Equal but not the same: why we need to rethink how doctors and nurses work

An equal relationship between doctors and nurses working in general practice will mean comprehensive primary health care for patients. nursing pins/Flickr

Doctors and nurses appear to work harmoniously together but this apparently serene state of affairs is actually hiding inequality. Instead of giving nurses the room to shine in their workplace, the traditional role of the doctor as the dominant professional means nurses face both structural and professional inequalities.

But a major change is occurring in Australian health care: if you pay a visit to your local doctor, there’s a good chance you’ll spend some time with a nurse.

Nurses in general practice provide specialist health services, education and advocacy. For patients with long-term health complaints, having a nurse involved in care can improve health outcomes.

Nurse-led clinics for people with coronary heart disease, for instance, have increased patient participation in continuing care and encouraged lifestyle changes.

In Australia, the number of nurses employed in general practice increased by 260% between 2003 and 2008. By 2009, it was estimated that 8914 nurses worked in general practice.

This growth doesn’t appear to be slowing. If anything, it’s speeding up and this is no accident.

Quiet revolution

Successive federal governments have and continue to encourage the employment of nurses in general practice (practice nurses), as one part of a wider strategy to address concerns about changes in the population.

As the population ages, more people will experience long-term health complaints and more people will have more than one health problem.

By increasing the number of nurses in general practice, it’s hoped these growing ranks of patients will be able to have their health-care needs met quickly and appropriately.

For patients, this raises questions about how they will experience a visit to their general practice. Nurses and doctors, meanwhile, are asking how they can work together to provide the best possible health care.

Nurses who enter the workforce today are prepared for clinical independence, critical thinking, and professionalism. No longer do they view themselves as doctors’“handmaidens”.

Nor are nurses substitute doctors in general practice – they meet the needs of patients by approaching problems in a different way.

They seek to understand how a person is experiencing both their health and their illness so the nurse acts as an advocate for the patient.

Better heath care

The general practitioner has traditionally been the sole custodian of care but as the number of nurses in general practice increases, it’s likely that this traditional role will be challenged.

Doctors and nurses working together can deliver comprehensive primary health care. In fact, evidence suggests when nurses and doctors work as equal partners, patients have better health outcomes and the health system saves money.

But the majority of nursing activities in general practice in Australia are only funded if a nurse is supervised and works on behalf of a general practitioner.

This may not be the best way of helping nurses and doctors to work in partnership.

Evidence suggests that for some health problems, nurses can achieve equivalent health-care outcomes to care by doctors but there remains a need for more research on the efficacy of nurse-led services.

In Australia, general practices operate as businesses and need to make money, so nurses cannot be a financial loss to a practice.

And the medical profession doesn’t have incentives to support the nursing profession to have independent access to Medicare funding unless those services are provided on behalf of the general practitioner.

Where nurses undertake consultation in tandem or on behalf of general practitioners, there’s potential for more patients to be seen, and increasing the number of patient consultations would increase the revenue of the practice.

But allowing the nursing profession to access Medicare funding independently of the medical profession may be perceived as eroding the potential income of general practitioners.

Such perceptions are problematic because if the nursing profession is denied opportunities to contribute to patient care because of real or perceived economic factors favouring doctors, it may result in distrust between the professions.

And such distrust is likely to hinder the development of equal and collaborative working relationships.

Advocating for themselves

It’s important for the nursing profession to demonstrate that it can deliver cost-effective healthcare. Nurses must also show that they are accountable for the services they provide.

Current research suggests that nurses in general practice may influence medical decision making as a way of getting around limitations to their role.

If this is the case, it calls into question the openness and transparency of nursing roles in general practice.

And openness and transparency about the relative contributions to health care by both nurses and doctors will greatly enhance the trust of the public.

While the onus remains on the nursing profession to demonstrate their value in general practice the support of the medical profession will go a long way to building collegial relationships.

Collaborative partnerships between nurses and doctors in general practice will result in comprehensive primary health care – the beneficiaries will be patients and the community.

Increasing the number of nurses in general practice has the potential to improve Australian primary health care services, but this is only part of the solution. Policy makers must also look at ways to support nurses and doctors to work together.

The future for nursing in general practice is bright. It will be even brighter when nurses and doctors become equal partners.