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I like to think I have a good relationship with my nursing colleagues. But sometimes, inevitably, tensions arise. One occasional source of disagreement is the issue of whose role it is to do certain tasks.
There was a bit of a discussion on my ward, for instance, about whose job it was to change the box on a patient’s chest drain. In my experience, this was something the nurses generally did. But the nurses on the ward hadn’t received the specific training. So when the time came for it to be done, it was assumed that I would do it.
I protested that I had never been trained in how to change a drain box either. In the end, we found a nurse from another ward who had been suitably trained, and she showed us all how to do it, for future reference. (There’s not much to it, as it turns out.)
But there seems to be the idea out there that doctors can somehow do anything without requiring the same training or experience that a nurse would need.
On another occasion, covering a psychiatry ward, I ended up personally administering a patient’s medication because it had to be given rectally using a syringe (it was a complicated situation), and the nurse had never done that before. Nor had I, of course. And I was extremely busy trying to cover several hospital sites and answer a constant barrage of bleeps.
There was a stand-off. The nurse refused to do it but the patient really needed the medication - so I did the necessary.
Making up and administering certain intravenous drugs is another area of contention. There seems to be a rule (as far as I can tell very much an unwritten one) that some infusions are only allowed to be handled by doctors. Precisely which medications fall into this category varies substantially between hospitals, sometimes even between wards in the same hospital.
Often it’s apparently related to some previous ‘adverse incident’. I find it a slightly odd assumption, though, that doctors will be safer than nurses. It’s something that we do much less regularly.
Perhaps there is an expectation that the status and salary we get as doctors comes with a greater burden of responsibility.
Perhaps nurses are also more closely scrutinised in terms of whether they have been fully and formally trained up in every aspect of what they do. There’s not so much of the ‘see one, do one, teach one’ attitude with nurses.
Complicating things further, the line that separate tasks which are a doctor’s job and tasks which are a nurse’s responsibility is increasingly blurred. Trained nurses do bloods, cannulas, catheters, and lots more. It can make a busy on-call shift infinitely more bearable to have their help. But it can also add to the negotiating that has to be done about who does what.
Ultimately, I suspect that underlying this tension between nurses and doctors is something we have in common - an increasingly unmanageable workload. With a bit less to do, I think we’d all be more willing to be flexible.
By the Secret Doctor. Read more experiences at the Secret Doctor blog and follow on Twitter
The nurses tell me they've never been so well trained, and yet never so discouraged from trying things outside their comfort zone. It's not their fault, and it's probably good clinical governance, but someone has to do all these tasks. So the F1s and F2s do them, with a lot of bluff and bluster. See one, do one, mess one up?
Love the Secret Doctor blog, by the way!
I think there is a problem for nurses who often only feel able to undertake something they have a certificate/training to do. The idea you can do something you have not had specific training is is anathema to them. However, a doctor is trained in problem solving and thinking - or used to be, so even when faced with a new situation, it is possible to assess the problem, the risks, what is needed, and whether it is reasonable to perform a procedure based on these criteria, even if not specifically trained. A reading of "The Reflective Practitioner: how professionals think in action" by Donald Schon expands this idea
Nurses support each other, if they say, we are not trained, that the end of the story. However, Drs can not say I have not been trained, because it looks bad
Nurses are increasingly trained to do and doing jobs junior doctors did in the past - maybe to save money?Maybe as there aren't enough doctors around? One of the results might be that some of the truly difficult cases in the end might still hang at the doctor but without the experience of having done umpteen easy ones before. Pity the patient! Another effect is that doctors are increasingly be landed with nothing but challenging tasks without easy successes in-between. At times I find this exhausting.
Several years ago now I was nervously starting my first day of Obs and Gynae F2 placement having only ever used a speculum on a dummy once and (with appropriate prior consent) an anaesthetised lady in theatre during my 4th year O+G placement. My reg seemed put out to supervise my first nervous speculum examination then instructed me to get on with the rest of the early pregnancy/gynae emergencies on call solo.
Yet I was asked by a midwife qualified 10+ years if I would observe and sign off on a sheet one of her required supervised examinations of patients, required for her advance practitioner status. She told me that until she got to 10 she was apparently not allowed to go solo...a case of teaching your grandmother to suck eggs I think!
I am a Retired Consultant but as my health has been very poor I have had to get used to people sticking painful things into me! I gather that a whole host of what used to be doctor only jobs are now undertaken by other staff. It depends on who is best at the particular task. I would much rather my annual blood samples be taken by a Phlebotomist who is skilled than by a houseman who is learning as I was at that time!
( on the internet and one time BMA Divisional Secretary )
I definitely agree with the premise that doctors are more willing to 'have a go'. The question should be WHY is it that nurses aren't? Is it because there is a senior strictly enforcing the rule that 'until you've got 10 signatures you are competent to do a cannula', even if that person was regularly undertaking the task in another trust? Or is it that they are more worried about litigation or stepping over the line, than they are worried about a patient suffering as a result of a task not being completed? It seems to me that quite frequently the book is passed to the (usually very junior) doctor so that the blame will ultimately lay with her/him, if something was to go wrong. People would rather get into trouble for something that they haven't done, than something they did.
I am a nurse and I completely agree with you. Nurses are scrutinised and reported if they do something they are not 100% sure about. It has unfortunately left nurses with a fear of "loosing their pin". I however practice safely and always want to do more, I find it more frustrating if I have to ask for help and would much rather learn new skills. It's ok not to know how to do a particular thing once but not twice.
I am a consultant, and in my experience it is the relationship between us and our nursing colleagues which dictates what they are/are not willing to do - quite apart from training and competence.
The same goes for doctors - if nurses have a good working relationship with you it makes them more likely to ask you to do things which are not necessarily "your job" - such as a simple prescription for a patient who is not yours.
No one can be trained to do or have prior experience of everything that crops up in clinical practice. We learn basic sciences to enable us to deduce and work things out from first principles. Doctors have more of this training so should be able to cope better in unfamiliar situations. Otherwise we risk standing by whilst a patient suffers or succumbs. That is unprofessional.
Really true , I think your experience is a general thing ' plus some nurse are taking delight in do only the administrative bites and neglecting patients care
The contents are extreemly interesting. That exactly what the Royal College of Midwifery has claimed to be superior than the doctors in case of delivering babies safely. This has ended up in a great mess in ( can not be named) maternity unit. Days gone by, when the nurses were trained in hospital, hands on these situation were a very rare occasion. Nurse used to train nurses, competent nurses knew what to do in multitask duties. Since graduation , away from the clinical making, nurses need more and more clinical training. We doctors are expected to know most of our complex clinical tasks as we are trained hands on from the day one of our clinical training days. So, any revised scheme for nurse training should be hospital base, not by reading books alone.
I find this a lot with things such as bloods and cannulas - despite the boundaries between the role of doctors and nurses blurring with the emergence of nurse pracs etc, these procedures are often seen as optional for the nurses who are trained to do them as it is 'not a primary nursing role'. Surely if you are trained to do something you should use that training and do it? Same with male catheters - working on a urology ward where some nurses refused to do male catheters was rather tiresome. I agree that a lot of it is due to the scrutiny that nurses are put under, whereas doctors are more independent and actively encouraged to have a go.
About one hundred years ago I was a Junior houseman in a urological dept. The nurses were well trained to catheterize our acute urinary retention "prostates" when they were admitted as an acute emergency at night. But: the really difficult ones they failed to catheterize so I had to do it since I was "the doctor" but obviously fresh from medical school had no experience of this whatsoever! I managed allrigh Tand I learnt many a skill from These nurses! But I changed to another medical specialty later. - Long retired now.
Nice to see there is nothing new under the sun (15 years since i was ona ward, >25 since i first came across the same issues! It is all about where the buck stops!