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2013
http://informahealthcare.com/jic
ISSN: 1356-1820 (print), 1469-9567 (electronic)
J Interprof Care, 2013; 27(6): 441–442
!2013 Informa UK Ltd. DOI: 10.3109/13561820.2013.846033
EDITORIAL
Medicine and nursing: a social contract to improve collaboration and
patient-centred care?
Scott Reeves
1
, Mary van Soeren
2
, Kathleen MacMillan
2
and Merrick Zwarenstein
3
1
Department of Social and Behavioral Sciences, University of California, San Francisco, USA,
2
School of Nursing, Dalhousie University, Canada, and
3
Centre for Studies in Family Medicine, Western University, Canada
Introduction
The call for effective interprofessional collaboration to deliver
safe, high quality patient-centred care has echoed across the world
for over the past 30 years (e.g. Department of Health, 1996;
Institute of Medicine, 2000; World Health Organization, 1988,
2010). Through such calls, it is argued that collaboration can
reduce duplication of effort, improve job satisfaction of staff, help
overcome fragmentation of service delivery and improve patient
safety and quality. While research has indicated that professionals
can work in an effective manner spread across the continuum
of care, professional biases, boundary protectionism and little
opportunity to develop interprofessional competence has made
effective collaboration extremely difficult (e.g. Gibbon, 1999;
Reeves & Lewin, 2004; Skjorshammer, 2001; Zwarenstein,
Goldman, & Reeves, 2009). However, the oldest of the two
health professions – medicine and nursing – are particularly
imbedded in this problematic relationship. In this editorial, we
argue that this combination of historical roles and practice
patterns, as well as a lack of understanding of the social contract
each profession has with patients, limits broad adoption of
effective collaborative practice and impairs patient-centred care.
Professional isolationism
Health care professions are extremely powerful entities (Hugman,
1991; Turner, 1987). Historically, their respective regulatory
bodies control who enters them, and through state legal frame-
works, they legitimize the scope of practice for members,
while restricting selected clinical activities to others (Reeves,
MacMillan, & van Soeren, 2010). This approach encourages
individual professions to emphasize distinctiveness rather than
togetherness, and protection of practices rather than evidence of
effectiveness. As a result, professional isolation over collaboration
remains dominant (Reeves, Lewin, Espin, & Zwarenstein, 2010).
This legacy strains efforts for interprofessional collaboration.
The historical emergence of health professions showed us that
occupations, such as medicine and nursing, attempt to profes-
sionalize through the engagement of a ‘‘closure’’ project
(Friedson, 1970). The aim of this project is to secure exclusive
ownership of specific areas of knowledge and expertise in order
to effectively secure economic reward and status enhancement.
To protect the gains obtained from professionalization all groups
guard the areas of knowledge and expertise they have acquired
through the regulation of entry and the maintenance of profes-
sional standards. Tension often arises, therefore, if a member
from one profession infringes into another’s area of expertise
(Donelan, DesRoches, Dittus, & Buerhaus, 2013; Dulisse &
Cromwell, 2010; Iglehart, 2013). Within this context, health care
delivery evolves because of dynamic patient care needs, while
professional protectionism seeks to maintain a status quo.
A social contract
The development of western medicine and, latterly, nursing has
generated a number of well-documented tensions for their ability to
collaborate in an efficacious manner (Reeves et al., 2010).
Nevertheless, the need for collaboration between these professions
is central to the delivery of effective patient care. These historical
strands have resulted in separate professional responsibilities and
different lines of management that make collaboration problematic
– even though these two professions are mutually interdependent.
For example, in general medicine, a patient’s medical needs may be
straightforward, but his/her need for nursing care may become
complex. Subsequently, responsibility for care, ideally, needs to
shift from medicine to nursing. However, the hierarchical division
of labour between these professions can impede this transition
often occurring, as the dominant position of medicine means that
they often retain control.
Given this enduring situation, we argue that there is a need
for a social contract that specifies roles/responsibilities with one
another as well as with the public. The use of such an approach
would help ensure clarity – medicine treats and manages
responses to illness (the cure mandate), while nursing supports
patients during illness, maintaining dignity, providing for their
safety and creating a therapeutic relationship to augment recovery
(the care mandate). It would help these professionals to have a
clearer approach to their work with patients, provide the basis
for constructive interprofessional negotiation, and also encourage
both medicine and nursing to focus on providing more patient-
centred care.
Shifting practices
The complexity of delivering effective care means that no one
profession can meet the needs of patients in the twenty-first
century. As a result, a new, more flexible approach is required.
A refocusing on the patient, for medicine and nursing, will
Correspondence: S. Reeves, Department of Social and Behavioral
Sciences, University of California, San Francisco, USA. E-mail:
Scott.reeves@ucsf.edu
J Interprof Care Downloaded from informahealthcare.com by University of Toronto on 01/16/14
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ensure that their dialogue is concentrated on the patient, thus
linking patient-centred care to the question of how to achieve
interprofessional care. Such a shift will need support. Better
preparation, training and on-going encouragement will help
physicians and nurses manage, on a local basis, the range of
negotiations and decisions they need to undertake their respective
work (Zwarenstein & Reeves, 2002).
Structurally, the hierarchical configuration between these
professions – which emerged from the crafts guild systems over
500 hundred years ago – will continue to make the role of
leadership a difficult one, especially as long as this history
remains a largely unacknowledged factor. Nevertheless, more
recent governmental and societal developments such as managed
care, the rise of consumerism and the emergence of new medical
and nursing roles (e.g. physician assistants, nurse practitioners)
may mark a shift towards more collaborative approaches to the
delivery of care. Nurse practitioners, for example, appear to
contribute a bi-cultural orientation to the team which may
promote better collaboration through interpretation across the
professional boundaries on both sides (Hurlock-Chorostecki,
Forchuk, Orchard, van Soeren & Reeves, in press; van Soeren,
Hurlock-Chorostecki, & Reeves, 2011). Clinical dominance and
traditional hierarchies need to give way to a new social contract
with patients – one that puts the patient first and relegates
interprofessional competition to history.
Concluding comments
Our focus in this editorial was on medicine and nursing, the two
largest professions with the longest history of collaboration;
however, the need for a social contract that embraces all the
different professions who work together to provide care is very
much needed. Such a contract, beginning with medicine and
nursing, then extending to other health and social professionals
could provide a firmer foundation to support effective inter-
professional collaboration and patient-centred care.
Declaration of interest
The authors report no conflicts of interest. The authors alone are
responsible for the writing and content of this paper.
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