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Is the doctor-nurse game still being played?

  • Comments (13)
  • Article: Holyoake DD (2011) Is the doctor-nurse game still being played? Nursing Times; 107: 43, early online publication.
  • Author: Dean-David Holyoake is a senior lecturer in the School of Health, University of Wolverhampton.

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

Let’s discuss

“Nursing has been so intent and fixated in mirroring medicine that it has turned itself into little more than a clone.”

Do you agree?

To think about:

  • Have doctors tactically delegated tasks to nurses so they can move onto more sophisticated aspects of care?
  • Is it relevant to measure the progress made by nurses in terms of medical functions they undertake?

Follow the debate on Twitter #NTjournalclub

  • Comments (13)

Readers' comments (13)

  • This is being debated in another thread too. I don't want to repeat myself to much, but want to say straight from the bat that THIS IS NOT ABOUT NURSES TRYING TO BE DOCTORS!!! WE CAN BE COMPLETELY DIFFERENT PROFESSIONS WITH COMPLETELY DIFFERENT PARADIGMS AND COMMON GOALS, BUT STILL FIGHT FOR EQUALITY AND PARITY BETWEEN THE PROFESSIONS!!!!

    Right, now that's over with!

    To answer your specific questions "Have doctors tactically delegated tasks to nurses so they can move onto more sophisticated aspects of care?"

    No, they haven't and that is a ridiculous notion. Nurses have taken on a whole range of clinical tasks that used to be purely a Doctors remit, yes. But this does NOT in any way make us mini Doctors or Doctor Wanabes, this make us NURSING professionals who can perform these tasks from a Nursing paradigm, with a wider range of clinical and specialist skills that can complete the cycle of care for our patients and offer more support and better care. I mean, what 'more sophisticated' aspects of care are there exactly? I would argue there are none. There is still a significant way to go, but I believe we will reach a point where Nurses and Doctors can perform a lot of the same tasks from different paradigms, both will be seen as equal in terms of status, respect and professionalism, and who performs certain tasks will depend on which is best for the patient at that time. Take prescribing for example, sometimes a patient may need to see a GP who can prescribe certain medication after an evaluation. Other times it will be more appropriate for that patient to access a Nurse led service and see a Nurse who can perform the same task from a Nursing paradigm. What is needed, is for our profession to get equality and parity with our medical colleagues in terms of professional status and respect, and also for the general public to see us as such, without - as I have said in other threads - always asking the Nurse led service 'shouldn't you ask a Doctors permission to do that? Because make no mistake, professional image and public perception DOES play a vital role here.

    "Is it relevant to measure the progress made by nurses in terms of medical functions they undertake?"

    Yes and no; no because we are still seen as a separate profession with uniquely Nursing paradigms, and yes, to an extent, but only when we are demanding equality and parity with the medical profession. We should be seen as professional equals, not a cheaper option than Doctors. If Nurses are now on a par with medicine in terms of education and qualification (this will become more relevant as more Nurses gain Masters and Doctorates as is very slowly becoming more prevalent) and we perform many of the same tasks, then surely our pay should be more on par too? Surely we should be able to have the professional status, respect and power to determine our own professional practice and working conditions (again, as I said in another thread, can you imagine the threats to our pay and pensions, the job freezes and post cutting, dangerous staffing levels etc, all happening if Nursing wielded the same power as Doctors do? Can you imagine their being any issues around Nursing not having any say or influence 'at the top table' in the new government reforms? No, that's because there wouldn't be!)

    The Doctor - Nurse game IS still being played by some Nurses and a few more Doctors (by no means all), who cling to ancient, defunct and archaic stereotypes. But these views are slowly becoming increasingly irrelevant in professional practice. I think perhaps our biggest hurdle in this Nurse - Doctor game is overcoming the still much more prevalent public and media attitudes and stereotypes of Nursing.


    "Nursing is more dependent on medicine than ever before and medicine still holds all the cards"

    This is still true to a limited extent, but only because Nurses for some inexplicable reason that escapes me are ALLOWING it to be that way!!! Instead of fighting the current Doctor led consortium's for example, Nurses all but rolled over and grinned inanely when we were given token seats like nodding dogs given a biscuit; look at the apathy on strike action for all the other problems that beset our profession. It's no wonder we are seen as 'poor relations' and 'handmaidens' sometimes!!!

    Nursing HAS changed, and it continues to change. But it risks being kicked back down to the dark ages unless Nurses as a whole stand up and fight for it!

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  • Anonymous

    We should just respect each other and treat each other as equals and listen to each other

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  • Anonymous

    The doctor-nurse game would, in my opinion, be very person dependent. I work with doctors who very much value their nurses as professionals who provide a contribution to a holistic, multi-disciplinary approach and also doctors who view nurses as their "doers". I also work with nurses who see themselves as an equal cog in the wheel of the patient journey and those who are much less autonomous.
    The increased diversity of nursing roles has led to an availability of roles requiring experience supported by increased academia. This is surely to be applauded. Fundamentally there are roles which have been created to fill the gap left by the reduction in junior doctors numbers, this does not mean that these nurses are wantobe doctors but rather they are nurses who can provide similar skills from a different standpoint- this is tremendous opportunity for those of us who are old enough to know that the traditional route of nurse was into ward/hospital management or teaching.
    Delegation or devolvement of tasks is a NHS phenomena. Have we considered tasks of the HCA that used to be in jurisdiction of a trained nurse, physio that is in the hands of the physio assistant etc etc. Those nurses who trained in the time where doctors gave IV drugs, took bloods and cannulated must recognise the more timely manner in which these are provided now that they have become embedded in a qualified nurses' role but nurses cannot be all things to all people and there is only a certain amount of time in each day. What are the more sophisticated elements of care the doctors are supposed to be moving on to that nurses are not also moving on to?
    Professional respect can be earned by performance in the same way as doctors. I think, in the main, doctors are not given automatic respect by healthcare personnel anymore....it is earned as an individual and not given as a right. The same should be said for advanced nurses. The claim for equal pay is not fair..we are not doctors and despite MScs (with the occasional PhD) we have not undergone the same training. Pay should be reflected in the banding and job descriptions of individual roles. This is not helped by the NMC dragging their feet in this regard. In my Trust and in my role, my team has earned the trust and respect of our medical colleagues. We sit equally with them in ward meetings as part of the Consultant team where comments and recommendations are valued.The direction of our role has been pushed by ourselves and facilitated through Trust hoops by Consultant support (Trust board level is an arena where frequently the problems arise.)
    It should be a fantastic time to be a nurse....opportunities are continually arising which should be grasped for personal satisfaction. As a profession we should be stressing the positivities and not harping on about doctors v nurses. We are both essential in DIFFERENT ways. After all, nurses will know that it is possible for a nurse (suitably qualified, experienced and trained obviously) to provide holistic care without a doctor but would a doctor be able to do the same without a nurse? However much doctor training has been improved with regards to communication, how often has a doctor changed a bed with a patient in, changed an incontinent patient, given mouthcare ....need I go on.

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  • michael stone

    Anonymous | 31-Oct-2011 4:16 pm

    Sound advice for most interactions, but commonly ignored.

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  • michael stone

    Anonymous | 1-Nov-2011 7:00 pm

    Your post is very rational and well-argued.

    But I am still fascinated, by the 'we have different paradigms, even when we are doing the same thing' argument, when viewed as a patient. You write:

    'Fundamentally there are roles which have been created to fill the gap left by the reduction in junior doctors numbers, this does not mean that these nurses are wantobe doctors but rather they are nurses who can provide similar skills from a different standpoint'

    What intrigues me, is if you are performing the same role as a doctor, in what way will the experience of the patient be different if a nurse does it, or if a doctor does it ? Because from the position of the patient, if the nurse or doctor BEHAVES identically, then 'they are indeed the same'.

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  • michael stone

    mike | 31-Oct-2011 1:19 pm

    As you say 'already stated elsewhere'. Yes, nurse are becoming more 'academic' and more highly qualified, but I am not convinced by your 'nurses are now as qualified as doctors' claim. Yes, there is a 'cloud perception' that doctors somehow 'rank higher' than nurses, and yes doctors do get more pay, etc. But the pay issue, comes down in the end to how easy it is sack and replace a nurse, compared to doing the same thing with a doctor - people are not paid what 'morally/ethically they deserve', but instead they get paid according to how difficult it is to replace them. I'm not saying that is fair - I think the amount of effort someone puts in, should be weighted much higher - but that is what actually happens, in our world.

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  • Anonymous | 1-Nov-2011 7:00 pm, I agree with everything you say apart from the issue of pay. I have never said that we do the same training as Doctors do, but we should absolutely have an increased wage that reflects first of all the degree profession that we are, and secondly the higher levels of Masters and Doctorates that we now undertake. This WOULD bring us comparatively into line with our medical colleagues in terms of pay status and respect. I mean look at any other profession where a Masters degree or a Doctorate is a requirement, are we even on a par with them? No. So why should we as a profession accept lower wages than most?

    Michael, you keep stating that from a patients point of view, if the nurse or doctor BEHAVES identically, then 'they are indeed the same', but it is obvious to everyone that this is blatantly not the case. There is a case of patients not understanding who is who or who to turn to, but you compare a Doctor to a Nurse practitioner or Specialist and there is a world of difference, we do NOT behave the same. The rest of your argument is fundamentally flawed too. First of all, as for the qualifications, yes some Nurses ARE equally qualified. is a Masters not a Masters, a Doctorate not a Doctorate? Is a Medical degree with the honorific of a Doctor, the same as an academic Doctorate? No. An academic Doctorate is longer and takes more training. All are very different of course, but can be weighted equally with many criteria; and that is the crux of the argument. Now, you said "But the pay issue, comes down in the end to how easy it is sack and replace a nurse, compared to doing the same thing with a doctor - people are not paid what 'morally/ethically they deserve', but instead they get paid according to how difficult it is to replace them." I can see what you are saying, but again I disagree, as this would not be happening at all if Nurses wielded the power they have, and got the respect and status we deserve on par with the medical profession.

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  • Anonymous

    michael stone | 2-Nov-2011 10:17 am

    The argument being that nurses generally approach things from the patient's perspective and give the human touch whereas doctors approach from the task perspective. Before anyone gets up in arms I know that is a generalisation but I still believe a nurse gives more rounded, holistic care than a doctor.
    It is reminiscent of the old adage.....its not what is done but how it is done and the same physical action does not always give the same psychological effect.

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  • michael stone

    Anonymous | 2-Nov-2011 8:39 pm

    Thank you - I instinctively agree with you.

    But the difference is what you refer to as 'the human touch'. And my problem, is that many nurses keep writing that they don't have the time, to pay much attention to providing 'the human touch'. They WANT to - but are PREVENTED from doing it by being too busy. Unless there is an OBSERVABLE difference in behaviour - something different when 'felt by the patient' - a different paradigm is irrelevant: it is a case of 'what I do' as opposed to 'why I do it'.

    mike, when you say 'An academic Doctorate is longer and takes more training.' I am not quite certain of that. You say it is true, but as I understand it you do not have either a medical or academic 'title' of Dr. I myself, have one of them - and I suspect that by the time a medical doctor's post-qualification examinations and training/learning are taken into account, your claim is wrong.

    I appears we will not agree on this point.

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  • michael stone

    With the exception of the ‘assumed respect’ issue – admittedly something mike is bothered about – I can’t understand why mike is obsessed with the idea that an ‘academic’ doctorate, is somehow ‘superior’ to a medical title of Dr.

    All having a doctorate ‘proves’, is that you were awarded a doctorate. It is highly unlikely that someone with a science doctorate, will not be fairly good at ‘analytical’ reasoning: so people will assume that is true.

    But NOT having a doctorate, or a degree, or ‘A’ levels, does NOT prove that someone isn’t ‘clever’ (whatever we take clever to mean – here, I will use it to mean ‘good at analytical reasoning’ to retain the theme of the above). An ‘analytical’ argument stands or falls on its own internal validity, and not on who made it: whoever makes an ‘analytical’ claim, it stands or falls on the ‘proof within the suggestion’. It doesn’t matter whether a professor or a cleaner claims something ‘should logically be true, because ….’: you judge the validity on the basis of the ‘….’ and NOT on who made the claim.

    And the ‘perceptual’ truths – the ‘in my own experience this is what happens’ are ALWAYS personally true, because all it is, is a factual statement of what happened to the individual. Whether ‘perceptual truths’ are all equally useful in things such as service design, is a different question – but ANYONE can perfectly validly say ‘that isn’t what happened to me – what happened to me, was ….’.

    And unless the qualifications which mike is so bothered about, are directly connected to the person’s actual job, then they do not matter very much at all: what matters, is whether or not people are doing their job well !

    And from nurses, a nursing doctorate is not, on its own, enough to earn unqualified ‘respect’ – Carter !


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