Change begets change

Perhaps the most obvious difference is that the context of the workplace has changed. Modern psychiatry now takes place in a number of different locations in addition to the acute in-patient ward. These include community mental health centres, patients’ homes and a variety of institutional and residential units caring for individuals with psychiatric disorders. These different milieux affect the nature of the relationship, simply because they result in different styles of working arrangements and determine different roles for the participants.

A consequence of this is that the nurse–doctor pairing is no longer exclusive. Most of psychiatry operates within a multidisciplinary framework, and interactions with other professionals, such as psychiatric social workers, occupational therapists, psychologists, outside agencies and service managers, have an impact on the doctor–nurse dimension, diluting its ‘specialness’.

Changes in the workplace are reflected in professional and institutional norms (e.g. medico-legal responsibilities and working shifts), and these define the nature of the interaction, setting expectations and requirements.

Nursing and medical education are undergoing major changes in direction, making the boundaries between doctors as diagnosticians and prescribers of treatment and nurses as obeyers of orders and dispensers of treatment less clear and more permeable.

The relationship between doctor and nurse is to some extent affected by what the patients think of them. Reference RadcliffeRadcliffe (2000) argued that the power within it is mediated by the patient: ‘If in doubt ask the patient who is in control. The public may love its angels but it holds its medics in awe’. This reflects the traditional, popular view of doctor and nurse roles. However, patients’ expectations of what nurses and doctors do and do not do is changing very quickly. Increasing publicity of medical and nursing fallibility and use of the internet have removed some of the magical aura and gloss from these professions (Reference Stein, Watts and HowellStein et al, 1990).

Patients and their families are also major players in the current culture of litigation, and the consequent emphasis on risk management can induce defensive practices on the part of both doctors and nurses.

In this evolving world of psychiatric practice, how well have doctors and nurses coped with these changes? Has the dilution of the ‘specialness’ of their relationship been more difficult for nurses or for doctors? How will future changes, such as those that will be determined by the European Working Directive, affect nurses’ and doctors’ roles, and thereby, their interaction? And how do new areas of collaboration between nurses and doctors become established so that improvements in patient care can take place?

Who makes the decisions?

Traditional relationships have been slow to change in the in-patient environment. Institutional and professional norms still defer to medical decision-making, the nurses’ code of conduct and management lines of accountability. The in-patient setting highlights an essential aspect of the doctor–nurse relationship: its mutual interdependence. Neither can function independently of the other. If the psychiatrist is the responsible medical officer and a patient is on section under the Mental Health Act, that psychiatrist is dependent on the nurses for the containment and safe care of the patient while in hospital care. Nurses rely on aspects of the doctor’s authority and medico-legal responsibility to support them and help contain the situation.

Nevertheless, doctors in psychiatry still hold essential powers and responsibilities that have an impact on this interdependence: for example, doctors are the ones who decide, either formally or informally, whether a patient is admitted and discharged. Under Section 12 of the Mental Health Act 1983, doctors have specific responsibilities that are not shared with other professional groups.

And who should make the decisions?

Daily decisions such as agreeing to a patient’s leave or the need for close observation are rarely delegated to nurses, even though in these areas doctors may have no more knowledge than their nursing colleagues. If anything, they are probably less able to make appropriate judgements because of their more distant contact with in-patients, and yet deference is paid to their ‘expertise’.

Current pilot studies delegating some of these responsibilities to nurses have shown no major difficulties, and have in fact reduced the need for expensive close nursing observations and reliance on agency staff (T. Reynolds & L. Dimery, personal communication, 2003).

The closer relationship with community mental health centres has produced some shifts in the balance of power. Community staff, whether associated with community mental health teams, assertive outreach or home treatment teams, now have more say in admission and discharge arrangements, altering what was once the exclusive province of doctors.

Although the decision to admit rests finally with doctors, it is helpful to make explicit that different staff will be able to contribute different knowledge to the decision-making process.

Senior doctors appointed to cover a catchment area are likely to be more familiar with past events in a patient’s life than most other members of the team, simply by virtue of having worked in that catchment area for longer. They therefore use experience of previous psychiatric interventions to guide their thinking when a new episode occurs. There is some suggestion that nursing turnover, especially in metropolitan districts, is increasing, making it even more likely that doctors will ‘hold the history’ of patients. Conversely, in the ‘here and now’ of an in-patient stay, nurses will be much more in touch with a patient’s current state and preoccupations. Depending on the attitudes of those involved, the nurses’ knowledge can contribute to clinical care or can become a source of contention in the battle about who knows the patient best and whose decision should prevail.

Traditionally, doctors have been seen as the repositories of clinical knowledge and have been charged with keeping abreast of recent advances and imparting this knowledge not only to their own apprentices, but also to nurses within the team. University education as opposed to hospital experience accounts for the public view that doctors ‘are educated whilst nurses are trained’ (Reference WarelowWarelow, 1996). Purported knowledge, therefore, is a source of the differential power that underpins the doctor–nurse relationship. To some extent this differential has been reduced by increasing university training for nurses, as envisioned in the Department of Health’s Project 2000 (United Kingdom Central Council for Nursing, Midwifery and Health Visiting, 1986). However, some critics have observed a gap between theory and practice and the creation of a training deficit at graduation, as it does not meet the practical nature of service demand (Department of Health, 1997). Shared learning (with doctors and other professional groups) is beginning to happen in areas such as Mental Health Act legislation, Health of the Nation Outcome Scales (HoNOS) and ethical issues.

Plus ça change?

A quarter of a century ago, a New Zealand anthropologist studied working relationships in a psychiatric hospital in Otago, New Zealand (Reference ParksParks, 1979). Many of the interactions that she described can still be seen in the UK today. She recognised that the rules operating between different staff groups in terms of lines of authority, responsibility and reciprocity were not explicit. A lot of emphasis was placed on the notion of ‘teamwork’, which implies a democratic structure, but in reality many teams were autocratically led and hierarchically structured. She also analysed the nurses’ notion of ‘supportive’ and ‘unsupportive’ responses by doctors, and found that they thought the doctors’ agreement with their opinions to be ‘supportive’, whereas disagreement was ‘unsupportive’ (rather than a factual correction or a constructive exchange of ideas). The third notion was that of ‘responsibility’: the nurses generally felt that it was the doctors’ responsibility to ensure patient compliance with the treatments they prescribed, even if the treatments were carried out by the nurses. These often unspoken beliefs indicated that there was still an expectation of a paternalistic, hierarchical relationship between doctors and nurses, even though nurses were demanding an equal say and influence. Most of these issues remained implicit and ambiguous, leading to conflict when the discrepancies were exposed.

The many hats of the psychiatric nurse

In a previous publication one of us (L.F.) discussed the apparent contradictory tasks of in-patient psychiatric nurses (Reference FaginFagin, 2001). They are expected to be ‘reality role models’ for patients, organising personal self-care, confronting inappropriate behaviour and encouraging community-mindedness, while at the same time providing care, nurture and emotional support. Nurses wear many different ‘hats’: they uphold institutional norms, contain physical aggression, set boundaries and timetables, and offer informal personal therapy to patients in states of heightened distress. Not surprisingly, nurses become the main recipients of patients’ projections. As a result they are often the targets of either erotic, loving gestures or hostile, aggressive and paranoid responses.

Nurses often comment on the distinction, in the patient’s eyes, between nurses, with their multiple roles, and doctors, who have a more distant and clearly outlined function. These varying roles, both within the nurses’ remit and between nurses and doctors, prompt split transference responses in patients, which can lead to splitting manoeuvres intended by the patients to accentuate disagreements between staff, particularly if these are unspoken.

Conflict between nurse and doctor

When conflict arises between nurses and doctors on communication and decision-making, the nurses’ objections are often buttressed by ‘You are not here as much as we are’. A familiar clinical situation is described in Vignette 1 below. The ‘parental’ couple of doctor and nurse are in a conflict generated (or exacerbated) by the pathology of the patient, who has a propensity to idealise paternal figures and vilify maternal ones. Such situations tend to reinforce stereotypical roles and require successful clinical management with some insight into psychodynamic interaction.

Family roles, patients’ projections and gender issues

The doctor–nurse pairing, not surprisingly, also becomes a potent target for patient projection. Father/mother fantasies are often mentioned, particularly by patients in vulnerable and regressive states. They expect the same total, unconditional care that they expected from their real parents. The relationship that doctors and nurses have with patients is also of an intimate nature, not only because details of the patients’ lives are shared, but also because physical contact is often required during treatment and care, and the patients’ illnesses might bring to the fore discussion of life and death. This is a domain that is not often shared with others in the team. In this setting the ‘specialness’ is regularly confirmed.

These projections are affected to some extent by gender. In contrast to general nursing, psychiatric nursing was traditionally a male domain, as working in asylums with potentially violent patients emphasised the need for physical containment. Although this is not the case today, in the UK male nurses are still relatively overrepresented in psychiatry (40%) compared with general nursing (1%; Royal College of Nursing, 2003). For obvious reasons, male nurses are still identified as those who will have a central role in control and restraint procedures when patients are agitated and at risk to themselves or others. In fact, anxiety can become palpable when there are not enough male nurses on a particular shift, especially when the unit is disturbed. These different roles and assignations have an impact on relationships between nurses as well as with doctors and patients.

Traditional sociological studies of the doctor–nurse relationship describe its patriarchal nature (Reference Dingwall and McIntoshDingwall & McIntosh, 1978), understood in terms of sexual stereotypes, with gender assignations of nurturance and passivity to the female role, and decisiveness and competitiveness to the male role (Reference SavageSavage, 1987). Drawing parallels with family roles, doctors assumed the position of the head of the family, deciding where and how the important work had to be done, while nurses (their ‘wives’) looked after the physical and emotional needs of those dependent on them, whether they be patients, junior nurses or inexperienced doctors (Reference OakleyOakley, 1984; Reference Willis and ParishWillis & Parish, 1997; Reference GazeGaze, 2001). Although this model still carries some validity, modern changes in nurses’ roles, particularly the introduction of clinical nurse specialists, nurse consultants and modern matrons, indicate major shifts in influential positions which are now fairly well established (Department of Health, 2003a , 2003b ; NHS Modernisation Board, 2003). The replacement of the ward sister with the ward manager in the 1980s has had a profound impact, some say by ‘selling nursing to management rather than being led by clinical imperatives’ (V. Franks, personal communication, 2004). Changes in the status of doctors have followed public airings of their fallibility, requirements to make them accountable for their actions and an increase in the general population’s medical knowledge owing to widespread use of the internet. Despite such changes, which reflect parallel shifts in all occupations, trust in the medical profession persists. Militant nurses are advocating a radical move from the status quo in terms of power relationships, and have raised awareness of their potential as agents for change in the medico-political arena.

Vignette 2

Conflicts about who is in control and who has ultimate responsibility for decisions about patients are more likely to emerge in community teams than in in-patient settings, where traditional medical hierarchies still exist and are accepted (even though this is rapidly changing). Very often, these conflicts represent not real differences in skills or ability, but notions of professional boundaries and perceived challenges to authority. With open discussion, explanation of how decisions are arrived at and clarification of appropriate delegation, these conflicts can easily be resolved, provided each member of the team takes responsibility for their own actions. In the case illustrated in Vignette 2, the team might decide that a small group of senior clinicians, including a psychiatrist, should meet separately from the main multidisciplinary meeting to allocate newly referred patients. This would free time for other clinical discussions during the full team meeting. If this solution is adopted, GPs must be informed and anyone can raise questions about these decisions if they have any objections.

The false lure of primary care

The move into the community opened the door for psychiatric nurses to show their independent skills, particularly when they left the domain of the psychiatric team to work in primary care settings. At first, many independently minded CPNs left secondary care psychiatric services to work in primary care, because they wanted to free themselves of the shackles of the authoritarian structure, not only within the psychiatrist’s domain but also within their own nursing hierarchy, which traditionally had been very controlling. Unfortunately, they soon discovered that they had switched one medically dominated field for another, in which GPs referred to them patients with complex problems and left them to their own devices, without the support of a psychiatric team. Some observers associated this development with the increase in job-related stress and burnout in psychiatric nurses (Reference Carson, Fagin and RitterCarson et al, 1995; Reference Fagin, Brown and BartlettFagin et al, 1995). Not surprisingly, the 1990s saw a retreat from primary care back into the fold of community mental health teams.

A flatter hierarchy

Traditionally trained psychiatrists accustomed to the formal protocol of hospitals and institutions can face stress when they move into the flattened hierarchy of multidisciplinary teams, albeit a hierarchy in which they still hold a central leadership role. Some have attempted to recreate an authoritative style of relationship in the community team, which inevitably has caused dissatisfaction and strain between professions, not least between doctors and CPNs, whose respective boundaries have had to be redefined.

Community teams tend to place greater weight on the combined efforts of all professions represented in them. In these multidisciplinary units, however, nurses often perceive that their contributions are less influential than those of others, or that they have been given much more restricted roles, for example dispensing depot injections or monitoring mental states. Even when this is not the case, however, nurses have to make adjustments in their professional relationships with doctors, which has become less unique.

Some nursing authors have cited the hierarchical nature of the nursing profession itself, which emphasises discipline, authority, punishment and adherence to rigid procedures, as the main barrier in their attempts to gain equality with other professions (Reference Walsh and FordWalsh & Ford, 1994; Reference OughtibridgeOughtibridge, 1998). Another obstacle is the absence of a progression pathway in clinical practice for experienced senior nurses who do not wish to take on management responsibilities (an implicit denigration of nursing care). Reference FarrellFarrell (2001) describes how aggression and hostility between nurses have undermined their position in relation to other groups within the medical profession. Observations of intraprofessional conflict suggest that nurses, unable to confront existing hierarchical structures, take their frustration and vindictiveness out on their peers, colleagues and juniors. Senior nurses, reacting to their awareness of their lower status relative to other professional groups, prefer to align themselves with those groups rather than with their own professional colleagues. These authors also suggest that, despite changes in the academic aspirations of nurses and the increasing numbers that gain a university education, there is still a prevalent ‘anti-academic’ attitude among many, which again prevents them from seeing themselves as innovators, capable of reflective practice and embarking on research initiatives.