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OPINION

The image of nursing: The handmaiden

  • 39 Comments

In the fourth of our series of blogs on the image of nursing, Sandy and Harry Summers wonder if to the public nursing is mostly about saying “yes, doctor!” and “no, doctor!”?

About the author

This article was written by Sandy and Harry Summers authors of Saving Lives: Why the Media’s Portrayal of Nurses Puts Us All At Risk

 

People might think so based on the popular media, which still tends to present nurses as the lowly assistants of physicians who direct all important health care. On major Hollywood television shows like House and Grey’s Anatomy, the paradigmatic interaction between the two professions is a bold physician “order” followed by a meek nurse’s “yes, doctor!”.

The “handmaiden” stereotype infects the real health care workplace. Physicians enjoy greater social and economic power, and many of them still see nurses as subordinate. So if physicians engage in or request care that is unsafe, it may be difficult for nurses to resist, even when they must do so to protect patients.

In December 2007, the Associated Press reported that operating room nurses at one U.S. hospital had failed to stop life-threatening surgical errors because they lacked the practical power to do so. And in December 2004 the Times of India reported that, after a local nurse dared to point out to a physician that he had failed to place a used syringe in the proper receptacle, offended physicians chose to “start a fight” with the nurses. Police were called in to restore order.

The handmaiden stereotype also encourages the belief that nurses can be abused with impunity, which is a factor in nursing burnout and the global nursing shortage. In November 2005, South Africa’s Cape Argus reported that research in South Africa, the U.K., and the U.S. suggested that nurses experience disproportionately high levels of violence and psychological abuse by patients and colleagues, especially physicians.

In fact, nursing is an autonomous profession and a distinct scientific discipline. Of course nursing overlaps with medicine, and one element of nursing is carrying out care plans crafted by physicians. But nurses train, manage, and regulate themselves. They have independent legal and ethical duties to patients, with a unique focus and scope of practice, including special expertise.

Occasionally the media has given a sense of nursing autonomy, for instance, describing nursing research or clinical leadership. A January 2010 BBC News report about Scottish medics on their way to war-torn Afghanistan featured authoritative commentary by a nurse who was to be the commanding officer of the field hospital the medics would soon take over. Ian McEwan’s 2003 novel Atonement and Joe Wright’s 2007 film adaptation also include strong accounts of British wartime nursing, showing the formidable authority of senior nurses in World War II.

But in the most globally influential entertainment media today, nurses are peripheral physician subordinates. Nurse characters on House probably speak and do even less than nurses on the other major Hollywood hospital shows, and as a result, the show’s handmaiden portrayal may be the most absolute. The vast majority of nurse appearances involve a character popping up out of nowhere to absorb a physician command, usually in silence; compliance is assumed. 

In an April 2008 episode that included a nurses’ strike plotline, House glibly said that he did not “use nurses.” Leaving aside how dead House’s patients would be without nurses, House could have simply said that he wouldn’t let nurses get near his patients. But “use” suggests that nurses are just physician tools. The show confirmed this attitude in an exchange between House and “dean of medicine” Lisa Cuddy indicating that Cuddy was in charge of the striking nurses.

No one could possibly think, from watching Grey’s Anatomy, that nurses were anything but physician subordinates. The vast majority of nurses who appear are mute servants. Nurses on Grey’s can display resentment and petty vindictiveness when they are abused by their physician masters. And nurse Tyler, a bitter lackey, appears once in a while to tell the physician heroes about the unpleasant tasks awaiting them, but he plainly has nothing to offer patients himself.

In an October 2009 episode, the main Grey’s hospital merged with another hospital, and chief of surgery Richard Webber—who also seemed to function as the hospital’s chief of medicine and CEO—made staff cuts. With no suggestion that nurse managers exist, Webber let many nurses go, including the pathetic nurse Olivia. Surgeon Derek “McDreamy” Shepherd offered to give Olivia a reference, since he doubtless knew her nursing skills well after years of supervising her.

ER certainly offered better nursing portrayals, occasionally even showing nurses providing important care on their own, but the long-running show also repeatedly indicated that nurses report to physicians.

In one December 2008 ER episode, after nurse Sam Taggart had taken time off to care for her injured son, chief of ED medicine Cate Banfield offered to give Taggart more time—clearly indicating that the chief ED physician was Taggart’s boss. And in a November 2007 episode, then-chief of ED medicine Kevin Moretti implemented new triage policies and at one point told Taggart that she was supposed to be covering triage. Taggart complied.

Even Nurse Jackie has suggested that nurses serve physicians. Early 2010 episodes at times indicated that physician Fitch Cooper directed patient care and even had some ability to have nurses fired, despite the presence of the strong nurse manager Gloria Akalitus and the fact that Jackie and her colleagues often provide life-saving nursing care with little or no physician involvement.

The entertainment media is the leading source of handmaiden imagery, but it can be found in the news as well. In September 2006, ABC News (U.S.) ran a report about long A&E waits, after an Illinois woman was found dead of a heart attack in a waiting room after a nurse told her to wait. The piece relied solely on comments from physicians. One advised patients who were dissatisfied with the triage nurse’s actions to “speak to the emergency physician,” as if that physician (instead of the nursing manager) directed triage and the triage nurse.

In fact, the handmaiden may appear anywhere. In February 2007, a New York Times Crossword Puzzle sought the answer “RNS” with the clue “I.C.U. helpers,” again suggesting that nurses are merely physician assistants, rather than central players in intensive care.

And yes, we tried the answer “DRS” first. No luck!

Read more

The image of nursing

*Authors’ note

We use the term “physician” because using the more common “doctor” to refer only to those who practice medicine wrongly implies that they deserve more respect than others.

Nurses and others earn doctoral degrees and make contributions to health and society that are just as valuable as contributions made by physicians. So the honorific should be available to everyone with that degree or to no one.

We also note that “physician” has been used in this way in texts ranging from Shakespeare to recent issues of the British Medical Journal.

  • 39 Comments

Readers' comments (39)

  • I totally agree with the essence of this subject, but I'm not sure I feel this 4th part of the debate is well argued. I'm left wondering whether the writers are American, given their nearly total referral to US drama? I do wonder whether in the US, as in some other countries whether the medic/nurse relationship is different? I confess to not watching Casualty or Holby City, but in the past there was a strong nurse presence in Casualty and I believe a Nurse Consultant in Holby? I stand to be corrected but perhaps the UK media does portray them differently, I believe they have nurse advisors? I caught the end of one show - not even sure what channel - called Super Nurses, and although I only saw the last 10 minutes that programme was showing the work of Oncology Nurses.

    Nurses should NOT be relying on US dramas to spread the word about their level of profession, capability, education or autonomous standing, that is the responsibility of the profession and body's such as the NMC, RCN and Unison - who I feel deserve more criticism than ER or House for not telling it how it is. House doesn't even represent medicine in a good light!

    We have to be stronger and better than to expect others, who are not even in this country to promote us properly, it isn't their responsibility it is ours and part of the problem is we haven't taken that responsibility.


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  • Yes Doctor, no Doctor? Of course the public are geared for that! That is mostly because the general public think that Doctors are the only ones who study and practice Medicine, so therefore they are the only ones who's opinions matter. Oh of course Nurses might know a few things but they are untrained aren't they? Best to check that opinion with the Doctor.

    I'm sorry if that sounds a bit cynical but that is the way it is for the vast majority of people.

    It is about time society came to realise that Physicians are not the only ones who have medical training or knowledge. Nurses also have that, albeit based around a different caring paradigm, but that does not make it any less valid. We are as well placed, if not more so, than many physicians, to offer medical assistance and advice. What is so hard to realise that we are both (Physicians and Nurses) autonomous medical specialists in our own professional right?

    Anonymous | 7-Oct-2010 9:36 am, I get what your saying, but (and I have to admit not watching any of these programmes either), even when Nurses in these programmes (American or British) have a high rank (such as Nurse Practitioner), aren't they almost always STILL seen as inferior handmaidens to the glorious Doctors when they sweep in and save the day, and then embark on an affair with the aforementioned practitioner of course?!

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  • Well, I am working in the US at present and here when a physician writes an 'order' it is exactly that. Even if not discovered until late in the evening ( the physicians don't usually speak to you directly!") you still have to wake the patient to give them the pill or do whatever, right away. It can't wait until the morning however simple it may be. To delay giving something (unless it is actually unavailable or needing to be ordered ) is considered a drug error warranting an incident report!

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  • Philip Darbyshire

    See the latest AMA response to the IOM report on Nursing in the US. http://bit.ly/aqm6vN to see that the old rules still seem to apply. For so many doctors, teamwork means: 'lots of people doing what I say'. What a waste of collaborative and interprofessional potential. In the UK, facing billions of pounds worth of spending cuts, and in almost every other country where health funding will never be 'enough', the idea that we can just keep working away the way we have done for the last 20 or 50 years is just crazy.

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  • I agree Mike, but it is not the responsibility of any programme maker, particularly ones from another country to be responsible for promoting the role of British nurses, particularly when we do such a rubbish job at it ourselves. They are responsible for making entertainment and given the popularity of those programmes they are getting it right and we are not.

    I re-assert my point that our professional and representative bodies are the ones letting us down - not House or ER.

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  • Society is not just going to 'realise' the role of the nurse - we have to educate them to it supported by unions and NMC.

    I don't in honesty 'realise' the true role of other professions or jobs.

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  • These shows are for entertainment purposes only...and its not as if they show medics in a particlularly good light either! They seem to spend most of their time sleeping with each other, getting wasted or arguing amongst themselves. Do you also think that The Bill or Waterloo Road are accurate descriptions for these public servants? Of course not. Those who are sad enough to believe what they see in TV drama/soaps are not going to want to know the reality of life in the NHS (or the police or teaching professions for that matter). If we want to change the image of nursing- and lets face it, only a very small percentage of the public will come into contact with us-we need to be pushing the NMC and unions to present a more positive image of nurses. TV soapland is not the place to expect the truth...

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  • Susan it is very very different here, a Doctor diagnoses a problem and suggests a course of action/treatment, (after all that is their specialty); but then a Staff Nurse would have no hesitation disagreeing with that if necessary and suggesting a different treatment, or if the course of action is sound, will at least use their own clinical judgement (based on best practice) as to how the treatment should be carried out. I would in no way wake a patient up at 3am just to give say pain relief for example (when they are obviously not in pain), (and yes I know thats a blatantly obvious example but I'm tired!lol!) Perhaps things really are that different in the US?

    Anonymous | 8-Oct-2010 2:00 pm, It's not that I disagree with you, you are absolutely right that Nurses are crap at asserting themselves and our so called unions SHOULD be fighting our corner so to speak. It IS their responsibility to be asserting our true role and they (and we as a profession) are failing miserably). But I still argue that the vast majority of the public out there are akin to sheep like zombies when it comes to forming opinions, and television DOES control what a lot of people think (unfortunately). I used an example in one of the previous articles in this series on how that pathetic reality TV can effect public thinking. In that way, if all people ever see on TV is Nurses as inferior and obedient handmaidens, then no amount of 'education' on our part will change their perception of that.

    Finally, Anonymous | 8-Oct-2010 2:03 pm. You may not fully know the ins and outs of every job out there, fair enough, but I don't think there are as many roles (lets just take the major public services for example) that are as misunderstood as Nurses.

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  • Hi,
    Thanks for your response Mike. It is very different here in the US but I suppose they don't know any different! I am very homesick for the UK especially the NHS which is so much better whatever anyone says. Working as a nurse is also better for the reasons you stated. There is a strange paradoxical situation here where they both expect nurses to work independently in the absence of doctors ( reporting changes in condition by telephone ) yet still have this 'orders' system which must be obeyed.

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  • No problem Susan, I was surprised to hear that is the situation in the US, I know that isn't the case in Oz, and I'm pretty sure it isn't the case in Canada either?

    To be fair though, I think even the Doctors over here in the UK do have the same superior ego and the expectation that everyone will follow orders (I think that stems from the past when they did use to be the sole authority on medical matters), but are sorely surprised when they find that Nurses here won't stand for that.

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  • I'm not trying to defend medics at all, I have met some right arrogant individuals, however, probably the majority of doctors I have met have been open to discussion, explanation, and willing to listen.

    I had heard from friends in the US that it was based on the 'orders' system and strange for an NHS nurse, I understood that that had come from fear of litigation, and also that in any case of patient complaint the finger got pointed firmly at the nurse - I would like to hear Susan's perception of that.

    Given that - perhaps the US programmes are a dramatic portrayal of the US situation - we can't expect them to represent NHS nurses - no matter what the people who watch may think?

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  • .Anonymous | 9-Oct-2010 2:23 pm you are right I'm sorry, I was tarring all Doctors with the actions of a minority here.

    As for the case of blame and litigation though, that is certainly true here, the buck does stop with us, not the physicians!

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  • why are nurses so concerned by the virtual reality of tv programmes - it is only entertainment media but which sadly seems to impregnate our culture. does it really matter if a few members of the public are dumb enough to believe what they see on tv is the absolute truth. if nurses are worth their salt, which some are, they are self confident in the work they are doing and their attitudes towards their patients and shouldn't be obsessing about their image.

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  • its all about teamwork around the patient who is central and not about who is more important than who else - those who value their patients and getting on with doing the best job possible don't concern themselves with such trivia.

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  • Anonymous | 10-Oct-2010 11:59 am and .Anonymous | 10-Oct-2010 12:30 pm
    I suggest you go back and read every one of this series of articles and all the comments because I think you've just missed the entire point.

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  • I am not really aware that there is a point!

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  • cinema is cinema and nursing is nursing. don't mix the two and there is no need to watch the entertainment. in fact some of these tv programmes are well researched with the script writers following nurses around in hospital for a period of time so there must be some element of truth and reality in some of them.
    but again those serious about their job have no need to take virtual reality into account it is confidence in what they do that is important.

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  • if you behave in a submissive manner to doctors, patients, managers, colleagues, visitors or anyone else it is human nature that they will take advantage of the situation and treat you accordingly. Grow up!

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  • The problem is that Jo Public DOES believe what they see on Tv and films. Their perceptions of nurses only alters when they are in direct contact with us as professionals.
    There are a group of doctors who look down on nurses as 'failed' doctors and not professional or, god forbid, interllectual equals. God forbid if you question their actions or treatments. I have spent half my professional life arguing with these bastards.
    AND If someone asks me again if I give out bedpans and why I have not married a doctor I shall kill.

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  • if one thinks of or refers to our medical counterparts in such derrogatory terms it is no wonder there is such a divide between the two professions. Such an attitude does nothing to improve interprofessional relationships. Many younger doctors also feel threatened by nurses and fear they may know more than they do or show them up. When on our ward it is up to us to set a good working atmosphere and working relationship and put them at ease. We need good public relations and diplomatic skills as well as all our other positive attributes.
    How can nurses be considered intellectual equals to doctors if one can't even spell the word correctly!
    Besides doctors have a doctorate, which most nurses do not have, to prove their intellectual superiority.

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  • doctors are human beings too and if nurses wish to be treated with respect they need to learn to treat others with respect as well!

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  • Dear oh me. Here is me with all my qualification including two degrees being criticised for bad spelling.
    One has to ask if anonymous, and I hate conversing with someone who will not give their name, has had any experience in the hard world of hospital life argueing with difficult doctors whilst trying to be the patient's advocate. Or even being a patient themselves - as I have - and being at the butt end of arrogant medical staff. I have never called a Medic a bastard to his face you foolish person I am and always have been professional and polite unlike some of the medics I have had to deal with. My personal experience was compounded recently when I was admitted to hospital with severe abdominal pains (gall bladder probs) and was told by the doctor that there was no point in admitting me as the only analgesic he would prescibe was paracetamol. Fortunately the nurses were kinder.Hurrah for us as advocates and why do I attract these dreadful medics? I was plagued by them as a child in hospital aswell before you ask!

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  • there is little point in arguing with someone so bolshy and insulting but there must be good reasons for such a sad attitude.

    I have never called a Medic a bastard to his face you foolish person

    I am certainly not foolish and using these derrogatory terms is cowardly and hypocritical. and yes I also have a higher degree which i don't need to brag about and 20 years of working on acute medical wards in a uni hospital plus further and diverse experience in other areas but I have never seen the necessity to fall into dispute with anyone let alone the doctors with whom I have always worked in partnership and in a climate of mutual respect

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  • from Anonymous | 11-Oct-2010 1:53 pm

    It is so sad that such hostile remarks and attitudes as those above pervade and destroy working relationships on wards and throughout the organisation. This has damaging effects on the reputation of the ward and the team as well as on recruitment and retention of ward staff, also with the results that doctors would prefer not to have to work there.

    those nurses who always pass their own judgements on others are often those who show no tolerance of others, with the exception perhaps of some of their patients, and provide no peer support which is essential for the well-being of all connected with the ward in some way and the inter-disciplinary team.

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  • The arguments above detract from what, until then had been a reasonable debate. And the person who said most doctors have doctorates - no they don't, although certainly some may do so.

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  • What is nursing? I ask this in all seriousness. It is not practicing medicine...or at least it didn't used to be.

    I'm not saying that it's wrong...it just blurs the boundaries a bit.

    Within nursing there are those that want to nurse and those that want to be called nurse but really aren't....and again that's no criticism...it's just the way of the world.

    Nursing is in the state it is in because the leadership over the past 20 years has been non existent.. The diversity of nursing hasn't been recognised, appreciated, rewarded or utilised properly.....and that is why we are still seen as Dr's lackies.

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  • Anonymous | 11-Oct-2010 10:18 am, first of all, Doctors do not actually have a Doctorate, that is a fallacy. The have a Medical DEGREE, which because of the length of time it takes (longer than a traditional degree but not as long as a Doctorate), and because historically they were the sole proprieters of medical knowledge, the title 'Doctor' is an honorific bestowed on them by the academic community. A more correct and traditional term would simply be 'physician'. Anyone who DOES study for a true Doctorate in any academic discipline is - academically speaking - superior to a Physician, and that includes Nurses with a Doctorate in Nursing. So bear this in mind when talking about intellectual equals.

    I respect Doctors and the role they play, it is a very different - if often intertwining - role than Nurses. But I will not accept the attitude, often from Doctors themselves, that they outrank Nurses and are superior to us. They are not, in both respects. To be fair, this attitude is getting less prevalent and is ususally worse in the older Doctors (just as the subservient attitude is still prevalent in many older Nurses). We are EQUALS, performing seperate yet similar roles in the care for our patients. Yes they get things wrong and are corrected by Nurses, just as Nurses get things wrong and are corrected by Doctors. It is a partnership, our two professions support each other and work well together to encompass a full circle of care for our patients.

    Yet despite this being the reality, the image is STILL (amongst some Doctors, some Nurses, and the public especially) that OUR medical opinion and body of knowledge is not to be respected, it is inferior to that of the Doctor and it is them to who they should turn. This has a knock on effect to many aspects of our profession, from lack of respect from the government and the public, low pay and a continued belief that we can be the easy targets for cuts and low pay (please read my post on the 'open letter to the NHS' thread, I asked why the government would not go after a GPs bloated salary for example and continue to cut our already woeful salary instead). ETC ETC ETC.



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  • P Damien, as I said in my last post, Nursing to me is a seperate role from that which a Doctor performs, but it is still closely intertwined. We are not practicing medicine from a physicians perspective, we give medical care from a Nursing perspective.

    And no, Nursing is nothing like it used to be. It is about time that is recognised.

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  • We have a TV in our waiting room that is tuned to BBC 1, which means that patients on a Saturday and a Tuesday sit and watch Casualty and Holby City; and people definitely expect real life to reflect what they see on the TV.

    The attitude of some of our senior medics towards nursing staff tends towards 'I am a doctor and I am superior to you', although a consultant being called 'nurse' by a member of the public because you happen to be female wouldn't help.

    It is not only medics that demonstrate this attitude, I have seen it in nurse practitioners who seem to have lost the word nurse that is present in their title.


    Sometimes I feel dismayed that here we have two sides of the same coin trying to score points off each other, neglecting to see that we are both trying to achieve a positive outcome for OUR patients.

    I will admit that if had a PhD, then I would insist that my ID badge included the title Dr. on it, although my role would still show Nurse. As it is, could I insist on my current title Mr. be included, or could I be mistaken for a surgeon?

    That is another example of the medical professions historical snobbery, calling someone who practises surgery Mr., because they were considered inferior by physicians as surgery was traditionally performed by barbers without training. Now on transition from physician to surgeon adapting the title Mr. is seen as a step up, bizarre.

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  • i have worked with doctors from all around the globe for 40 years and been raised and lived in a doctor's household for 50 years and in a medical social environment but never have i been made to feel inferior as a nurse or female nor had my professional opinion not listened to or accepted by any of them. the only times I have met disrespect is from senior nurses and some peers who also give the same treatment to their juniors, medical colleagues and worse still their patients. it seems to be a question of attitude and if you treat others with respect this will be reciprocated.

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  • I haven't worked all around the globe, or been raised in a doctors household but my experience with medics and some of the nursing profession have a great similarity to Anonymous | 13-Oct-2010 12:05 pm.

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  • conclusion to the above:

    bolshy nurse = bolshy doctor - it takes two! In other words, if you expect respect, treat others the same way. It is up to nurses to create a good working atmosphere on their own wards for both staff, patients and visitors. Entering a ward for whatever reason can be highly intimidating and even more so if the nurses are fearsome, non-welcoming and bolshy or put on a of 'don't bother me, I'm busy' façade even when they are not. A pleasant, open, friendly, helpful and professional attitude costs no more effort than a bolshy and hypercritical one and in fact usually reaps far more rewards. If a doctor or anyone else makes a mistake this can be discussed amicably and non-judgmentally - after all how many mistakes have you ever made, or do you try to hide them? Don't project your worries and insecurities onto others with criticism or blame. Don't expect others to always agree with your way of thinking. There is no problem under the sun which cannot be discussed in order to seek a mutually agreeable soution.

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  • Dear Anonymous (11th October) - don't assume that simply because physicians are called doctors means that they have PhD. Most certainly do not, and the Dr title is purely an honorific title associated with their professional status. Similarly, a PhD is no better a measure of someone's ''intelligence'' than any other qualification. A PhD is intended to demonstrate the attainment of many skills, competencies and abilities, albeit at an advanced level, but intelligence is definitely NOT one of them; which is why I trust the people I work with on the basis of their deeds (i.e. what they do) and their ability (i.e. how well they do it) rather than their titles! There are lots of RNs who have PhDs and many others that could given the chance. There are also lots of "MD's" who couldn't hack it, and many more that could, but don't need to because they have the honorific anyway. Personally, I think that respect has to be earned, not awarded on the basis of your job title or payscale, and that goes for any professinal group.

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  • so what do people then have to do to earn your respect? are you too grand or intelligent to accord it to all human beings who come into contact with you? do you look down your nose at all those who have not yet figured out how to earn your respect?

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  • with the cheaper employment of more nurse assistants in the place of RNs does this mean that nursing will revert back to the doctor's handmaiden role? this could reduce training and employment costs but then doctors would have to taken on more of the more specialised nursing roles and then as the role of the HCAs developed and expanded they would require lengthier and more expensive training setting up a vicious circle and what financial gains would have been made?
    another model would be that of the Latin countries where relatives carry out basic care but then there are in our society a high proportion of patients who are on their own without the support of a family.

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  • Hello fellow-commenters,

    I am working on project regarding nurse stereotype as being doctor's handmaiden, is there any video or episode of some TV show where I can see a nurse pictured as the handmaiden. Thank you very much in advance.

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  • Martina Ondrasekova | 23-Mar-2012 6:24 am

    http://www.youtube.com/watch?v=tvgPsy_iBs8

    might be useful

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  • In my play nurses are strong and able to stand up for themselves

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  • It's an entertainment FGS! Get a grip! The buck stops with the doc or at least it should be-we are not handmaidens but neither are we there to diagnose and God help the pt. if we do.

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