The professional relationship between nurses and doctors
Gonzalo Herranz, department Bioethics, University of Navarra
lecture the Campus University
Rome, March 1995
attention and professional respect between doctors and nurses
Respect for area work area , cooperation, and interdependence
Do not delegate your own duties to someone who is not competent.
Recognize the legitimate chain of command
Report those who behave carelessly or negligently
Nurses and doctors cannot work independently, as in hospitals or clinics, health centers, and even in patients' homes, providing quality care requires them to collaborate closely. This means that they must develop and maintain very close interprofessional relationships, in which ethics play a prominent role.
Since ancient times, these relationships have generally been characterized by harmony and mutual understanding. Doctors are vested with a certain authority, as they bear ultimate responsibility for the care received by patients. However, the power of the doctor has limits in terms of intensity and scope, which are determined by local customs and traditions, work contracts, egalitarian social trends (feminist emancipation, for example), and the internal evolution of the professions themselves (autonomy of the "nursing process," democratization of the medical profession).
partnership requires doctors, nurses, and other healthcare professionals to share common ideals and goals, so that their specific skills are integrated into their collective responsibility—serving the patient—through, on the one hand, mutual support that creates team spirit, and, on the other hand, by following ethical standards that regulate hierarchical communication, coordinated problem solving, fair distribution of roles and tasks, equitable conflict resolution, and, finally, assessment of work skill.
Interprofessional relationships are enriching, although not without complications. To alleviate any tensions that may arise and reduce the risk of potential conflicts, professional organizations have proposed appropriate ethical standards, which should be understood and practiced. Careful consideration of these standards can provide us with a comprehensive overview of the ethics of these relationships.
The Spanish Nursing Code of Ethics (CDEE) devotes considerable attention to nurses' relationships with other members of the healthcare professions. It bases the ethics of these relationships on respect for individuals and their specific roles (art. 62), on diligent partnership members of the healthcare team, on recognition of their respective areas of skill, and on the duty to apply for partnership required apply for the best quality of service to patients (art. 63 and 64). The rules of good Education courtesy govern attention to everyone: superiors and subordinates, colleagues, and other healthcare professionals (art. 66). The CDEE prohibits nurses from delegating their own duties to those who are not competent (art. 59) and imposes on them the obligation to report negative attitudes and careless or culpable behavior by other members of the healthcare team (art. 61).
For its part, the Code of Medical Ethics and Professional Conduct, although much less explicit on the subject, describes similar duties in Chapter VIII.
Thus, the ethics of relations between nurses and physicians are defined by the reciprocal duties of:
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respect people and treat them with courtesy,
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do not invade each work area work area ,
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Do not delegate your own duties to someone who is not competent.
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recognize the legitimate chain of command, and
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report anyone who behaves carelessly or negligently.
These, then, are the issues that need to be considered.
attention and professional respect between doctors and nurses
The common rules of good Education are fully applicable in interprofessional relationships, as they symbolize and express the appreciation that each person feels for the human dignity of others in society. These rules require basic things: greeting each other; addressing each other by their first name, preceding the surname , when acceptable, the first name—with the appropriate term of courtesy (Miss, Mrs., Mr., Doctor); making very restricted use of informal language, as it tends to diminish respect; asking for things politely; and giving thanks for financial aid . Taking care of one's appearance—composure, attire, and grooming—is also part of the debt of respect we owe to one another.
Secondly, interprofessional relationships require, beyond common attention , a attention professional attention : that which should be given to each other by qualified, certified, or soon-to-be-certified individuals, such as doctors, nurses, midwives, and medical and nursing students. All of them are entitled to a special quality attention , which is equally distant from rigid coldness and silly familiarity. Healthcare professionals are people who are knowledgeable about their art, with the capacity for judgment and a sense of responsibility, morally mature, whose professional convictions and dignity must be recognized in their attention each other and to third parties.
Among the manifestations of this professional respect are things such as granting everyone credit for honesty and skill, which leads to trusting them, asking for and listening to their opinions, and communicating (giving and receiving) the necessary orders with rationality and restraint.
You cannot immediately, impulsively, and thoughtlessly discredit someone's actions and verbally abuse them, especially in front of others, because this not only upsets patients and colleagues, but also opens up very painful wounds that take a long time to heal. There is a very effective and dignified way to respond to angry quarrels and intemperate rebukes: silent and rational serenity, which reveals by contrast the psychological and ethical inferiority of those who allow themselves to be carried away by anger. When, whether intentionally or not, you offend someone, you must apologize: it is the best vaccine against resentment. Corrections, when necessary, should be made privately and with equanimity. It is unethical to gossip about another healthcare professional behind their back. There is a moral obligation to restore the good reputation of another that has been damaged by slander.
Respect excludes any concession to frivolity from the relationship between nurses and doctors. If professional respect is replaced by excessive camaraderie, flirting, or erotic banter, the sense of authority will inevitably suffer greatly and there will be a dangerous deterioration in the quality of service provided to patients. In the work, any form of abuse of people—contempt, practical jokes, psychological or sexual harassment—is absolutely out of place. It would be a disgrace if the human tone of interprofessional relationships in a hospital service were to be dominated by vulgarity and rudeness.
The respect demanded by professional ethics leads to recognizing other members of the healthcare team as active moral agents, endowed with conscience and responsibility. It is not compatible with the ethics of respect to regard others as mere automatons, obliged to blindly obey the orders given to them. It is deontologism of the worst kind to assert that every order must be obeyed without further inquiry. No one can subject their professional conduct to blind obedience to their superior and justify it by saying that moral responsibility lies exclusively with the person giving the orders, not with the person who merely carries them out. Such an attitude is equivalent to voluntary submission to a regime of ethical slavery, incompatible with dignity and human rights. Employment contracts that oblige, without any possibility of appeal, the fulfillment of any action ordered by those in authority would therefore be contrary to ethics.
When compliance with an order causes moral repugnance, the need to object on grounds of conscience arises. This is discussed further below (see the section Recognizing the legitimate chain of command).
Respect for area work area , cooperation, and interdependence
The partnership nurses and doctors has as its primary goal the provision of good patient care. To achieve this, each person must commit to contributing their own part to the common effort. This requires a minimum of organization. Cooperation must be orderly. It is therefore necessary for someone to take charge: whoever does so must be exemplary in their commitment to the common goal. Obeying basically consists of expressing in deeds the ideals that everyone has made their own.
Cooperation brings together everyone's initiatives, the best that each person can give, into a higher unity. For nurses, the partnership doctors is not limited to receiving and carrying out their orders, informing them of what has happened to patients, and answering their questions. The classic paradigm of the nurse-doctor relationship, with its stereotypes of woman-man, obey-command, or care-cure, has been enriched in modern times with other elements that have created, in interdependence, areas of specific responsibility.
It is important for interprofessional harmony that, when starting to collaborate, before signature work contract work moving to a new work space, nurses and doctors negotiate and establish a good distribution of functions, tasks, and responsibilities, define the boundary between medical decisions and nursing decisions, and set the technical, human, and ethical style of work to each and assumed by each.
Setting limits is a tool for order and freedom. However, it should not become an excuse for indifference towards anything beyond the established boundaries. It is incompatible with the ethics of work to limit oneself to scrupulously fulfilling one's assigned tasks, without ever lending a hand to others even in cases of need. It is unethical to say, "That's not my job," when another team member in trouble. The patient's well-being occasionally requires the nurse to cross the line and make decisions that normally fall to the absent physician, as occasionally happens in emergency situations or frequently in intensive care units.
Interprofessional respect prohibits invading, without serious reason, the area , in a modern work organization, is assigned to the responsibility of different professions and individuals. This recognizes the dignity of each profession and the specific contribution that each person makes to the whole. Therefore, nurses cannot interfere in the specific tasks of doctors, for example, by operating on patients or issuing official certificates; nor can doctors invade the field of nursing and usurp its functions, forcibly imposing certain ways of scheduling, controlling, or executing nursing care.
Respect also dictates not adding extraneous elements to the tasks of others, imposing extra-contractual duties or those that do not correspond to the degree program assigned function. Neither in public service nor in internship can a doctor, thinking that his time is the most valuable, ask a clinic assistant to go to the tobacconist's to buy him a carton of cigarettes, or order a nurse to please take his broken-down car to a repair shop.
Do not delegate your own duties to someone who is not competent.
As we have seen, clearly defining boundaries prevents the risk of intrusion, i.e., performing acts specific to a profession without possessing the corresponding degree scroll . But at the same time, cooperation requires a certain degree of permeability, freedom of movement between both sides of the boundaries. The efficiency of groups made up of assistants, nurses, and doctors depends largely on proper coordination and mutual financial aid.
The correct delegation of duties requires an equally strong sense of responsibility in both the person delegating and the person receiving the delegated duty. Both must be accountable for their conduct in the event of an accident or conflict. Therefore, the physician can only delegate, under his or her own supervision and being available intervene immediately at any time, to those who have the sufficient and necessary training. The nurse must judge in all sincerity whether she considers herself fully capable of assuming the duties assigned to her. She cannot, out of vocational enthusiasm, a desire to please, or to obtain better pay, assume responsibilities for which she is not properly prepared. A specialized nurse may possess a great deal of skill and be capable of assessing relatively complex clinical situations, but their prudence and responsibility—which are a qualified part of that same skillwill lead them not to alter the conditions of the delegation received and not to deviate from the ordinary guidelines for action without consulting the physician.
In recent times, there has been a tendency among both doctors and healthcare service organizers to establish so-called nursing consultations, that is, to entrust certain medical functions, such as the monitoring of chronic patients, to suitably trained nurses. Undoubtedly, a specialized nurse may be trained to obtain data a patient's progress and perform certain examinations and analyses to confirm the continuation of treatment or introduce certain predetermined adjustments. However, they must also know which changes in the patient's condition should be brought to knowledge and which situations are exclusively for the doctor to decide. They cannot cease to be a collaborator and become the protagonist.
There are medical responsibilities that are always ethically and legally non-delegable: neither the doctor can entrust them to a nurse, nor can a nurse, however competent, assume them. These include things such as establishing a medical diagnosis through medical history and examination, or checking the data to issue a certificate.
Recognize the legitimate chain of command
In the past, doctors enjoyed unquestioned authority by virtue of their greater knowledge exclusive responsibility: they gave orders and nurses obeyed. The hierarchy was then exercised with a certain military style. We cannot forget that modern nursing, born on the battlefield, received from Florence Nightingale not only a highly hierarchical internal organization, but also an almost military dependence on the orders of doctors. Later, very rigid models of organization and decision-making were proposed, taken from industrial contexts that were also strongly hierarchical. Things have changed a lot in more recent times: nurses, as group, have acquired a great deal of skill , with it, greater autonomy and responsibility, as well as their own system of governance, that of the Nursing Unit, with which the doctor must negotiate and which he must respect. Nursing and medicine must coexist in interdependence, they must communicate with each other following their own lines of governance, the corresponding hierarchical channel.
Medical decisions are, logically, above nursing decisions. Nurses usually have no problem taking responsibility for carrying out these orders, putting their own professional style staff emphasis on their execution, moving with ease in the field of professional autonomy.
However, there may also be occasions when the orders given by the physician seem unacceptable. Is it morally justifiable for a nurse to disobey the physician's orders? Furthermore, is there a moral duty to disobey them in certain situations? Professional disobedience can occur in two different areas.
In the first of these, which has to do with conscientious objection, refusal to obey is based on the respect that each person professes for certain deep and non-negotiable convictions, which, in addition to being a substantive part of their moral identity. An ethically mature society respects certain legitimate areas of conscientious objection as a respectable manifestation of ideological pluralism and freedom of conscience, protected by Constitutional Law. When an order causes serious moral repugnance, the nurse will make this clear to the doctor and ask to be relieved of the duty to carry out such an action. The doctor, after considering the matter, may withdraw or change the order. If he maintains it, he should find another nurse who does not object to carrying it out. He can never force anyone to act against their conscience. It is obvious that conscientious objection must be reserved for actions of fundamental moral significance: invoking conscientious objection to exclude oneself from heavy, tedious, or acceptably risky work would be an irresponsible and perverse use of it.
In the second case, disobedience simply seeks to prevent an order that is considered wrong from being carried out: a prescription error, for example. There is no moral rebellion here that contradicts the superior's order. The rebellion is only apparent, as it seeks to avoid an error: complying with the erroneous order would harm the patient and go against the ideal of non-maleficence, shared by doctors and nurses. The just defense of the patient's interests, the role of advocacy, provides an ethical basis for the nurse's disagreement, and even disobedience, toward the doctor.
There may occasionally be situations in which it is not enough to disobey, but rather to report the situation.
Report those who behave carelessly or negligently
In recent decades, doctors and nurses have claimed the role of patient advocate for their respective professions: they feel professionally obligated to protect patients from injustices that could harm them, whether these injustices come from family members, public or private healthcare administrators, or any other healthcare professionals.
The Code of Nursing Practice of committee of Nurses states that "nurses shall take appropriate action to protect those whose care may be endangered by a colleague or any other person."
Thus, nurses will sometimes be faced with the unpleasant duty of reporting a doctor whose professional conduct is inappropriate to the management assistant judicial authority or to their high school . They may do so to put an end to persistently careless or incompetent behavior, situations of administrative chaos, shortcomings that are not only not corrected but are getting worse, or to prevent serious harm to the patient's health due to the deterioration of the physician's physical or mental health.
To be ethical, a complaint must meet certain requirements: it must be based on facts or very solid suspicions, not mere hunches; it must refer to subject or legal subject defined in codes, statutes, or regulations; it must concern violations of a certain consistency, not trivial matters. Simple differences of professional opinion, character traits, or work style are not grounds for reporting. subject reporting is that which, if not reported, creates a justified conscience of feeling complicit in abuses or omissions that harm patients or defraud third parties.
Malicious or slanderous accusations are a serious offense, as they are an attack on the human right to honor of the unjustly accused. It is imprudent to accuse another person under the influence of the indignation that their culpable conduct may have provoked: one must wait for the moral passion to cool down. Furthermore, it is highly advisable to talk to the person in question to find out the motives behind their actions and determine whether it was an occasional mistake that the perpetrator sincerely regrets.
But it is also unacceptable not to report those who should be reported. Reporting in subject is a duty of justice towards patients and corporate organizations, a duty whose intensity is proportionate to the seriousness of the reprehensible conduct. Those who refrain from reporting become accomplices of the guilty party, as their tolerant passivity encourages them to persist in their misguided actions.
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