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The relationship between nurses and medics is pivotal to patient safety and multidisciplinary working, so balancing professional respect with constructive robustness is essential
When the then health and social care secretary Matt Hancock told a conference in 2019 there were still some ‘archaic corners’ of the NHS where nurses were expected to stand up when doctors entered the room, he was lambasted for being out of touch.
Nursing Standard. 37, 7, 40-42. doi: 10.7748/ns.37.7.40.s21
Published: 06 July 2022
Nurses used social media to accuse him of ‘not getting the memo’ about multidisciplinary working, with many stating doctors had great respect for nurses, and that they worked well together as a team.
Mr Hancock’s views on workplace culture aside, few could deny that the nurse-doctor relationship has evolved since his nurse grandmother’s day. Nursing is a graduate profession; its members are no longer considered doctors’ handmaidens. And there is a continued focus on multidisciplinary team working that should help to flatten hierarchies and give everyone a voice.
At least that’s the theory, but does it work in practice? Has the move to a graduate-only profession given nurses more status?
Have new – or relatively new – nursing roles such as consultant and advanced nurse practitioner helped redress the power imbalance? Could the pendulum have swung in the other direction?
After all, Mr Hancock did joke in the same speech that if anything, it should be doctors who stand up when nurses walk in the room.
Having trained in the 1970s, former director of nursing Elaine Maxwell has many decades’ experience in the health service, including a recent ‘hands-on’ spell in intensive care when she volunteered as part of the COVID-19 response effort in 2020.
She says the nurse-doctor relationship has changed since her early days on the wards – but not necessarily entirely for the better. ‘I remember as a night sister in the 1980s that we had good relationships with the junior doctors,’ she says. ‘It was a bit hard [for them] – they practically lived on the wards, because they were doing 100-hour weeks – but they were attached to the wards and they knew us and we knew them. That meant that trust built up – they had confidence in what we did, and we knew them and knew they would back us up.’
Now, she says, for good reason, doctors’ hours have been cut and they change specialty frequently – sometimes every three months – and they cross-cover at night in complex ways.
‘The relationship between nurses and doctors in hospitals has become less close on an individual level. It’s not a fault of the doctors – it’s just the way the system has changed.’
Denise Guzdz, nurse and ambassador for the Civility Saves Lives campaign, advises:
» Recognise that your contribution is valuable to the team and patient care
» Role-model positive behaviour to less experienced colleagues – this includes speaking up
» Be engaged with the whole process For example, in an operating theatre, show an interest and ask the medical team what is going on with a patient rather than staying in the background when you are not directly involved
» Be honest about your level of experience and that includes your training needs
» Ensure your colleagues know you trust them and will back them up
» Assume colleagues also have a patient’s best interests in mind Even if you haven’t had a chance to build up a trusting relationship, go into any interaction making the positive assumption that the other person also wants what’s best for the patient
» Speak up If you are unhappy about the way that a medical colleague speaks to you or behaves, do not be afraid to speak up. Talk to your line manager and, if necessary, approach your trust’s freedom to speak up guardian
Good relationships are vital to negotiate change in a workplace like the health service, says Dr Maxwell, whose PhD research centred on professional jurisdiction and changing roles.
She chose this topic, she admits, because as a director of nursing she had tried without much success to introduce nurse consultants to her trust – and wanted to know how she could have made it work.
‘The conclusion of my PhD is that you’ve got to spend time looking at organisational readiness, negotiate with people, and actually agree a change in workplace jurisdiction,’ she explains. ‘You can’t change nurses’ jurisdiction by legislating for it – you need to make sure that the public accept the change, and you need to negotiate it in the local workplace.’
‘Everyone in a team has something to contribute, everyone knows something nobody else knows’
Chris Turner, consultant in emergency medicine
Building trust is important to enable these conversations to happen, but also to develop a workplace culture where the roles and contribution of different healthcare professionals are accepted by the public and all staff.
Co-creating this respectful culture requires commitment at all levels. Taking social media as a reflection of reality, you might be forgiven for thinking that the nurse-doctor relationship isn’t that good. Twitter, Reddit and Quora abound with posts making claims about nurses bullying junior doctors or doctors mistreating nurses.
Discussion of the relationship between the two professions often descends into heated argument – which can only stoke any tensions that do exist.
704,520 nurses are on the UK register as of March 2022 (excluding dual registrants)
Source: Nursing and Midwifery Council
348,000 doctors are on the UK medical register
Source: General Medical Council
38% of staff reduce the quality of their work after someone has been rude to them
Source: Civility Saves Lives
Civility Saves Lives is a campaign that aims to raise awareness of the power of civility in healthcare.
Founder Chris Turner, an emergency medicine consultant at University Hospitals Coventry and Warwickshire NHS Trust, says: ‘I use Twitter a lot, and find it interesting, but I’m appalled by some of the turf wars that appear to happen.
‘This is particularly the case where it’s two groups of people working in an under-resourced sector. So you have doctors and nurses having a go at each other, which is effectively the poor fighting the poor, rather than looking at the system that’s causing us not to have enough resources.’
There aren’t enough characters in a tweet to reflect the nuance of a situation, and people can become entrenched in a position, which also isn’t helpful, he says.
Having worked in the NHS for more than 30 years, Dr Turner believes that developing good relationships between professional groups is crucial.
‘As you get more senior, your relationships with nurses changes, particularly when you’re in a place for a long time. As a junior doctor rotating through departments, I’m not sure people get long enough to develop good relationships.’
Relationships are incredibly important to high-performance teams, he adds.
‘Everyone in a team has something to contribute, everyone knows something that nobody else knows. And the thing that determines whether or not those pieces of information get out, is do people feel respected in that team? Do they feel that what they are bringing to the party has relevance for other people and will be valued and respected?’
Getting the workplace culture right is vital to good care, says Dr Turner, and that includes having each other’s back.
‘Working in teams in the emergency department, I’ve lost count of the times that nurses have stopped me making an idiot of myself. And people stop you making an idiot of yourself because they trust you, and they know you’re not going to treat them poorly for having called them out on something.’
That trusting relationship also means that if that nurse has made an incorrect challenge, the doctor is not going to give them a hard time, he adds.
‘This becomes about who we are to each other, and treating each other with respect. The longer I’ve been in healthcare, the more I’ve recognised the absolute interdependency of all staff.’
‘A flat hierarchy and viewing each other as colleagues is key – camaraderie helps too’
Stacey Finlay, intermediate care centre unit sister
Denise Guzdz began nursing in 1979. When she started out as a theatre nurse, there was one surgeon who expected the senior sister to lay out scrubs for him, and would only allow two senior sisters to work with him. This had a negative impact on the rest of the nursing team.
Ms Guzdz, pictured, recalls: ‘If we ever had to go in at the weekend for an emergency he would say to people to go and stand in the corner and speak when spoken to.
‘It was a really awkward environment. There were consultants that were getting ready to retire, and the sisters had them on pedestals.’ Today, although Ms Guzdz is semi-retired, she still works part-time as theatre co-ordinator for Sherwood Forest Hospitals NHS Foundation Trust. She says the atmosphere – and relationships between doctors and nurses – has transformed since she started out.
For one thing, consultant surgeons have a team approach, conducting thorough briefings with all staff before operating, and expecting nurses to speak up if something concerns them, or to offer help if they notice a potential issue.
This is good for patient safety as well as team morale, says Mrs Guzdz, who is also an ambassador for the Civility Saves Lives campaign.
‘If I’d been scrubbed up with that particular surgeon who wasn’t nice, then you wouldn’t say if you noticed something – you’d be in fear of saying “have you thought of trying this?” or “do you want this instrument?”.
‘You wouldn’t say anything for fear of looking stupid, being ignored, or being frogmarched out of the theatre by the sister. It’s completely changed now, and people feel able to speak up – and they do.’
However healthcare – perhaps particularly surgery – still has its hierarchies, she says.
‘I don’t think we’re there yet, but comparing it to my time, the change is massive. There’s no way on earth any one of my colleagues would put out a surgeon’s set of scrubs – and there’s no way any of them would expect it either.’
Dr Turner acknowledges healthcare can still be hierarchical, with greater weight given to certain professions. He also believes the professions are regulated in distinct ways, which means nurses and doctors can have different perspectives.
‘The Nursing and Midwifery Council has historically been very rule-bound – if the rules say you do this, you must, and any deviation is the sort of thing you can lose your PIN for. Whereas the General Medical Council has generally taken the perspective that says “what made what you did right in that setting – please explain”. The rules have historically been different.’
Unit sister at Domnall Intermediate Care Centre in Belfast Stacey Finlay believes rather than considering workplace relationships as a hierarchy that focuses on differences between professional groups, taking a team-based, patient-focused approach should be the norm.
‘I’ve always found a flat hierarchy and viewing each other as colleagues or team-mates rather than a nurse being subordinate to a doctor is key,’ she says.
‘It’s about having true respect for each other’s knowledge and skills – and at least a dash of camaraderie helps as well.’
Civility Saves Lives campaign www.civilitysaveslives.com