THE DOCTOR–NURSE GAME IN THE AGE OF INTERPROFESSIONAL CARE: A VIEW FROM CANADA

Abstract

Recent headline initiatives for closing the healthcare 'quality chasm' in Canada have been paying for physician performance (Bell and Levinson 2007) and suing hospitals (Annas 2006). Also ongoing are quality improvement, clinical guidelines and information technology (i.e. computerized physician order entry). Despite their respective contributions to enhancing accessible high-quality services and limiting spending, a central obstacle that faces governments and service providers alike is the acute shortage of health professionals — with all projections indicating the situation will certainly worsen as the skilled workforce shortage hits in the coming decades (Health Canada 2006). These issues, along with a heightened public awareness of patient safety issues (Canadian Patient Safety Institute 2002), provide the context for a rejuvenated interest in the healthcare team as the site of both education and service delivery. In Canada, interprofessional collaboration is now the much-vaunted way in which care can be organized and delivered in a safe, effective and sustainable fashion, with high amounts of interest at the federal (Health Canada 2007) and provincial (Health Force Ontario 2007) levels. Given this current preoccupation with collaboration, it is timely to reflect upon the key players in this team, the vexed doctor–nurse relationship, and examine how Leonard Stein's (1967) 'doctor–nurse game' is playing out in this new landscape of healthcare quality, team training and patient safety. Leonard Stein's seminal paper on the doctor–nurse relationship described the rules of an interprofessional game, where dominant male doctors, responsible for diagnosing, operating and prescribing, were being covertly guided in clinical decisions by apparently acquiescent female nurses, supposedly responsible only for 'housekeeping' and patient service. He criticized these convoluted communications, designed to avoid confrontation and called for more openness. When Stein and colleagues revisited the doctor–nurse game some years later, they found that the game had somewhat evolved (Stein et al. 1990). Nurses were beginning to offer direct advice, resist handmaiden tasks, and assert a new role as social and psychological carers. These developments were linked to an equalizing power balance between the genders and changes in the professions, particularly, the increase of female doctors, an ascending nursing status (particularly linked to the creation of nurse practitioner roles) and declining medical status (due in part to the rise of patient access to online medical information and a growth in the influence of clinical management). Stein's observations continue to have resonance today. The relationship shared by doctors and nurses, in essence, remains the same — they are locked together as key partners in the care and cure complex illnesses experienced by individual patients in ageing societies often with reduced social support systems. Healthcare delivery, however, is often unpredictable. It occurs in constantly changing environments, where doctors, nurses and other healthcare providers are often changing due to different shifts, vacation, sickness and professional development activities. As a result, effective collaboration is a difficult task to achieve. Nevertheless, given the link between collaboration and positive healthcare outcomes (Zwarenstein and Reeves 2006), the focus placed on the doctor–nurse relationship by Stein requires us to reconsider its role for patient safety and, more generally, to close the quality chasm. Indeed, for us, what has been strangely absent from the menu of recent quality interventions, but we believe in plain sight of the workplace, has been a focus on the doctor–nurse relationship. As the complexity of delivering care rises, and specialization, task deregulation and role substitution increase, the risk of errors linked to breakdowns or shortfalls of communication becomes a critical issue for all health systems stakeholders. While doctors and nurses are certainly not the only figures in the healthcare team, there is no doubt that the status of medicine and the sheer size of nursing continue to ensure that any successful model of service delivery relies upon the effective collaboration of these two professional groups. The combination of reduced social support systems and the imperative to limit costs and ensure sustainability of services places doctors and nurses in an interesting bind. Collaboration between these professions works to break down boundaries, facilitate communication and create the conditions for a seamless delivery of care. Noble though this goal is, the carefully negotiated historical territory of doctor–nurse relations, let alone the pillars of professional autonomy and responsibility clearly impede the simple transition from professionally anchored care to collaborative care. Although the issue of professional territory and regulatory systems are generally construed as a historical residue limiting a progressive flexibility in workplace and service arrangements, one of the ironies of the current doctor–nurse game, arguably, is that these old adversaries find themselves on the same side of the fence: defending professional boundaries, resisting regulatory and financial restrictions from eager employers and health ministers. For the healthcare team to embrace medicine and nursing, along with the multitude of colleagues in other health fields, it needs to enable professionalism, not destroy it. Ensuring patient safety and a sustainable health budget relies on health professionals, in particular nursing and medicine, reaching a new and much higher level of mutual trust, respect and a more flexible form of collaboration. While this seems to be straightforward, the web of structural factors such as professional power and gender that must be modified to find this new level of collaboration is not going to make this an easy path. The use of negotiation theory — a sociological perspective developed by Strauss et al. (1963) to understand how informal microlevel interactions help create a formal organizational order — may be a helpful agency-based path to explore. As we have previously argued (Zwarenstein and Reeves 2002), regular, ongoing interprofessional negotiation between individual nurses and doctors and other health professionals could help create mutual understanding and respect for the multitude of elements involved in delivering patient care. Over time, collaboration between nurses and doctors may flow from successes at the local level, negotiated individually in a range of different wards, practices and teams.