The nursing profession's coming of age
BMJ 2005; 331 doi: https://doi.org/10.1136/bmj.331.7529.1415 (Published 08 December 2005) Cite this as: BMJ 2005;331:1415
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We are being witnesses of a great revolution, which is bringing us to
the sprouting of new medical paradigms. The great development of Molecular
Genetics, Immunology, Molecular Epidemiology, Endotheliology, the
Coagulology, Telemedicine is the result of the introduction in research
of new methods that use the computer like an indispensable resource.
Although we are living one on the most pleasant moments in the history of
diseases’ diagnosis and treatment, really is very little what it is made
in Colombia to introduce a new dynamics in our daily practice. The reason
of this may be the conservative characteristic of Medicine and the health
sector in Colombia, with too rigid and very obsolete organizational
schemes. A classic example of this situation is the use actually of the
same methodologies and resources that were used before the decade of 70-es
years of the last century. Although now there are the minimum resources
indispensable to bring the system to a contemporary level, we are in a
deadlock, characterized by a conscious lack of attitude towards the
massification of new procedures. The new technologies of the information
and the computation offer the best means to transport to the 21 century
the system of health, obsolete, restrictive and lack of vision that is
used anywhere in the world. Many of the routine, rational and algorithmic
procedures that we do in the health clinics, can be done now with
applications (software) specially designed and constructed by professional
personnel in health, whom have considered those aspects that have validity
in the daily medical practice. There are many examples to illustrate this
evidence. In the Seventies of the last century, and even now in some
places of our country, to determine the daily dose of a medicine for a
patient, many doctors ask for the collaboration of auxiliary nurses with
experience, or they meet in groups of three or more, because it’s
difficult to them to calculate the amount of a drug that is due to provide
to a patient of 70 kilograms of weight. A lot of doctors in Colombia even
don’t understand the difference between a microgram and a milligram, a
milliliter and a microliter, or between a concentration milimolar and
other micromolar. Although the pharrmacological industry, significantly
helped to solve this problem, distributing many medicines in a special
presentation with the daily doses form, I believe that the best
contribution, mainly in the units of intensive care, made the computers.
Many medical protocols, which include the application of confused
mathematical procedures, were facilitated significantly with the computers
use, to such level, that many medical procedures can be made now by
auxiliars of nurses, previously trained in the handling of these
equipment.
By that same time, the determination of the blood glucose levels only
could be done in specialized laboratories. We needed up to four hours to
determine by spectrophotometry the glycaemia of a patient. Now any enabled
person in handling of a glucometer can do this in very many less time, and
not only that, with the help of the glucomter he can inform to us about
how the patient, in relation to this parameter, has evolved.
The stethoscope and the tensiometer were tools of exclusive use of the
doctor, who was the only person who could determine the patient’s blood
pressure. Now, by the streets easily we can find people, without medical
formation, measuring systolic and diastolic pressure levels and in
addition recommending a good diet. The arrival of the computers, their
memory, rapidity of answer, minimal size, and their great versatility
revolutionized the processes of intellectual and moral formation of the
people and its social and laboral impact has been very significant.
The daily doctors and nurses’ work , and in general the one of all
the health’s personnel, including the patients dynamics, necessarily must
adjust to the new changes of the society’s informatization. We can not
remain isolated of the new world dynamics. I think that to auscultate, to
watch signs of a disease, to ask for symptoms, etc. at macroscopic level,
to diagnose and to treat a disease must be a work for the nursing
personnel. The work of the doctor must be more academic and must be
directed to the clinical and basic research, in a dynamics oriented
towards the search of true solutions to the world problems of health and
nutrition attacking to the humanity mainly in countries like ours.
Competing interests:
None declared
Competing interests: No competing interests
Like many others I have read with interest the view of Young and the
wide spectrum of responses.
I am an RN who was lucky enough to work in oncology/haematology from
qualification. Perhaps it is the different socialisation processes of the
specialities but I have always felt valued (and equal to) my medical
colleagues in terms of clinical skill if not financial reward. My skills
are different, that’s all. For me gaining "medical" skills such as
physical assessment was really just about having tools in the toolbox.
This was brought sharply home to me a couple of years ago when I spent a
few years as a cancer specialist nurse in a surgical unit. I found that
generally my surgical colleagues, who were good surgeons, felt a bit
uncomfortable with the issues of death and dying or talking about cancer.
I had the right tools for those patients at that time-its situational
leadership-right person, right time with the right attributes. Prior to
coming into nursing I was a career scientist with an MSc in haematology-
very useful for interpreting results-another tool in the toolbox
I also think the issue of "mini doctors" is more about the devaluing
of nursing by society. I note that some of the respondents cite "basic"
nursing skills-there is nothing basic about assisting patients with
activities of daily living-these are fundamental skills, not basic ones. I
am also dismayed that educated people are being encouraged to do routine
tasks when they could be alleviating suffering through good nursing
practice (Eric Cassell’s work on this is excellent-The Nature of Suffering
and the Goals of Medicine 2004)
Competing interests:
RN (and just finnished a PhD in medicine-a tool for the toolbox!)
Competing interests: No competing interests
Dear Editor
Young reports that there is greater patient satisfaction with nurse
practitioner consultations, but has not made any response to the point
raised that, given the amount of time available for the consultation, that
medical practitioners might also have equal outcomes.
Patient satisfaction is only one indicator of quality (although it is
of course a worthwhile one). I also suspect from my reading of press
coverage that Dr Shipman would have scored very highly on patient
satisfaction! This admittedly extreme example demonstrates that to focus
on one aspect of care is missing the holistic approach that we are all
aiming for.
Fiona Hayes
Competing interests:
registered medical practitioner
Competing interests: No competing interests
I read Sister Young`s original letter, watched the debate unfold on
DNUK, and read the rapid responses with interest.
One thought springs to mind.
I entered medical school in 1985.
I have been fortunate to have worked with a great many peers and
colleagues who have been enthusiastic in their teaching, and modest when
it came to blowing their own trumpet.
Often, those who made the most noise, sought self publicity and
expounded their extensive education included the folk whose judgement I
would take least cognescence of.
I have seen a great deal of Nurse Practitioner self congratulatory
back slapping both in the original article , and in the responses.
I married a nurse... a good "old fashioned" nurse with a good brain, and
common sense in spades.
Luckily, many of my district nursing colleagues locally come from a
similar background.
In out "modern" world, all too often the nursing profession makes these
folk feel unwanted and irrelevant, the "Supernurse" of the Noughties being
much more politically correct.
If you want to bask in your own glory, so be it, but do not be
deluded.
Twenty one years after entering medical school, the thought that occupies
my mind in every day practice , is how much more there is for me to learn.
The day that I feel I know it all, is the day I should retire.
After accumulating lots of letters after my name, I still regard myself as
simply a GP.
Competing interests:
None declared
Competing interests: No competing interests
As a medical student I have only had minimal experience of Nurse
Practitioners. At the hospital I was attached to recently they staffed the
night on-call and undertook clerking and admission of patients. As I
student I know of many other students who are concerned about what their
place will be in the future as a junior. Will it be confined to form-
filling and minimal clinical work. The other concern is in training. With
all these people to train it is bound to impact on our already valuable
clinical time on the ward and remove exposure and opportunities of basic
medicine for juniors. Colleagues have been overlooked to assist in theatre
to NPs. Surely this will impact on our very worring future.
Competing interests:
Medical student
Competing interests: No competing interests
1)"There is much research evidence to show that in comparison with
doctors we deliver safe and effective health care, but with a difference:
patients often prefer consulting nurses because of our communication
skills and because our approach centres on the whole patient"
During the epilepsy review at Leicester one of the common complaints I
heard was that the children were seen by a Nurse specialist rather than a
trained Paediatric neurologist.I dont know about selective research but if
patients are given a straight choice prior to diagnosis of complex
conditions I wonder what the preferences may be.Some of the preferences
are also due to the fact that help from secondary care would be avaliable
when indicated for non medical profesionals
2)"I was not surprised that the BMA responded so negatively to nurses
having enhanced responsibilities. A power struggle is going on.
Historically nursing was a docile and predominantly female profession, but
now we are challenging doctors on their own territory"
Above are verbatim quotations from MS young so I think people can be
excused in thinking the call to arms is directed against other members of
the same team and we may need to challenge equally vigorously the
competence and skills of members of the team who are being given enhanced
roles.I think it is the doctors especially the specialists who are most
docile in this debate.As somebody else said we should not accept any
medical care as better than no care in a first world health system which
may otherwise go the way of "Bare footed doctors" in other countries
.Hyperbole?perhaps not if current trends go unchallenged and are
introduced with very little evidence base other than subjective factors.
Competing interests:
None declared
Competing interests: No competing interests
Editor,
As a GP working for the last several years in an area of high demand
and socio-economic deprivation, the biggest challenge has been to develop
effective teamwork and to retain both medical and nursing colleagues.The
new NHS that demands and rewards only the quantifiable is in danger of
driving us all away and so we need to interpret Ghislaine Young’s personal
view (1), with caution. Some may read it and feel that she has scratched
the festering sore of inter-professional jealousy, not surprising given
the uneasy history of our con-dominion. But to do so would be unwise as
internecine squabbles serve only to divide and fragment the NHS. To me her
piece reads more like a call to arms, and for this I applaud it.
Modern high quality health care is a team affair and we should resist
all attempts to disrupt it.
(1) Ghislaine Young.
The nursing profession's coming of age. BMJ 2005;331:1415
Competing interests:
None declared
Competing interests: No competing interests
Many of my thoughts on reading Nurse Young's article have been
eloquently expressed by other rapid responders, however they have not
reflected the extent of my outrage at such an offensive, patronising and
ignorant personal view.
Worryingly, her views reveal the extent of her ignorance about the
skills and knowledge that doctors gain over their years of training and
postgraduate experience. Like all surgeons I have learnt that experience
teaches you when 'not' to operate, as much as 'how' to operate. The 'Oh, I
could do that' attitude to healthcare is permissive and disastrous to
providing a quality service. Whilst medical staff are increasingly
monitored, judged and quality controlled, non-medical staff are being let
loose with an armful of vaguely relevant certificates and minimal training
to do just about anything - except perhaps taking responsibility for the
outcome.
I agree with all the respondents who wrote that these nurses are
wanabee doctors and that they should apply 'successfully' to go to medical
school, complete the numerous exams such as pathology and pharmacology we
all remember well, do house jobs and at least 3 years of postgraduate
training if they wish to become a salaried partner in a GP surgery. Does
anyone know of a doctor who has become a maxi-nurse or gone back to
nursing school after their medical degree?
I, too, am increasingly dismayed by the never-ending expansion of the
maxi-nurse, mini-doctor, while postgraduate medical training becomes ever
more restricted. We are following the example of the underdoctored third
world where health care is provided by individuals with limited training,
but where the government's attitude is that any healthcare is better than
none. We all recognise the political expediency responsible for these
changes, but like the emperor's new clothes should not delude ourselves
that this is progress.
Competing interests:
I am a doctor
Competing interests: No competing interests
All my career, when people realize that I have 3 advanced degrees
including a MN in Advanced Practice Nursing, they always say "Why didn't
you become a doctor?". I tell them that I do not want to be a doctor, but
a nurse. I will not profess that we are more empathetic or holistic or a
better profession than doctors, but that is what I wanted to be... a
NURSE. Just as many of you wanted to be a DOCTOR. However, being a nurse
does not mean that we cannot grow in our profession, academically and
clinically. Because we get advanced education does not mean we are trying
to be MD Wannabes. We want to be better nurses who get respect for having
knowledge and skills. We all grow in our careers and I, for one, would not
like to be considered a handmaiden, like nurses in the 1800's and early
1900's. I want other professionals to say, "yes, your opinion counts and I
respect what you say". I know that simply getting more education does not
mean you will get respect (since that needs to be earned), but I can tell
you that my MN on my lab coat has allowed me to climb to a level of esteem
I never achieved before. I simply want to be the best NURSE I can be
(Nurse Practitioner)...not an MD. I respect what MDs do and feel that I
could never replace what they do...however, I do feel that there is room
for growth in both of our professions.
Donna L. Alden-Bugden
Competing interests:
I am a nurse practitioner.
Competing interests: No competing interests
Nurse Practitioners
I feel saddened to read MS Youngs article. I have enjoyed many years
in the nursing profession and have been fortunate to work with extremely
caring doctors and nurses.
I too am an independant prescriber, assess, examine and initiate treatment
for patients of all ages as several other experienced nurses do in our
Practice. I deliver care both, in General Practice and to patients who
are housebound. I am able to care for these patients due to the support
of all of my colleagues. It should never be seen as 'them and us'
The majority of our nurses are authorised to refer to consultants,
admit to hospital and request all investigations. I also visit patients at
home. I see this as an extension of my nursing role which also helps
reduce the pressure on our team of doctors. I certainly do not see myself
as a mini doctor, or a maxi nurse. I see myself as a highly trained
nurse, who is continually studying and who works within a team of highly
trained doctors who can work effectively together to deliver the best care
to our patients. I also care for patients with Long term Conditions and at
End Stage Ilness at home, real hands on nursing and I love being a nurse.
I too would like to become a partner one day, salaried or otherwise.
There is too much in a title.
Competing interests:
None declared
Competing interests: No competing interests