Responses to the 2013 Question of the Year
What is a doctor? What is a nurse? These two questions might tempt one to examine and focus on the differences between the two professions. Differences certainly exist—in education and training, in scope of work, and in the nature of engagement with patients and families. These differences are a major focus of interprofessional education efforts that address what each group brings to the health care setting and how each can contribute to a team-based approach to health care. It may be useful, though, to address the questions from a different perspective: What unifies these two professions? What commonalities exist between them, and what are the shared obstacles to ideal practice? How can we work together to achieve a healthier and more effective health care work environment?
So what is the ideal doctor, what is the ideal nurse? They are individuals with deep senses of commitment to the welfare of their patients. They are technically competent, and this competence is solidly grounded in a firm understanding of the sciences underlying clinical practice. They are kind, compassionate, and their work is guided by strong values and ethics. They have excellent communication skills and competently interact with patients from different cultures. They are aware of and work actively to overcome their personal biases. Committed to high-quality, cost-effective care, they practice mindfully, work effectively in teams, and are alert for the possibility of medical errors. They are kind and patient with students and trainees.
For far too many nurses and doctors, this ideal is not a reality. The education and training they have experienced has had a toxic impact, leading to cynicism, burnout, and/or depression. Too often, the clinical work environment is a place of extreme stress and lack of recognition and support. At its worst, the environment is one in which staff do not feel safe from emotional and even, at times, physical mistreatment. The evidence of distress is overwhelming. Medical residents have been found to have burnout rates ranging from 41% to 76%.1 Physicians suffer from depression and suicide at rates significantly higher than the general population.2 Nurses experience similarly high levels of burnout, and nursing attrition is recognized as a major problem facing the United States. One study found that 13% of newly licensed RNs had changed principal jobs afterone year, and 37% reported that they felt ready to change jobs.3 Stressors from the clinical work environment do not only impact the well-being of medical professionals. Burnout and depression in health care providers have been linked to a decrease in professionalism and altruism toward patients, as well as an increase in medical errors.4
Efforts to address the problems in the health care environment should be collaborative between medical and nursing administrations and staffs. The Lucian Leape Institute of the National Patient Safety Foundation recently published a report that makes a compelling case for comprehensive change in health care administration that includes “developing and embodying shared core values of mutual respect and civility, transparency and truth telling in decision-making, and a commitment to the safety of all workers and patients.”5 Programs to promote resilience and help health care workers find joy and meaning in their work need to be woven into the fabric of the health care practice environments. Effective models exist to help with this work. Schwartz rounds, Healer’s Arts courses, narrative medicine, and mindfulness-based stress reduction programs have all been shown to be effective at reducing perceptions of stress, and should be employed more widely. All of these programs can contribute to a sense of kinship and mutuality between doctors and nurses. Additionally, concerted efforts need to be made to reduce and, when possible, eliminate non-value-added work and unnecessary stressors. Finally, similar initiatives are needed to reduce the harm that is too often inherent in the educational experiences for medical and nursing students. If these steps are taken, a reality may be possible in which the ideal nurse and physician described above can exist and work together.
1. Thomas NK. Resident burnout. JAMA. 2004;292:2880–2889
2. Center C, Davis M, Detre T, et al Confronting depression and suicide in physicians: A consensus statement. JAMA. 2003;289:3161–3166
3. Kovner CT, Brewer CS, Fairchild S, Poornima S, Kim H, Djukic M. Newly licensed RNs’ characteristics, work attitudes, and intentions to work. Am J Nurs. 2007;107:58–70
4. Shanafelt TD, Sloan JA, Habermann TM. The well-being of physicians. Am J Med. 2003;114:513–519
5. National Patient Safety Foundation. Through the Eyes of the Workforce: Creating Joy, Meaning, and Safer Health Care. Report of the Roundtable on Joy and Meaning in Work and Workforce Safety. 2013 Boston, Mass National Patient Safety Foundation