent. There's a world of difference between being rude and aggressive. You can be pleasant but assertive and some confuse that with 'stroppy'.

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  • in an open and collegial interdisciplinary team such dialogue is no problem as decision making is a team effort, as it should be, apart from the odd unfortunate character who lacks self assurance and feels attacked when challenged. those with such 'perfectionist' personality traits never like to be perceived to be shown up as being wrong and require more sensitive and tactful handling, that is all, and if that does not work they need further feedback and discussion. don't be afraid to communicate with others, most will welcome it and won't bite!

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  • When I was a student nurse back in the 80s I expressed concern about the professional behaviour of a ward sister. It was made quite clear to me that I would be considered as the un-professional party should I make a formal complaint and that I had better drop it if I wanted to continue in nursing. Things were not much much different when I raised concerns about the professional behaviour of a doctor a couple of years ago. The problem was seen as 'stress' and I was referred for counselling. The doctor continues to behave as he has always done. I would think carefully before challenging another professional again.

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