On Nurses and Doctors

Martin Benjamin is Professor Emeritus of Philosophy at Michigan State University.  Joy Curtis, R.N., is Professor Emerita of Nursing and Ombudsman Emerita at Michigan State University.  Together they wrote, Ethics in Nursing: Cases, Principles, and Reasoning, 4th edition.  The book provides a useful introduction to the identification and analysis of ethical issues that reflects both the special perspective of nursing and the value of systemic philosophical inquiry.  In the post below we learn about the history of the nurse-doctor relationship.

During the earliest period of nursing history, nursing and medicine developed independently and had little contact until recognition of the medical value of bedside nursing brought them together in the late nineteenth century.  With the development of the modern hospital came the introduction of the trained nurse, and patters of relationships in hospitals developed that affect current nurse- physician relationships.  Physicians developed the medical staff, but as a part of that staff, they were not employed by, subordinate to, or responsible to the hospital administration.  Physicians could and did, however, issue orders directly to nurses.  The nursing staff’s position was quite different from that of the medical staff.  Nurses were employed by, subordinate to, and directly responsible to the administration.  Thus, nursing developed under the dual command of physicians and hospital administrators.  The two lines of authority severely limited and complicated the decision-making role of a hospital nurse.

The Nightingale plan for nursing schools, which included instruction in both scientific principles and practical experience, appeared in the United States in 1873.  Unfortunately from American nursing, the schools had no endowment or financial backing, and hospitals quickly seized the opportunity to gain inexpensive student nurse labor.  Nursing education was essentially an apprenticeship, and, as late as the 930s, student nurses received little formal instruction in some hospitals.

Under the dominance of male doctors and administrators, schools of nursing grew, and they were not noted for encouraging nurses to think critically and for themselves.  Students entered nursing schools already expecting that women would defer to men, and therefore, that nurses would defer to doctors.  Adding to the traditional subordination of nurses to physicians, nursing school faculties often culled out overly questioning and rebellious students.  The students’ socialization and education taught them to be deferential.  Many diploma schools included the study of textbooks such as L. J. Morison’s Steppingstones in Professional Growth, published in a revised edition in 1965, which tells the student to cultivate loyalty, prudence, willingness, and cooperation since the physician has the right to expect such qualities.  Further, the nurse must follow orders and uphold the physician’s professional reputation.  Expected by society and trained by the nursing school to act as subordinates, most nurses behaved acordingly.

Yet tradition and nursing education alone cannot be blamed for the dominance of physicians and the deference of nurses.  In the late 1970s, Beatrice and Philip Kalisch argued that a physician who seems himself as an independent, omnipotent man with mystical healing powers relates to coworkers as he does to patients and therefore insists that nurses and other health care providers serve him in his “so-called captain of the ship role.”

The relegation of nursing to the subordinate position in the nurse-physician relationship limited collaboration between the two professions.  Empirical studies showed that physicians were at the center of the decision-making process and that nurses carried out those decisions.  In 1968, psychiatrist Leonard Stein described nurse-physician relationships in terms of a doctor-nurse game in which a nurse must appear to be passive.  In this game any suggestion a nurse makes to a doctor must be masked in such a way as to seem as if it were his idea, and a doctor may not openly seek advice from a nurse.  The historical legacy of nurse-physician relationships, while affecting specific nurses and doctors in various ways, gives decision-making power to a doctor and requires passivity (or biting one’s lip) of a nurse.  If a nurse and physician deviate from this pattern, the exchange of information and recommendations must occur in such a way that the doctor still appears to lead, the nurse to follow.

A study published in 1985 reports, among other things, that the “doctor-nurse game” described by Stein nearly 20 years earlier was still being played.  A resident interviewed for the study commented:

I have seen nurses, who really knew a lot more than an intern, kind of gently guide him [the intern] into making the right decision…They make some very good decisions and make some very helpful suggestions sometimes..It is like trying to guide the ship without actually taking hold of the wheel…There are nurses who are good at that.

A nurse in the same study claimed:

You have to be careful whenever you talk to them [physicians] that you are not telling them what to do.  You have to talk to them in such a way that you are asking their opinion and work in what you want to say without being overbearing or threatening…make them think that the idea is partially in their mind too.

In 1990, Stein claimed most nurses had stopped playing the doctor-nurse game.  But the legacy of the traditional pattern of dominance and deference has continued.  In a 2005 study involving physicians’ and nurses’ perceptions of collaboration and communication, researches found a positive effect on those perceptions following three interventions: “institution of daily multidisciplinary rounds, addition of nurse practitioners, and appointment of a hospitalist medical director.”  Researches concluded, however, that “physicians reported improved collaboration with nurses, but nurses did not improved collaboration with physicians.”

The difference between physicians and nurses in their reports of a collaborative effort is striking.  Physicians may define or view collaboration in a different light than do nurses.  We did not specifically define collaboration for the survey, but it was distinct from communication on the survey.  Perhaps the physicians thought that collaboration implied cooperation and follow-through with respect to following orders rather than mutual participation in decision making.  Although communication is a necessary component, it alone is not sufficient to allow collaboration.  Possibly, communication styles differ between nurses and house staff, so that physicians perceive collaboration whereas nurses feel they (i.e., the nurses) are being ordered to do something.  A second possibility is that nurses did not feel comfortable “challenging” physicians by giving a different point of view.  Or, possibly the input the nurses gave was not valued or acted upon, and thus the interaction was not perceived by nurses as collaboration.

Until the relationship between doctors and nurses can be fully restructured so as to be more collaborative and morally egalitarian, nurses may still have to choose, on occasion between optimally serving their clients and playing the classic doctor-nurse game…