Changing how the world thinks about nursing

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Q: Do physicians help nurses improve health? (AKA  Are nurses the captains of the health care ship?)

A: Yes. Nurses may be considered the "captains" of the health care ship, but physicians certainly play a vital supporting role!

Physicians provide critical assistance as nurses and public health workers pursue their overall mission to restore and maintain the health of society. Like nurses, physicians have significant clinical skills. Nurses generally take a more holistic approach to the health and wellbeing of patients and communities, whereas most physicians are specialists who handle specific illnesses and conditions that persons may encounter at particular points in their lives. Thus, though nurses' primary focus is to prevent illness through advocacy and education, to promote healing and protect the ill from any factor that may threaten their well-being, physicians provide vital technical expertise in diagnosis and treatment when someone does encounter a disease or illness that requires medical intervention, such as surgery. Nurses typically coordinate such care by physicians and other professionals in hospitals and other settings. Of course, nurses have significant expertise and play key roles in what is commonly understood to be "medicine." As a practical matter, nurses diagnose and treat patients every day, though there may be reluctance to admit it due to long-standing turf battles. Advanced practice nurses and physicians who are general practitioners may be seen to have elements of both of these complementary roles.

It may appear that physicians--most of whom step in only to help address very specific problems--have a more peripheral and therefore less important role in global health, which is far more dependent on the day-to-day lives of citizens and their overall physical and mental environments than it is on occasional medical interventions. However, in fact physicians play an indispensable role in improving modern health, helping nurses and public health workers save lives and improve patient outcomes every day.

One analogy that may be useful in thinking about the complementary roles of nurses and physicians is the sailing of large ships. Nurses (and to some extent physician general practitioners) may be viewed as the captains of the health care ship. Of course, given the great power imbalance between nurses and physicians today, it may be difficult to conceive of nurses as "captains." But like captains, nurses do sail the ship of health expertly through its long and at times arduous journey, navigating through weather and other challenges, thinking of the smallest details, but always of the big picture and the vessel's long term destinations and wellbeing. This calls for a combination of broad general knowledge and very practical abilities, as well as a deep understanding of how the ship operates day to day: a feel for the ship. This combination of skills may be described--as nursing often is--as both an art and a science.

However, at certain points in the life of a ship, special expertise is needed to allow the vessel to do its job and preserve its condition for the long haul. Thus, when a ship reaches a port, it is typically handed over to a local pilot, who knows how to maneuver large ships into and out of the tricky port area, a highly specific and specialized expertise. Likewise, when the ship encounters a severe emergency on the high seas, it may be necessary to call in rescue and salvage specialists. At times the ship will need major repairs, and it is taken to a shipyard where the relevant specialists can fix the particular problems it has. And of course, ships would not exist without the highly complex work of marine engineers and naval architects. All of these latter roles are similar to that of specialist physicians and many other professionals, such as occupational and physical therapists, who step in when there is a major problem with the normal functioning of the human "ship." These vital other professionals may not sail the ship through the diverse hazards of its everyday existence with a view to its long term goals--none may have as close and deep a relationship to the ship as the captain and her crew--but they are often critical to a long and successful shipping life.

Political scientist and anthropologist James O. Scott, and more recently Suzanne Gordon, have proposed a more limited counter-analogy (from which the above analogy was derived) which also has merit. In this counter-analogy, it is the physicians who are the captains and the nurses who are the local pilots. The physicians have what is termed the more "abstract" and "general" knowledge required to navigate the ship in the open seas, and the nurses have the more "specific" and "practical" knowledge needed to pilot it in and out of local areas so it can deliver its passengers and goods. This analogy has a certain appeal. It certainly shows the indispensability of nursing--ships aren't much good if they can't actually dock. And nurses certainly do have more "specific" knowledge of certain aspects of patient care. However, because the ship (not the port) is central to this analogy, we think that nurses' broad and specific knowledge of the ship--the patient--is more relevant. Moreover, it's not clear to us that medical knowledge is more "general" than nursing knowledge. We're also not sure why the pilot's skills should be considered any more "practical" than the sea captain's--storms and other hazards at sea seem about as real as it gets, and a ship isn't much practical good if it just stays in the port. We are also uncomfortable with the extent to which the counter-analogy confirms the prevailing sense that physicians are the overall "masters" of the health care ship. The counter-analogy does not appear to account for the wide range of different professionals who are involved with the entire shipping endeavor.

Neither of these analogies is perfect. Both oversimplify the complex and overlapping roles of nurses, physicians and other key health workers. But both provide useful ways to think about how skilled caregivers work together to help society improve health today. Under either scenario, both nurses and physicians are indispensable to health. And under both, nurses play a far more important role than they are commonly understood to play; communicating that in a provocative way was the main goal of this FAQ. Of course, we do not really regard any one category of professional as the "captain" of the health care ship. We would hope that the "captain" of each citizen's ship of health would ultimately be that citizen.

last updated: January 25, 2011