I am a nurse, and I have the following comment:

First, I think it will be a mistake to think in a competition roles rather than complimentary and integration roles between nurses and physicians. Nurses are not prepared to order drugs, and do surgery,,,etc. and the courses as well as practice for medical students is much far advanced than what nursing students are prepared to in relation to patients treatment. In addition, the specialties in medical models only allows the physician who spent at least 10 years learning to be authorized for some action related to his/her specialty only.

I think nurses can do a lot of work that they don’t do under excuses such as “we don’t have time”, “nurses shortage”, “we are not prepared for doing this…” We don’t want nurses to turn as physician.

The caring job which include; but not limited to: teaching, advocacy, therapeutic communication, observing, hygiene,,,are very important to reflect the positive image for nursing.

It is not enough as a nurse to say that I have 5 years experience in this word, so I know as much as the physician. I   wish that all nurses keep doing the Continue Educations Hours, and keep updating themselves.  

The rise of the medical profession has been successful in maintaining its position of dominance within the bureaucratic hierarchy by controlling access to health care delivery. This has been termed the ‘hegemony of the medical profession’. The medical profession has formed itself as a powerful professional pressure group and although not a complete monopoly, because of the growth of other health professions, has been granted considerable control to maintain self-regulation and clinical autonomy in its work. This dominance, for example, has been blamed for the historical subordination of the nursing profession and a key challenge to nurse empowerment. Much of the power held by the medical profession is supported by the public who expect confidentiality in the special relationship that they hold with their doctor. The medical profession is also dependent on alliances with other health professionals, the government, the private sector, science and activists. It has been careful to create an alignment between both professional and public interests, for example, in regard to the under-resourcing of the UK National Health Service, long waiting times for treatment and the unacceptable demands placed on hospital staff. This professional dominance has also been paralleled with an increase in the legitimacy of medical knowledge, urbanisation, the expansion of health insurance and the growth of bureaucratic settings such as hospitals as centres for ‘professional excellence’. Despite the dominance of the medical profession there have been challenges to its expert wisdom from, for example, the Health Social Movements.

I am a nurse, and I have the following comment:

First, I think it will be a mistake to think in a competition roles rather than complimentary and integration roles between nurses and physicians. Nurses are not prepared to order drugs, and do surgery,,,etc. and the courses as well as practice for medical students is much far advanced than what nursing students are prepared to in relation to patients treatment. In addition, the specialties in medical models only allows the physician who spent at least 10 years learning to be authorized for some action related to his/her specialty only.

I think nurses can do a lot of work that they don’t do under excuses such as “we don’t have time”, “nurses shortage”, “we are not prepared for doing this…” We don’t want nurses to turn as physician.

The caring job which include; but not limited to: teaching, advocacy, therapeutic communication, observing, hygiene,,,are very important to reflect the positive image for nursing.

It is not enough as a nurse to say that I have 5 years experience in this word, so I know as much as the physician. I   wish that all nurses keep doing the Continue Educations Hours, and keep updating themselves.  

I may have to not agree with the above comments and also the perception that Nurses have less authority than doctors.

Firstly, Nursing and Medical practice is 2 different disciplines aimed to worked towards the common goal patient care. As the health care system and model has been devolved so much that we got many disciplines within the system, all disciplines had to work complimentary to have effective patient care. 

Nurses definitely have authority and autonomous in Nursing aspects of the patient care. However we should have a clear scope and boundary of practice for each discipline and should be respected and adhered too. There begins the challenge!

To date we still have Nurses, Medics and even patients and public have the historical view on how the health care system works. Educating the health care professional alone is not enough to change this perception, public and patients should be made aware of the model of care. In recent times, Specialist Nurses are performing all the practices which has been traditionally performed by non consultant doctors. 

Depending upon the role, Nursing role includes but not limited to conducting clinics, assessment, Non- medical or Nurse prescribing, Invasive and Non Invasive investigation and treatment.

We should consider the scope of practice for the individual nurse and their role before making a generalized comment either way.  Unless the care provided is not up to the patient expectation and norms, there is no correlation between the outcomes and who provide the care documented as far as I am aware off.  Personally I don't envisage equal partnership between disciplines unless it is warranted for the individual case which is rare in practice. 

Having observed some of the above comments, i think its much better to admit that nursing and medical proffession  are two different disciplines with  different expectations from clients. Some times after gaining some good experience , nurses forget their roles and start assuming roles of physicians (such as medical prescription). This puts them under attack both in society and in health facilities hence creating  inferiority complex.  I have on several occassions settled arguments between physicians and nurses partaining clinical diagnosis and quit often nurses end up  losing the point not because they dont know,but because they were not trained to do certain things. I also admit  that without nurses, physicians will be helpless.

The nursing and medical professions are very different, and in a perfect world should work collaboratively for the welfare of the patient. However, historically public perception is that the doctors have more authority. In my experience, this stereotype is changing slowly but surely, however the degree of this change depends on a number of different points such as ; patient age and socioeconomic group, environment, and clinical area to name just a few. In my current role as a specialist Clinical Research Nurse, we have a very collaborative approach - however this may be due to each member of the team being an expert in their own field; the nurses being specialists in research practice, and the doctors being specialist in the clinical area the study is focussing on.

The challenges nurses faces as having lesser authority than doctors in the decision making process relating to patient care can be seen from various perspectives. These perspectives are

Environmental, political, and educational preparation

As a Nigerian I will discuss the above listed challenges based on Nigeria context because challenges nurses faces are multi factorial and regionally based. For what is peculiar to one region may not be for another region though there still exist a common factor.

Environmental/societal factors

Nurses face a lesser authority than doctors in patient decision making because of the environment nurses find themselves. There is this public perception that nurse are subservient to doctors, this perception has eaten deep into the fabrics of an average Nigerian. This perception stem from the fact that nursing right from inception especially during the modernization of nursing by nightingale has been predominantly female and from the context of the environment/society which we live in, women are subject to men in all areas of life right from the home to the place of work and in the society in general. So the society who the nurses and doctors served had already had a prejudice that nurses are lesser in terms of authority in patient decision making and also ascribes high status to the doctors whom they held in high esteem in terms of confidential health issues. This has led to one of the major challenges of feminism and gender imbalance in nursing as compare to medicine that is more gender balance.  

Political factor

The environmental/societal factor discussed above gives doctors the opportunity to hijack the politics and policy of the health sector. Such that all units in the health sector is virtually headed by the doctor. For example in Nigeria, the minister of health is a medical doctor, the second in command to the minister is a medical doctor, the various directors in the ministry of health are all medical doctors, these are the people involved in the policy/decision making at the federal state and local government level. Since all these position are saturated by medical doctors are they are in position to make policy and run the politics in the health sector here comes the challenge, that nursing and other health professional are barely recognised when it comes to decision making since all these other health profession including nursing are not in the top bureaucrats or at the policy making level. The highest health decision making in Nigeria is the national council on health. This council on health is being attended by the minister of health, minister of state for health who are doctors, directors of all parastatals in the ministry of health who are also doctors, chief medical director/medical directors of all the federal and state health institution whom are all doctors. Here decisions are taking on how the health sector will be run. There is every tendency that decision taken at this level is in favour of doctors in terms of who and who will be in charge of making decision with regard to the patients since other health professional are not represented and if they are represented their voiced will not be heard because of their insignificant  number.

Educational preparation

Educational preparation of nurses in Nigeria hinders them from being an authority in the decision making in patient care. For example the majority of nurses in Nigeria are prepared in the hospital based school of nursing which is a three year programmed culminating in registered nurse certificate(RN) as oppose to the medical doctor who has a university preparation with a minimum of eight year including national youth service crop programmed. The curriculum for both are quite different in scope and depth. So one can say that the doctor is well and adequately prepared to make a decision on patient care than the nurse. However recently nursing education has started in the university with a minimum of six years as against eight years of medicine with expanded role and scope of learning but has only few who has graduated. Even at that much has not been change as the already established status quo between nurses and doctors still persist. But with time I think things might change for the better for these graduate nurses as they are normally called.

The point here is that the level of education also poses a challenge for nurses in terms of decision making with regards to patient care, but this does not suggest that nurses cannot or are not contributing to decision making in patient care. Nurses in Nigeria do make decision with regards to patient care and there are records which shows the nurses has really contributed to the health sector positively. However I perceived they might do better if their level of education is upgraded at least to a minimum of first degree as entry requirement for nurses in Nigeria.

Does this perception increase patient negative outcomes?

Yes this perception increase patient negative outcome because patient outcome depends highly on team work, collaborative effort of the health team which nurses are the fulcrum, therefore without nurses stamping their authority in decision making process there might be some error which unavoidably will be committed that is subject to nurses detection and correction. Furthermore the coordinating role, advocating role, counselling and caring role etc has a great effect on the outcome of the patient no matter what the doctor does. If these roles due to lack of authority or lesser authority are not well expressed or delivered, the patient positive outcome will be hindered.

Does historical stereotypes that influence current behaviours?

Yes this was explained in the environmental factors above. I will suggest that you read one of my published article MALE CHOICE OF NURSING CAREER AMONG SECONDARY SCHOOL STUDENTS………………… for more explanation and findings on this.

What would equal partnership in an inter-professional team look like?

Equal partnership in an inter-professional team is respecting each other authority in each other’s area. For example nursing and medicine are two different professions with similarity but different scope of practice. It therefore means that each should respect each other idea, decision in as much as it is center on the patient care outcome. Equal partnership is each profession bringing out his or her own ideal based on the patient care and harnessing these ideal to bring out the best for the patient and not segregating because these ideal came from the nurse, therefore it is not good or cannot carry the day. It is team works where ideas are shared and nobody takes the glory rather everybody celebrate the patient positive outcome.

 thanks

Historical stereotypes have a negative effect on how nurses view themselves and/ or by doctors and patients as members of the health care team.  Nurses must not undermine themselves, they are professionals in their own right. Although the superiority-inferiority complex may sometimes not be evident because of the tendency to display a more "friendly'' attitude towards each other. Doctors and nurses are independent practitioners with different scopes of practice but work interdependently as partners for excellence in patient care. While the nurse has an instrumental role, the expressive role is equally important to provide a humane service which is evident in nursing. Empowerment of nurses in patient advocacy, advances in nursing education (including specialization) and research will definitely enhance the role of  nurses and their perception as partners in provision of high quality patient care. 

I am a registered nurse and International Board Certified Lactation Consultant. I know and understand breastfeeding. I have faced many challenges educating the medical community regarding the benefits of human milk for human babies and on the superiority of human milk to artificial formula. The evidence-based education provided to my mothers has been undermined repeatedly by physicians who lack a basic understanding of lactation. However; over the ten years I have worked with these physicians I have earned their respect and confidence in caring for and educating lactating mothers. A key to this respect came from the mothers themselves. Our current generation of mothers are more independent than previous generations. They choose what and who they listen too. The mothers chose to be successful with breastfeeding. This generation is tech savvy and has instant access to the internet and answers to any question. When the physicians saw the success and joy of successful mothers and the health of the babies -they began to understand how important breastfeeding has become. Many midwife, nurse practitioners are also lactation consultants, and over the last few years many pediatricians are also learning more about lactation and earning certifications in lactation. The market influences receptiveness.

Here in Indonesia, we face similar problem with our colleagues in Nigeria. In some places, people see nurses as the "doctor assistant". But slow but sure, that is changing, started from the educational level. We held inter professional education to emphasize the students of medicine, nursing, and other profession that we have different area in caring of the patient.

At the end of the day, every discipline need to earn their respect and trust by their practice and the decision they make on the day to day interaction with multi-disciplinary team. This is ultimately down to the individuals, however, the culture within the Nursing practice is fast changing to scope in the independent practice. Hope in 5 to 10 years time, all this conversation will be history, to make this happen all level of people strategic (Government and Organisation) to floor level Nurses needs to be engaged and culture change should happen.

On the positive aspect, Nurse Practitioners, specialist and Consultant are in rise both in developed and developing country. Even in some of the underdeveloped country there are gleams of improvement already seen (www.icn.ch)

With being in the celebratory month for Nursing practice we should embrace and have positive views and look for ideas and thought to change other views instead of going on about what happened and happening. Lets move forward.

I think that the legal aspect is quite important in this discussion. because sometimes we can have all kind of interactions with our patients,,,then we end up with a statement of let me get doctor`s order. automatically that generate the impression of we power and authority ONLY for physicians . so we should also focus on an aspect of let see your medical options , and then you can negotiate your goals with the attending team who is following your case, give the patient the power...and he/ she will give it back to you! because even patients are treated sometimes in a very paternalistic pattern, they even include themselves in this struggle of power, when it should be a struggle to achieve patients goals. we as an interdisciplinary team, WIN only when achieve what is the patients is expecting from us.

YES, we teach , advocate, care,..and all of the mentioned above tasks. I have found as I practice, that nothing is more powerful than good reliable knowledge, that is up-to-date, and presented in an open forum of communication with the patient, where the patient himself , should feel that he is the one responsible for making any decision after all , it is HIS authority over all of the team. so once you really work on a specialty area, and have strong set of communication skills, and able to genuinely pass that feeling of advocacy to your patients, they will see you differently for sure. and same thing as you start to add in your input and assessments regarding the patients in interdisciplinary rounds and meetings, no one will know more than the nurses, because they are the ones at the bedside all the time, so once you start pitching in, adding your own scientific remarks, and suggesting even alternatives, you can see that the dynamics of the whole team will start changing, bringing balance back to all members in the team, as  matter of fact, nurses are the most powerful players in any team ( forget about legal power here), they are the  liaison persons, ...they are the case managers ( note the terms...only nurses get that, while physician get attending) . it is not about stereotypes or people playing you down, its is about you working hard on yourself, showing your value to patients and teams, you and only you will make  a place an status for yourself, regardless what s the setting of practice, or how long you have been practicing nursing. do not fall in the stereotype that you hate..simple! I can say that new generations ( which i like to consider myself among...) are picking that up, and overcoming what previous generations of nurses used to do ( though that they have paved the way for us, because any beginning, is never easy), and the media influence is never really gone, but if you track the typical role of a nurse in media previously and now, many things are definitely changing,  

Nurses are not doctors. There are probably nurses who are frustrated doctors and seek more authority than they are allowed or capable. I see the roles as very different roles in a patient's life and care. Nurses are trusted, for the most part, by their patients. They are the healthcare provider they see most often, they are the ones that tell them what is happening in their care everyday. If a nurse feels a doctor or any other provider for that matter has ordered something they feel would harm or otherwise not benefit their patient, they should  discuss it with the doctor to obtain a rationale that they can physiologically apply. If I believe it will harm my patient and I cannot agree with the doctor, I go to the Chief Nursing Officer. That is why they are there, to support the nurse and clarify issues with the doctors and/or nurse. I have had to do this on two occasions in my career. I was supported whole heartedly on one report and thanked for my patient advocacy leading to a good patient outcome. I was overruled on the other, and the outcome was not good for the patient. I was a new nurse and didn't quite understand the proper steps to go beyond that level when I felt I didn't  have resolve. If a doctor doesn't have an ego, they will listen to the nurse and value their discussion. They may not necessarily agree but they should be able to give/teach a rationale that substantiates why they are doing what they are doing. Questioning a doctor is not challenging them, it can be a teaching moment. There are times in a nurses career when your patient looks good on paper, vitals etc. but you know something is not right, can't point to it, can't really explain it other than , it is just a sense something is not right. When a nurse calls a doctor and tells them this, good doctors run to see what may be happening. Doctors with egos will ignore the nurse, usually ending in a bad outcome.  I believe we want to make sure the best possible outcome are being considered for our patient. Nurses are part of a team and within teams, everyone should have a voice for the best outcome.