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Is the doctor-nurse game being played?
Abstract
Forty years ago, Leonard Stein outlined his theory of the doctor-nurse game. In 1990, he revisited his theory and found that the game he had described no longer existed, mainly because nurses were no longer willing to play. Since the publication of the original theory, attempts have been made to professionalise nursing and to negotiate a sense of identity within the somewhat patriarchal doctor-nurse relationship. I believe, despite denials from the nursing establishment, the doctor-nurse game continues, and changes to the profession have not been as far-reaching in this respect as hoped.
... d) The "doctor-nurse game" 3. Organisational factors affecting IPC practices 4. Factors relating to IPC policies and/or their implementation Note: 1. Previously reported (42) Professional stereotypes. ...
... In 1990, he suggested the "game" had all but ceased because of changes in professional education, roles and gender ratios.(41) However, persistence of this "dance of deference" has been recently implicated in communication failures, blame-shifting and mutual mistrust, causing harm to patients (42)(43)(44). Our ndings suggest that the 'rules of the game' mean that a nurse, who seeks to remind a doctor about an IPC breach, must balance the likelihood of success (the doctor's compliance) vs failure (being ignored or humiliated) and act accordingly. ...
Background
Hospital infection prevention and control (IPC) depends on consistent practice to achieve its purpose. Standard precautions are embedded in modern healthcare policies, but not uniformly observed by all clinicians. Well-documented differences in attitudes to IPC, between doctors and nurses, contribute to suboptimal IPC practices and persistence of preventable healthcare-associated infections. The COVID-19 pandemic has seriously affected healthcare professionals’ work-practices, lives and health and increased awareness and observance of IPC. Successful transition of health services to a ‘post-COVID-19’ future, will depend on sustainable integration of lessons learnt into routine practice.
Methods
The aim of this pre-COVID-19 qualitative study was to investigate factors influencing doctors’ IPC attitudes and practices, whether they differ from those of nurses and, if so, how this affects interprofessional relationships. We hypothesised that better understanding would guide new strategies to achieve more effective IPC. We interviewed 26 senior clinicians (16 doctors and 10 nurses) from a range of specialties, at a large Australian tertiary hospital. Interview transcripts were reviewed iteratively, and themes identified inductively, using reflexive thematic analysis.
Results
Participants from both professions painted clichéd portraits of ‘typical’ doctors and nurses and recounted unflattering anecdotes of their IPC behaviours. Doctors were described as self-directed and often unaware or disdainful of IPC rules; while nurses were portrayed as slavishly following rules, ostensibly to protect patients, irrespective of risk or evidence. Many participants believed that doctors object to being reminded of IPC requirements by nurses, despite many senior doctors having limited knowledge of correct IPC practice. Overall, participants’ comments suggested that the ‘doctor-nurse game’ - described in the 1960s, to exemplify the complex power disparity between professions - is still in play, despite changes in both professions, in the interim.
Conclusions
The results suggest that interprofessional differences and inconsistencies constrain IPC practice improvement. IPC inconsistencies and failures can be catastrophic, but the common threat of COVID-19 has promoted focus and unity. Appropriate implementation of IPC policies should be context-specific and respect the needs and expertise of all stakeholders. We propose an ethical framework to guide interprofessional collaboration in establishing a path towards sustained improvements in IPC and bio-preparedness.
... " In 1990, he suggested the "game" had all but ceased because of changes in professional education, roles and gender ratios [43]. However, persistence of this "dance of deference" has been recently implicated in communication failures, blame-shifting and mutual mistrust, causing harm to patients [44][45][46]. Our findings suggest that the 'rules of the game' mean that a nurse, who seeks to remind a doctor about an IPC breach, must balance the likelihood of success (the doctor's compliance) vs failure (being ignored or humiliated) and act accordingly. ...
Background
Hospital infection prevention and control (IPC) depends on consistent practice to achieve its purpose. Standard precautions are embedded in modern healthcare policies, but not uniformly observed by all clinicians. Well-documented differences in attitudes to IPC, between doctors and nurses, contribute to suboptimal IPC practices and persistence of preventable healthcare-associated infections. The COVID-19 pandemic has seriously affected healthcare professionals’ work-practices, lives and health and increased awareness and observance of IPC. Successful transition of health services to a ‘post-COVID-19’ future, will depend on sustainable integration of lessons learnt into routine practice.
Methods
The aim of this pre-COVID-19 qualitative study was to investigate factors influencing doctors’ IPC attitudes and practices, whether they differ from those of nurses and, if so, how this affects interprofessional relationships. We hypothesised that better understanding would guide new strategies to achieve more effective IPC. We interviewed 26 senior clinicians (16 doctors and 10 nurses) from a range of specialties, at a large Australian tertiary hospital. Interview transcripts were reviewed iteratively, and themes identified inductively, using reflexive thematic analysis.
Results
Participants from both professions painted clichéd portraits of ‘typical’ doctors and nurses and recounted unflattering anecdotes of their IPC behaviours. Doctors were described as self-directed and often unaware or disdainful of IPC rules; while nurses were portrayed as slavishly following rules, ostensibly to protect patients, irrespective of risk or evidence. Many participants believed that doctors object to being reminded of IPC requirements by nurses, despite many senior doctors having limited knowledge of correct IPC practice. Overall, participants’ comments suggested that the ‘doctor-nurse game’—described in the 1960s, to exemplify the complex power disparity between professions—is still in play, despite changes in both professions, in the interim.
Conclusions
The results suggest that interprofessional differences and inconsistencies constrain IPC practice improvement. IPC inconsistencies and failures can be catastrophic, but the common threat of COVID-19 has promoted focus and unity. Appropriate implementation of IPC policies should be context-specific and respect the needs and expertise of all stakeholders. We propose an ethical framework to guide interprofessional collaboration in establishing a path towards sustained improvements in IPC and bio-preparedness.
... Having a diverse group of healthcare professionals engaged in IPC with different backgrounds, insights and perspectives increases the chances of generating unique and innovative solutions to challenges that often arise with regards to care quality in clinical practice. However, there is a long history of shortcomings in IPC that have a deleterious impact on patient safety arising from conflict relating to professional boundaries, license, jurisdiction, and mandate between different healthcare professionals, such as doctors and nurses (4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14). These recurring narratives about the relationships between doctors and nurses, who are in two of the oldest healthcare professions, highlight the challenges that exist in facilitating IPC which achieves the lofty aim of consistently delivering safe, high-quality care to all in a just and equitable manner. ...
... "diagnosticar e tratar" da medicina. O médico não parece reconhecer na sua identidade o papel de cuidador.O relacionamento entre o médico e os demais profissionais de saúde, em particular os enfermeiros, mostra uma percepção de maior valorização do médico, que aparece numa posição superior de concentração de autoridade e de poder consolidada sobretudo nos espaços hospitalares11 .Sabendo que as barreiras interpostas entre esses profissionais perpassam pelas diferenças de renda e gênero orientando expectativas e escolhas de formação universitária, a graduação em medicina parece reforçar mesmo que sutilmente essas visões[12][13][14][15] . Essa diferença de percepção de valores foi nítida entre os entrevistados e a fala de uma das enfermeiras foi particularmente interessante ao estranhar que médicos se sintam desvalorizados quando a visão de indivíduos de fora do ambiente médico é de uma hipervalorização médica em relação às demais profissões.A questão da construção de uma identidade médica ao longo da graduação foi tangenciada em algumas das entrevistas: algumas falas já incorporam uma perspectiva médica quando usam "nossa" ("nossa profissão") como um determinante de pertencimento ao grupo médico, enquanto outros ainda se reconhecem predominantemente como enfermeiros e usam os termos "eles" ("eles são muito mais valorizados do que a gente"), "deles" ("a valorização deles é muito grande") como ainda não tendo absorvido plenamente essa identidade médica. ...
... During his data collection the author was able to theorize that practitioners have ideas about their supervision that are dependent on what colleagues think about supervision including the expectation that 'good practitioners' attend supervision in order to 'reflect'. The dominant themes of reflection include the 'shocking things I have seen', the 'way I dealt with stuff', 'the awe of others opinion and practice', 'testing and comparing myself against other colleagues' and 'my advice to others is to remain detached' (Holyoake, 2011(Holyoake, , 2000. These themes appear again and again in the supervision room. ...
This article explores the expectations made of organised supervision in health and social care settings. In particular, the way that supervision claims to be meeting the needs of the supervisee yet, is so often instructed in those of the organisation. Using the notion of conversations from supervision sessions and extracts from his ethnographic research with healthcare practitioners working with mentally ill young people and their families the author examines some of the interpersonal dilemmas practitioners encounter. His use of narrative and interpretive method allows him to reflect on how some practitioners view supervision with suspicion and as driven by systems which have no restorative characteristics as so often claimed.
... Stein (1967) further conceptualised the relationship between doctors and nurses as a game of interdependent interaction. Although his study is now more than 50 years old, Stein based his findings on relationships between health care professions that still exist today (Holyoake, 2011). Other studies have examined what the logic of integration promises, such as mutual trust and respect, communication and sharing of knowledge, and positive attitudes (O'Carroll et al., 2016;Sangaleti et al., 2017). ...
Much research has used three logics to understand the dynamics of interprofessionalism: 1) assimilation, that is, adapting the work of others; 2) segregation, where professional roles are separated and boundaries defended; and 3) integration, a perspective on the complementarity of professional roles. However, we found no studies analysing all three logics in connection with each other. Based on an ethnographic study of interprofessional teamwork in the field of mental health and substance use in Norway, this article explores the dynamics of interprofessionalism from all three perspectives. The data collection consisted of 14 observation sessions and 18 in-depth interviews of professionals in the field of health and social work. Investigating how, when and why each logic came into play, the results show the importance of including all three logics to leverage each one’s purpose and function, and how they appear almost simultaneously in many situations. By investigating all three logics, the paper provides a broader, more comprehensive view of interprofessional teamwork.
ARTICLE INFO ABSTRACT The aim of this research is to examine nurses and physicians' own occupational groups and their perception of each other according to the personality dimensions based on the adjectives in the Five Factor Personality Theory. This descriptive study was carried out between October-December 2017 and 309 persons (n = 153), nurses n = 156) who agreed to participate in the study in private hospitals operating in the European provinces in Istanbul and allowing them to work. "Personal Information Form" and "Adjective Based Personality Test Scale" were used to gather personal data. The obtained data were analyzed using the SPSS 23 packet program. In the analysis of the data, descriptive statistical methods (frequency and percentages), the significance between the two means (Student's t) test and the Mann Whitney U test were used for averages with statistically significant differences from the normal distribution. Physicians and nurses had a mean total score of 2.78 ± 1,542 on the adjectives-based personality test scale, and it was found that they defined the test personality moderately. Moreover, when physicians assessed themselves and the nurses, the mean scores of conscientiousness, softness, responsibility, emotional imbalance, experiential openness subscales and sums of scale were higher than nurses. The difference between physician and nurse professional groups was significant (p <0.05). Personality traits are characteristics that can change with education and social environment, even if they are partly innate. These characteristics are reflected in one's social life and working life and are preventing the establishment of a professional career relationship. The acquisition of a professional qualification of the physician nurse relationship in the health sector is a situation that can affect patient safety and productivity and can be supported with appropriate studies.
This article explores collaboration specifically from the perspective of nurses and offers salient points for nurse leaders to consider as they work to establish a collaborative practice environment.
Interprofessional collaboration (IPC) is crucial to efficient patient management in the modern healthcare setting. We sought to determine the attitudes of physicians and nurses working in different hospitals in the Islamabad–Rawalpindi region of Pakistan. We employed the Jefferson Scale of Attitudes toward Physician–Nurse Collaboration (JSAPNC), a 15-item questionnaire that quantifies these attitudes in a meaningful way. Higher scores indicate a more positive attitude toward IPC. Four domains (shared education and teamwork, caring vs. curing, nurses’ autonomy, and physicians’ dominance) represent the intricate factors that influence IPC in a hospital setting. A total of 374 healthcare professionals responded. Nurses had significantly better opinions about IPC compared to physicians (mean: 50.81 vs. 47.48, p<.01). Nurses also outscored physicians in all four domains of the JSAPNC (education and collaboration 24.87 vs. 23.72 p<.001, caring vs. curing 10.88 vs. 9.42 p<.001, nurse’s autonomy 10.89 vs. 10.51 p=.004, and physician’s authority 4.17 vs. 3.82 p=.044). The results show that nurses in Pakistan value IPC more than their physician colleagues. Inculcating the importance of IPC through educational methods might help improve these attitudes.
Aims
The current study aims to examine the attitudes of healthcare professionals towards nurse–physician collaboration and to explore the level of satisfaction concerning the quality of collaboration among them.
Design
A descriptive comparative study design was used to demonstrate attitudes of 338 participants (158 internship nurses, 139 nurses and 41 physicians) working in intensive care units, surgical department and medical department.
Methods
Two instruments were used, socio‐demographic data sheet and Jefferson scale of attitude towards nurse–physician collaboration (JSANPC), it consisted of 15 items under 4 dimensions.
Results
The internship nurses have the high score (38.6%) in poor level of satisfaction regarding quality of collaboration between nurses and physicians comparing to staff nurses and physicians. Physicians are satisfied (61%) with the level of collaboration between them and nurses. Staff nurses have the high positive attitude (48.45 (4.03)) towards collaboration between nurses and physicians comparing to physicians and internship nurses.
Conclusion
Internship nurses were not satisfied with the level of collaboration between nurses and physicians.
Cristina Bicchieri examines social norms, such as fairness, cooperation, and reciprocity, in an effort to understand their nature and dynamics, generated expectations and evolution and change. Drawing on intellectual traditions and methods, including those of social psychology, experimental economics and evolutionary game theory, Bicchieri provides an integrated account of how social norms emerge and why and when we follow them. Examining the existence and survival of inefficient norms, she demonstrates how norms evolve in ways that depend upon the psychological dispositions of the individual and how such dispositions may impair social efficiency. © Cristina Bicchieri 2006 and Cambridge University Press, 2010.
In this pithy and highly readable book, Brian Skyrms, a recognised authority on game and decision theory, investigates traditional problems of the social contract in terms of evolutionary dynamics. Game theory is skilfully employed to offer new interpretations of a wide variety of social phenomena, including justice, mutual aid, commitment, convention and meaning. The author eschews any grand, unified theory. Rather, he presents the reader with tools drawn from evolutionary game theory for the purpose of analysing and coming to understand the social contract. The book is not technical and requires no special background knowledge. As such, it could be enjoyed by students and professionals in a wide range of disciplines: political science, philosophy, decision theory, economics and biology.
Evolutionary game theoretic accounts of justice attempt to explain our willingness to follow certain principles of justice by appealing to robustness properties possessed by those principles. Skyrms (1996) offers one sketch of how such an account might go for divide-the-dollar, the simplest version of the Mash bargaining game, using the replicator dynamics of Taylor and Jonker (1978). In a recent article, D'Arms et al. (1998) criticize his account and describe a model which, they allege, undermines his theory. I sketch a theory of evolutionary explanations of justice which avoids their methodological criticisms, and develop a spatial model of divide-the-dollar with more robust convergence properties than the models of Skyrms (1996) and D'Arms et al. (1998).
The relationship between the doctor and the nurse is a special one, based on mutual respect and interdependence, steeped in history, and stereotyped in popular culture. The underlying interaction can often be characterized as a game. In 1967 one of us described how doctors and nurses related to one another at that time.1 In this article we address the question of change. From our observations we are convinced that there have been major changes in the doctornurse relationship over the past two decades. To describe these changes we will briefly review the relationship that prevailed in 1967 and contrast it . . .
The purpose of this historical research was to explore the evolution of the doctor-nurse relationship. Specifically, older nurses were interviewed regarding their nursing interactions with physicians approximately 50 years ago. A grounded theory approach was employed to analyse the data. Inherent to the difficulties nurses experienced was the dominant power position assumed by doctors in the health profession. The data give added insights into the development of this relationship. It was found that because nurses were educated primarily by doctors and because they were hired by doctors if they were considered to be 'good' nurses, a sex role stereotype of the nurse emerged. Historically these roles have influenced and continued to influence the nursing profession.
THE relationship between the doctor and the nurse is a very special one. There are few professions where the degree of mutual respect and cooperation between co-workers is as intense as that between the doctor and nurse. Superficially, the stereotype of this relationship has been dramatized in many novels and television serials. When, however, it is observed carefully in an interactional framework, the relationship takes on a new dimension and has a special quality which fits a game model. The underlying attitudes which demand that this game be played are unfortunate. These attitudes create serious obstacles in the path of meaningful communications between physicians and nonmedical professional groups.
The physician traditionally and appropriately has total responsibility for making the decisions regarding the management of his patients' treatment. To guide his decisions he considers data gleaned from several sources. He acquires a complete medical history
The disciplines of nursing and medicine are expected to work in unusually close proximity to one another, not just practising side by side but interacting with one another to achieve a common good: the health and well-being of patients. This selective review of literature addresses some of the issues arising from the frequently controversial subject of the nurse-doctor relationship and seeks to draw out the principal themes emerging from the application of sociological theory to the nurse-doctor relationship and research into its operation in clinical settings. Particular attention is paid to the 'doctor-nurse game', a stereotypical pattern of interaction, first described in the 1960s, in which (female) nurses learn to show initiative and offer advice, while appearing to defer passively to the doctor's authority. This pattern of interaction seems less common in clinical practice today but the problem remains of each profession having ideal expectations of one another which inevitably fall short as a result of differing views of qualities of doctors and nurses to be valued.