Power & Conflict between Doctors and Nurses: Breaking through the Inner Circle in Clinical Care

An important issue to emerge from consideration of decision making in the clinical setting was the nature of medical and nursing roles. This included how doctors and nurses described their roles in the decision-making process, and how doctors and nurses demonstrated these roles in the clinical environment. In this chapter, both these elements are described and explored further through reference to work undertaken on the division of labour.

At its most basic level, examination of the decision-making process between doctors and nurses in intensive care revealed a recurrent pattern that demonstrated the respective roles adopted. The following field note excerpt demonstrates this:

Nurse [to doctor]: 'Come and look at this drain. It's making a hideous noise and causing a huge air leak.' The nurse takes down the dressing and prepares the site for the doctor, then gets pad and new dressing. The doctor looks at the drain: 'I can put a stitch in it if you want, it doesn't really matter … The nurse finally says: 'Well OK, put one in then.' The doctor renews the stitch and then as he leaves the room: 'I'll leave you to dress it.'

This incident simplistically distinguishes the different role functions identified in clinical decision making. In explicating this at its most fundamental level, the nurse in surveying the patient as part of nursing work, identified a problem (increased air leak). Through the nurse highlighting this issue to the doctor, the decision-making process was then informed. From this, a decision was made (to place a suture), and this was then implemented (new suture inserted). Throughout this, the environment was managed to enable the process of care to continue (area prepared for procedure, and wound re-dressed afterwards).

Through analysis of these events, key issues are now explored concerning: how nurses survey their working environment; the nature of authority within the decision-making process; how the decisions that are made are then worked with; and the need to manage the environment in which decision making is undertaken.

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