Educational Research Applications(ISSN: 2575-7032)

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Changes in Professional Relationships between Doctors and Nurses in the Face of the Challenges of Modern Medicine in Poland

Piotr Pankiewicz1, Małgorzata Filanowicz2*,JErenc3, Magdalena Lemska4, Anna Maria Strzałkowska3

1Department of Psychiatry, Medical University of Gdańsk, Poland

2Department of Internal Medicine Nursing, Collegium Medicum in Bydgoszcz,Nicolaus Copernicus University in Toruń, Poland

3Department of Socjology, University of Gdańsk, Poland

4Department of Sociology and Social Pathology, Medical University of Gdańsk, Poland

*Corresponding author:MałgorzataFilanowicz, Department of Internal Medicine Nursing, Collegium Medicum in Bydgoszcz,Nicolaus Copernicus University in Toruń. 11, Gagarina Street, Poland. Tel: +48501601780; Email: gosiafilanowicz@cm.umk.pl

Received Date: 07September,2017; Accepted Date: 25 September, 2017; Published Date: 02 October, 2017

 

1.      Abstract

Fighting for the life and health of the sick is a real essence of ethics and a common denominator for the medical and nursing professions. The particular importance of this relation is determined by the fact that it co-determines the effectiveness of restoring the patient to health. 

Aim:The purpose of this study is to describe the relationships between two main groups of health care workers, i.e. doctors and nurses, in Poland. 

Method: The data collection method was that of Focus Group Interview (FGI).The interview was carried out according to a previously prepared outline, i.e. a separate interview for each focus group (one for the doctors and one for the nurses). The purpose of the study was, among other things, an attempt to answer questions about the expectations of the groups surveyed and the possible solutions in building a doctor-nurse relationship. 

Results: Diagnosing and determining the core and causes of antagonism are intended to describe and remodel professional relationships in order to form professional therapeutic teams which will be based on real partnerships and which are responsible for the health and well-being of patients and meet the expectations of modern medicine. In practice, they should make the system more efficient and improve the quality of service in medical institutions.

Conclusions: 1- Today, modern understanding of vocation and willingness to serve people in both professions equal professional help and empathy. 2- The role and obligation of continuing education are currently included in the medical professions; the reason for that is the rapid devaluation of knowledge and changing social expectations. 3- It is necessary to work out a set of principles that will help to form effective and well-integrated therapeutic teams. And this should be done at the university level by introducing changes to the curricula. 4- Professional dominance should evolve into partnership and collaboration where the rules are clear and changes in formal regulations are introduced.

2.      Keywords:Doctor; FGI; Nurse; Relationships

1.      Introduction

Dynamic changes in the twentieth and twenty-first century which are closely related to the technological and institutional progress as well as the continuous growth of knowledge and opportunities in medicine, have a direct impact on social relationships among the medical staff, particularly on the relations among members of a primary therapeutic team, i.e. between doctors and nurses. This makes us reflect on what the interaction among modern medical staff should look like and what social expectations towards them will be in the future. The original principles of collaboration between the doctor and the nurse used to reflect a higher position of the former and his/her professional authority. This was often highlighted by L. Stein, among others, in his famous article which was often treated as a certain basis for the interpretation of the primary medical roles. Already in the late 1960s he paid attention to the ongoing game around professional relationships among doctors and nurses [1].Professionalization of medical jobs in modern societies means that both the doctor's and the nurse's professions call for a specific set of skills and activities that have been socially determined and legally defined as well as the required knowledge which includes professional competence [2]. 

Medical staffs as well as nursing staff have specific social roles to fulfill that are determined by three types of conditions:

1.              Expectations determined by the rights and duties, cultural patterns and differentiated by the specific place of the individual in a particular social situation, e.g. in relation to the patient or in the professional group of doctors or nurses;

2.              Social position: a place of the doctor and the nurse in the system of social relations;

3.              Behaviour of doctors and nurses who hold certain professional positions and participate in the interaction with the patient or other partners in their professional groups. 

Both professionalization and social roles of the medical professions alongside the above mentioned common conditions point to "The relationships between the doctor and the nurse, which are determined by both the formal attributes of their professional positions and the psychosocial conditions characteristic of the representatives of both occupational groups". It should be added, however, that all these relationships are embedded in the social system whose "/.../ determinants such as value systems and attitudes towards various elements of culture related to the cultural environment also play an important role"[3]in both medical professions. 

2.      Historical Similarities in Shaping the Ethos of Medical Professions 

In the mid-nineteenth century, the notion of a significant role of physicians in shaping reforms and participation in social activities was firmly established. This was also the time when the ethics of the medical profession based on the principle of vocation and almost "Priestly Ministry" started to evolve. W. Biegański wrote that "The one who is not a good man will not be a good doctor" [3].

In a similar vein, we can talk about shaping of professional nursing. The pioneer of the secular professional nursing care was an English social activist Florence Nightingale, now called the forerunner of nursing, who developed a nursing model still valid today. It refers to the need for nursing and care based on the laws of science as well as training nurses and developing their skills bearing in mind the latest advances in medical science. At the same time, she points to the necessity of subordinating the services of nurses to doctors. What she meant was the treatment itself and matters related to it as well as a loyal following of the doctor's orders. Nightingale paid attention to: 

·                     The choice of candidates for the profession according to their age, personality and education,

·                     Ensuring the quality of education through a good theoretical and practical curriculum,

·                     Individualization of patient care, including observation and a good rapport with the sick. 

Florence Nightingale was the first to have founded a school in London in 1860, in which women could master their profession which was considered a vocation. The development of medical science raised the expectations towards medical staff, including nurses, and in many countries nurses started to be professionally trained (since 1911 in Poland). It can be said that the integrated and systematic education of women in this profession has increased the existing opportunities for patient care [4]. 

Over the years, customs, procedures and nursing education have changed. These changes occurred in response to the demand for appropriately specialized medical staff. At the same time, the importance of nursing as an element of treatment and therapy has been gradually recognized. 

In Poland since July 5, 1996, according to the law, a nurse is an independent health care worker who provides quality medical care for a patient, assists in surgeries, operations, follows medical orders in the diagnostic process, treatment and rehabilitation, and who deals with broadly understood health education and health promotion (Journal of Laws from 1996, no. 91, item 401)[5]. Nursing education is currently only provided by the institutions of higher education, and the prerequisite for gaining the right to practice is to receive a bachelor's degree. Professional activities of the nurse consist in providing health care services such as nursing, prophylactic, diagnostic, therapeutic, rehabilitation services as well as encouraging health promotion (Journal of Laws from 1996, no. 91, item 401). In modern health care which aims to provide better and better support to people in achieving optimal health, nursing is becoming an increasingly significant area of medicine. 

Previously, the way of organizing and approaching the care of the sick, resulting from the centuries-long tradition of Christianity, caused that the role of the nurse was not treated as a profession, but was closely linked to charity, sacrifice and help to the needy. The consequences of such an approach are still felt today as the medical professions are more often seen as a vocation and a service rather than performing the duties of the profession and a way of earning a living. Such are also social expectations, which, by referring to the existing stereotype, prefer to see the nurse and the doctor as people full of empathy and dedication, bringing selfless help, rather than professionals performing their duties and responsibilities [6]. The very concept of "Health care" aptly characterizes the type of these activities and their nature, hence it is impossible to separate or isolate the elements of empathy from the medical activity. The attempts at focusing only on professionalism in these areas, disregarding dedication and compassion, lead to dehumanization of these professions. 

The current provisions in the Polish normative acts concerning health care regard treatment and nursing services as an economic activity, i.e. an activity which is profitable, just as in the case of doctors. This means that the state does not treat health care only as an aid to the sick, but as an activity that aims to make a profit. Healthcare facilities have been obliged to produce specific economic outcomes, which has led to a number of problems such as the fall in employment of qualified staff due to savings, worsening of working conditions, great wage inequality that cause conflicts among healthcare workers. The decline in employment has most severely affected nurses. Their work conditions and pay have deteriorated, which caused an exodus of nurses who went abroad to look for a better job. Another reason for intensifying the conflicts within this group of employees is the constant strengthening of the financial position of the doctors, especially those of well-paid specialties, compared to employees of lower paid specializations and other medical services. 

3.      The Current Doctor-Nurse Relationships. Focus Study Results 

Changes in nursing as well as in medicine itself have burdened nurses with new tasks and set up expectations that do influence their collaboration with the doctor. Nurses insisting on their rights focus primarily on being perceived and appreciated as highly specialized professional staff. Without professionalism and professional competence, it is not possible to achieve satisfactory results in restoring patients to health and at the same time be motivated to show empathy, sensibility and understanding of their needs which give the treatment a "Human face". However, as noted in the literature of the subject, the doctor "still determines the nurse's duties to a great extent by giving her orders that she is required to follow." The relationship that develops at that time is often compared to this existing in the military between two people of different rank, e.g. an officer and a non-commissioned officer. "The doctor expects the nurse to monitor carrying out his/her instructions so that no mistake is made. On the other hand, the nurse cannot expect the doctor to be tolerant of the mistakes that she may commit at work" . Here the pattern of doctor's domination in the professional hierarchy is perpetuated, without taking into account the specific nature of the tasks performed by the nurse. However, the achievements of the last few decades point to the development of professional nursing care models for patients with various types of chronic diseases, as well as the nurses' active participation in the implementation of educational programmes among patients, resulting in a change in the nurse-doctor relationships for the autonomy of the nursing profession in relation to their tasks in caring for the sick. It can be stated that the current working conditions of the therapeutic teams are determined by the patient's health condition and the complexity of the tasks performed within the professional capacity of the doctor and the nurse. The particular importance of this relation is determined by the fact that it is to be effective in restoring the patient's health.

Three focus groups (FGI) which comprised both nurses (6 people) and doctors (9 people) were interviewed between October and December 2016. The study was conducted in two university centers educating medical staff, e.g. Gdansk and Bydgoszcz.The selection of the participants for the focus study was deliberate. All nurses were employed in the public healthcare institutions, five of them in hospitals (a wide range of specialization) and one in a nursing home. The respondents were university graduates, five of them had many years of work experience (between 19 and 28 years), and one was at the beginning of her career (2 years). All nurses who took part in the survey completed a number of courses and participated in various kinds of training to broaden their professional qualifications and had at least one specialization or were in the process of getting one. Three of them held higher positions such as, for example, that of a head nurse. The doctors interviewed were highly diversified in terms of their specialty, seniority and, which is understood, the positions they occupied. Four of the doctors had a short period of employment (3-5 years), three of them were residents while the other three were long-term employees (between 28 and 38 years). The long-term physicians have been department heads and one of the respondents has had many years of experience working in Germany. All doctors who take part in the survey were employed as hospital doctors. 

The fieldwork conducted focused mainly on the relationship between nurses and doctors and the change in the nurse's professional status in recent years, especially after the introduction of a law increasing the rights for this occupational group.Detailed research questions concerned, among other things, how doctors rate changes in nursing education and qualifications. They tried to answer the questions whether and how these changes affected the relationships doctors-nurses-patients. What is the assessment of nurses' qualifications? Are there any communication difficulties in the treatment team? What are the causes of tensions in therapeutic units? What is the problem in collaboration between nurses and doctors? What changes do doctors expect with regard to their work? How do they assess the current protests of nurses and resident physicians? 

4.      The Situation in Doctors' Opinion 

The doctors interviewed, especially those with greater experience, notice a clear change in collaboration with nurses. In their opinion, this collaboration is more difficult than it used to be because the "Boundaries" between the medical professions "Have been blurred", also in terms of the hierarchy/position of nurses in the organizational structure of the hospital. The doctors emphasized that nurses "Forget that their job is to serve". According to the respondents, nurses feel inferior to doctors’ due to their lower position and have had a grudge against them for previous years of collaboration. 

Furthermore, doctors believe that there is a reluctance on the part of nurses can be found in the comments made by the doctors. They said that " nurses want to compensate for their frustration related to their lower position and inferior treatment by doctors, especially now when doctors and nurses are said to be two equal professions." The appearance of nurses with higher education results in a change in expectations as to how to treat them and take account of their opinions in the decision-making process regarding the patient treatment. The doctors point to undermining teamwork, which was a principle in medical treatment, especially in hospitals or clinics. They sense the tension between doctors and nurses, which causes that there are no longer therapeutic teams focused on helping the patient. The current organization of work is very individualized: there are individual hospital workers who provide services within their competence and between whom there is "Constant scrambling". 

An additional factor that affects professional relationships is the age of the medical team members. The resident physicians pointed out that particularly difficult relationships exist between them as young adepts of medicine and older, experienced nurses. There are situations in which they treat them somewhat coldly, disrespectfully and are reluctant to follow their orders, which often happens in front of the patients. A situation recalled by one of the study participants can illustrate a tense atmosphere in the hospital. Namely, when a resident doctor upon entering the patient's room was asked by a nurse in the presence of the family: "Have you come to examine the patient here and there or do you want us to do something else?" 

Solving difficult problems between doctors and nurses has become more complex since the introduction of changes in the organization of hospitals. The nurses ceased to be directly subordinate to the head of a hospital ward and their superiors became a head nurse and the director of nursing. What once could have been settled face to face and immediately, at the present moment must go through official channels and be "Mediated" by the head nurse or the director. This can be illustrated by the situation where a doctor, in the face of escalating conflict, requested a direct meeting with the nurses. However, the meeting did not take place because "This is not what the doctor is responsible for". 

The opinion that raising formal requirements for the nurses, i.e. an M.A. diploma, destabilized working conditions clearly predominates among doctors. The doctors prefer to work with the nurses with the secondary level education because they are more efficient and possess better skills. According to the doctors, nurses are of the opinion that they did not study in order to perform simple hygienic services for the patient. According to the doctors, the most difficult is collaboration with those nurses who are about to complete a bridging undergraduate course (a higher education course for nurses to get a bachelor's/master's degree). They have high expectations and have adopted a demanding attitude. 

During the interview, the respondents drew attention to the difficulties in a nursing job and the reasons why their motivation to work has been lower than before. Nurses feel frustrated for financial reasons. Objectively, not only do they earn not enough but the problem is also the disparity in earnings between doctors and nurses and among nurses themselves. Doctors have won a significant increase in their wages in recent years, which nurses failed to obtain. There are large pay differentials among nurses because young beginners with a bachelor's degree receive a higher salary than a senior, experienced nurse who graduated from a high school. This is a source of conflict and gives rise to a feeling of injustice. 

The absence of a generation change poses another problem. The average age of nurses on some of the wards is over 50. Moreover, there is too few of them and after many years of manual work (e.g. lifting patients) they suffer from back problems and other ailments. 

The doctors hold the opinion that the lack of solidarity in the profession makes nurses' situation worse, i.e. chambers of nurses do not function properly, there are no trade unions, and should any difficulties arise a head nurse "Will always be on the side of the administration or the family of a patient". Even when nurses try to go on strike and make demands on the hospital, there are still such nurses in a team who will "come to an agreement" with the management of the hospital disregarding the commitments to their own team.The respondents set the situation of nurses against the relationship among doctors, i.e. the fact that they have succeeded in winning higher salaries is the result of greater professional solidarity among doctors. 

The changes the doctors expect to happen include, first and foremost,: 1) changes in work organization regarding the relationships with the nurses (clear setting out of a range of duties and responsibilities, the division of labour); 2) organizing team-building meetings in hospital teams (such meetings are organized regularly in Germany and they are an important element integrating the team); 3) raising salaries for the nurses and employing more staff, for example, nursing assistants; 4) placing more emphasis on practical skills rather than theoretical knowledge while educating nurses; 5) an introduction of medical secretaries to help doctors because of the increasing amount of paperwork; 6)  adjusting the way finance of individual departments to existing realities and making it more efficient and flexible; 7) obeying labour law in the case of the doctors involved in compulsory specialized training.

Finally, the investigated doctors said they supported the protests of the nurses because they believe that this is a good time to integrate both environments. 

5.      NursesOpinions 

On the other hand, the study conducted among the nursing staff focused on the change in the status of the nursing profession that has occurred in recent years, especially after the introduction of a law increasing the rights for this occupational group.

Clearly, the main issue raised by all the respondents with regard to each question was the underestimation and treatment of those who work as nurses without respect - first of all by the doctors, secondly by the families of the patients, and finally by the patients themselves. 

As far as doctors are concerned, it should be emphasized that only male doctors were given as an example, which, in the context of the feminization of the nursing profession, should also be regarded as the reflection of the male-female relationships. 

The respondents said that they did not want to be treated "As servants" (...). The lack of respect and undermining of nurses professional competence can be illustrated with many examples. The question of nomenclature is the key here, i.e. "Doctor" and "Sister". "Today we are educated women who do their jobs as professionals. We are nobody's sisters." 

All the respondents agreed that there were hierarchical relationships in their workplace. They talked about their dependence on the doctor. Particularly difficult situations occurred when the nurse noticed a medical error or had doubts about the unusual procedure. Doctors consider such a situation unacceptable or even a sign of hostility towards them. 

Another issue touched upon by the respondents concerned the changes related to the introduction of a law enhancing the competencies of nurses, including the right to write out prescriptions. The nurses surveyed stated that the law did not change anything in their work. They pointed out that it is difficult for them to imagine that they write out prescriptions in hospitals where they work and according to them this can be done only in the case of primary health care. There, a community nurse is often the only person who visits the patient at home and knows his/her condition better than a doctor. Therefore, in this case additional rights would be helpful. The nurses emphasized that they did not know yet how this change is supposed to work in practice. Their worries are compounded by the current frustration stemming from the doctor-nurse relationship and a complete lack of information from the legislator. 

The antagonism between nurses and doctors has also been revealed in the assessment of new powers for nurses, which, according to the respondents, are associated with a new responsibility rather than raising the status of their profession: "Take on such responsibility? In the name of what? It is only to relieve the doctor". The issue of "Relieving the doctor" was understood by the nurses in an oppressive way: now when the law has been changed, if the doctor orders them to write out a prescription for specific medicines, they will have to do so. The nurses interpret the attitude of doctors as seeking the means to transform their work into that of a doctor's secretary and it should be mentioned that doctors already assign some tasks to them which are not within the nurse's duties (e.g. filling up patient cards, writing out sick notes, bringing patients, catheterizing male patients). 

The financial issue which was also discussed during the study, did not become a dominant topic. Although nurses' earnings are rated as low and the interviewees feel they should be better paid, it is perceived that the essence of their dissatisfaction lies in the relationships they are experiencing in various medical institutions, particularly the relationship with the doctors.Nurses have a sense of their knowledge not being used and that the final word rests with the doctors, even when this is not necessary. One of the nurses explained that they often advise doctors on what medications to give or what medications stop administering, update the doctor on the patient's condition because they are often better informed than the doctor. They must also report all information to the doctors who cannot find time to read the reports of their predecessors. 

It should also be added that the nurses when asked what needs to be changed in their work did not mention financial matters as the most important ones, but changes in their position in the hospital hierarchy and the attitude of doctors towards them. They emphasized that partnership would be of the utmost importance to them. 

6.      Conclusions 

The essence of the medical profession is the provision of health services, the extent of which is determined by the qualifications of doctors and nurses. In keeping with the spirit of change, modern nursing consists in, first and foremost, the extension of professional tasks and the progression from nurses' absolute subordination to the doctor in the process of treatment to the autonomy in carrying out the tasks related to it, in collaboration with the doctor and under his/her supervision. Identifying the causes and areas of the currently occurring antagonisms aims at remodeling of the professional relationships and creating professional therapeutic teams that are responsible for the health and well-being of the patients and at the same time meet the expectations of modern medicine, which in practice means that they improve the organization and quality of service in medical institutions. 

The opinions of the participants in the study, however, point to a clearly emerging conflict between the two professional groups. It seems that they are currently unable to clearly identify the areas of interaction and what is more, their definitions of participation in therapeutic and caring services are contradictory. The nurses treat the ongoing changes in terms of certain liberation of their profession and giving it the attributes of autonomy. On the other hand, the doctors seem to defend the current state of professional relationships and treat it as the status quo so that the situation does not get worse. It is also characteristic that both professional groups are blaming each other for the situation which has arisen. It is evident that there is a lack of willingness to understand the situation of the opposite party, so we are dealing with a more or less confrontational attitude and a lack of attempts at finding solutions in a pleasant atmosphere. 

7.      Recommendations 

1.                  The role and duty of continuing education, which is inseparably linked to medical professions and results from rapid devaluation of knowledge and social expectations, and a highly developed specialization in both medical professions, require the adaptation of work organization to these requirements.

2.                  The the level of material gratification which the nurses receive now is disproportionate to the expectations towards professional nurses and this requires solutions which would be innovative and appropriate to the level of their qualifications.

3.                  It is necessary to develop work rules for the therapeutic teams and such rules should be taught at the university level. This can be done by changing curricula where interdisciplinary courses would be introduced (in the course of medical and nursing studies), which in turn would improve the collaboration skills, partnership and mutual respect for their work. As well as regular training in the course of specialization and professional career.

4.                  Professional superiority should be redefined and transformed into specific partnership and collaboration rules with appropriate formal regulations. This means that the management and operation systems of the medical institutions should be remodeled effectively so that the medical staff working there can successfully and effectively fulfill their professional roles.

 



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