Nursing Model vs Medical Model

PA-C in Texas · Jun 25, 2004

Nursing is holistic and focused on health whereas medicine is problem-based and focused on illness. Nurses are also charged with protecting the patient (if need be) from medical incompetence. No longer can a nurse have "MD orders" to fall back on - there is a responsibility to know and understand whether what is ordered will benefit or harm the patient. That is why nurses are EDUCATED and not TRAINED. That is why we are PROFESSIONALS and not TECHNICIANS.
Docs do not like this. They like to feel all-powerful. They expect to write an order and have nurses falling all over themselves to carry it out. They get defensive and pouty when nurses question their almighty wisdom (even if they are not as wise as they like to think they are). Not all docs are like this, of course - the best of them welcome input from nursing and value the professional nurse's assessment and opinion - but many docs do not like to admit that nursing even has a scope of practice, much less that nurses can exercise independent judgement about what is best for the patient: hence- the medicine vs. nursing battleground.

The above paragraph is so loaded that it is hard to figure where to begin. There is obviously an inferiority complex underlying this issue, otherwise nobody would feel the need to make statements such as the one above.

I believe that is the reason for the development of the nursing vs. medicine debate. In the traditional health model, nurses are below physicians, but "nursing theory" has evolved in order to give nurses a rationale for claiming that there is no subordination, just a difference. Rather than physicians being better educated and more advanced, the two are just different. This gives rise to semantical arguments such as "education" vs. "training", and "professional" vs. "technician", in an attempt to derive some superiority over other professions while simultaneously claiming to be on par with physicians in that both are educated professionals. People claim that nurses and physicians shouldn't be compared because they are different, but then they go and compare nursing to other professions to show that they are better. You can't have it both ways.

I believe this stems from years of maltreatment of nurses by physicians. Nurses got tired of going to school to be dumped on, and so they made a move away from medicine. Doctors make claims to knowledge, so nurses frequently make claims to "caring about the whole person", and some try to imply that the diagnosis and treatment of disease precludes a hollistic approach. I believe that the nursing model has developed in response to the conflict with medicine as opposed to any great ideological divide, or a legitemate historical claim to nurses using a different approach, and as such, the difference is once again semantics over substance. The Medicine/Nursing relationship has moved from one that was authoritative to one that is widely considered to be collaborative.

I think that "collaborative" is a good word to describe the relationship. Most nurses do not work for doctors. Both professions work together to provide care. Nurses have the duty and the obligation not to be complicit in providing treatment that would harm a patient. However, I think the burden on any nurse who decides not to execute a physician's order is fairly high. Refusing to provide treatment for a patient based on a physician's order because the nurse doesn't feel that is the best treatment is not a valid reason. That is a medical decision, and if you want to make those sorts of decisions, it is time to go to medical school. In order to withold prescribed care, the treatment must likely be harmful to a patient.

I am, quite frankly, worried that the practice of medicine will largely grow to be contingent on nurses giving their stamp of approval to every treatment before they carry it out, or else they will just refuse to do it. The intrinsic problem with this is that doctors and nurses are not on the same level with regard to education, even if they are both professionals. A physician's knowledge may make him comfortable with a treatment, while a nurse would not be comfortable because of a knowledge gap. You might say, "just let them do it themselves", but if you say that too many times, you quickly argue your profession out of the rationale for its existence- to implement prescribed treatments. I would support regulations that would release nurses from the burden of having to determine if a treatment is medically appropriate, since so many of you seem to be concerned about liability issues.

Let the flaming begin...

Frethel · Jun 25, 2004

On another site someone posted this:
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Reality is that there is "nursing" model is just a stupid catch phrase that nurses use to try and claim that they provide "different" and "better" care than doctors.

Its used as a ploy to increase nurses scope of practice. They try to claim that doctors have no say over what they do because they operate under a "nursing" model whereas doctors are on a "medical" model.

Its all a bunch of BS pandering and propaganda.
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As an outsider, I don't quite comphrehend the Doc vs Nurses battle. I always asummed that it was medical team that was working together. Sort of a technician working in conjunction with an engineer. Or in perhaps another naive way I thought that nurses monitored/assessed patient health and Doc's worked on diagnosis and treatment.
So with that bieng said what is the differnce between the two models?

I don't think there is a battle between nurses and doctors. We are supposed to be working together for our client's welfare. If there is a battle, then they are from those who are very proud and arrogant about their profession. If this battle happens, aour clients who were entruster to us would be at risk?

Dayray, RN · Jun 26, 2004

Let the flaming begin...

Whoot here ya go buddy!

Let me first say that I really am impressed by the things that RN4NICU and chris_at_lucas said I agree with them.

As for you Mr.PA your view is quit flawed. Your screen name suggests that you are PA so that is my assumption. If you are in fact PA you are in for a world of hurt if you are ever allowed (by your supervising physician) to practice in a hospital.

You see some of the things that you said about a nurse exercising judgment or choosing not to implement a MD order are true in regards to the limited capacity that PA's function in. A PA practices under an extension of the MD's license and although as a PA you bear some professional liability, You are still acting in the doctors stead. Nurses do not work this way and haven't at anytime during the modern age anywhere in the western hemisphere. RN's are (as much as it may pain you to know) independently licensed and don't function as an extension of the MD who wrote those orders. When an RN chooses (notice I used the word chooses) to implement an MD's orders we are in fact acting independently of that MD. In other words when we fetch the pills (as you might put it) we are in the eyes of the law making a professional judgment for which we can be held both legally and ethically liable.

So if the orders written by the MD are not congruent with the patients best possible chance for recovery then it would be the nurse who would be held liable for it. Now before you author your next rebuttal to this debate take a moment to let this all sink in. You have the MD to fall back on because he is responsible for training you in the procedures he chooses for you to perform. Nurses don't have that luxury.

So what you choose to see as a response to an inferiority complex is not so. It is actually an awareness to a burden placed on us by our BON. We are not allowed to approach MD orders as mindless automatons and simply do what the doctor says we are expected to do this and legally accountable for it. Strange isn't it? that every state in the US chooses to make nurses responsible for poor or undesired outcomes that occur simply by enacting an MD order. MD's being more educated and superior (as you have pointed out to us) should be more responsible for their own orders don't you think? well they aren't.

This in and of it's self should be enough to convince you that nurses are not subordinate to doctors but I have still more to convince you. The important point of this first example however is, that the autonomy nurses assume is not an assumption of privilege or of accenting to some higher level it is a product of responsibility placed on us by the same system that assumes MD's to be superior (quite antiquated don't you think?, but wait it gets worse).

OK so MD's have more formal education then nurses, this is true. However consider a 35 year old MD and a 35 year old RN. Both went to good schools and started strait out of high school. The MD would have spent what 12 years in training while the RN had spent 8 of those working and gaining real experience. who would have spent more hours with living breathing patients? Who would have seen more patients die? seen more mistakes made in management of care? Who would have more hands on time?

Now I am not saying that that makes the RN better (although I might be thinking it) I am simply saying that those two individuals would have different kinds of knowledge.

Also consider this MD's are taught to gather information and formulate a DX and then line that up with a Tx. Thats great! patients need this type of care but the MD can't watch the patient 24 hours a day to truly evaluate how well this is working but guess who can? nurses. The nurses observations can then be used as data for the MD to alter or continue Tx (here one of the many points where the difference in models comes in). How did the RN gather that info? can it be put into SOAP format? probably not. It was threw observation that the MD would never see it was threw being with the patient (not just observing but being with the patient).

OK thats a small taste I'll continue.

Last night I held the hand of a women while she cried because she was scared of the procedure the MD had to perform. She was jumping off the table because she was afraid. I could not (and would have no desire to) do the procedure the doctor was about to do. At the same time the MD could not have calmed her down and made her understand what was happening, he could have explained it to her but he could not have made her feel safe.

Now you may be thinking that calming a patient is no great skill but wait for a second and lets expand on it. Why was I able to do that? What skills did I have that made me able to turn, what in this patients mind a terrible thing into an uncomfortable but yet good and necessary thing? It was because I understood her, not just her Dx or the Tx but I knew her as a human being. An MD cannot do that they don't have time, they focus on problem and resolution, I focus on the rest and try to blend the doctors plan into it so that it all clicks.

You are right a doctor can practice holistically but they cannot treat the whole person (like nurses can) because they can't spend the time to monitor 24 hours a day or to really know patients but nurses do. That my friend in Texas, is where the alternate models begin to emerge.

Nurses treat people with problems, Doctors treat problems that happen to be attached to people. Now I'm not demeaning doctors I love having them around because I don't like to have to do everything. At the same time if you talk to a nurse that has been around a while their knowledge of medicine will surprise you they may not have as much background in bio and chem but they blend what they have with other skills and knowledge of human beings that doctors will never have time to acquire.

That's only the begining, if it sounds simple it's becuase it is these basic ideas extend and grow to become the nursing modle of care.

I could go on and on but I think I've nearly exceeded the limit of the board and I'm lookig forward to your rebutal so ill save some for that.

Farkinott, RN · Jun 26, 2004

Good nurses won't sabotage a doctor's "medical plan," their care facilitates it.
The difference between nurses and doctors is that doctors deal with the disease process, and nurses deal with how that process affects the person.
There is no reason for there to be this sort of competitive attitude, we are not in the same race, as it were.
On the other hand, after centuries of having nurses as toadies, I can see how the doctors would be upset with the changing relationship. Kind of like slave owners who really, really didn't like emancipation.
I kinda like that metaphor..... :) Good thread, thanks for posting it.

Good post Chris!

epiphany · Jul 11, 2004

Dayray and Chris_at-Lucas, you make me so proud to be a nurse. On entering my final year, I've been struggling with this notion of the nurses' role. Not a lot of role models in school, I'm afraid.

nursbee04 · Jul 11, 2004

I am, quite frankly, worried that the practice of medicine will largely grow to be contingent on nurses giving their stamp of approval to every treatment before they carry it out, or else they will just refuse to do it. The intrinsic problem with this is that doctors and nurses are not on the same level with regard to education, even if they are both professionals. A physician's knowledge may make him comfortable with a treatment, while a nurse would not be comfortable because of a knowledge gap. You might say, "just let them do it themselves", but if you say that too many times, you quickly argue your profession out of the rationale for its existence- to implement prescribed treatments. I would support regulations that would release nurses from the burden of having to determine if a treatment is medically appropriate, since so many of you seem to be concerned about liability issues.
Let the flaming begin...

PAC, whether you choose to believe this or not, nurses ALREADY place their stamp of approval to every order before it is carried out. We must sign off on the orders the physicians write, and our signature is in effect saying that the order will be carried out and it is appropriate/not harmful to the pt. So if a physician writes an order to administer a medication that is 3x the normal dose, you better bet I'm going to call him on that and he is going to give me either a correct dosage or an explanation as to why he is prescribing 3x the nl dose. You really wouldn't believe how often this happens. So if you can't convince me that you have a valid reason behind that dose, then yes, you're gonna have to give it yourself, because just like every other nurse that has posted in the thread, its MY license on the line. And by the way, if you honestly believe that nurses' sole purpose is to "implement prescribed treatments," well, that's just really sad.

OneRN · Jul 12, 2004

This is the bottom line:

MDs troubleshoot, diagnose and treat a pts medical problem (i.e., CHF).

RNs troubleshoot, diagnose and treat a pts problems regarding care (i.e., how will this person with CHF use the toilet).

When a person is sick--sick enough that they can't care for themselves--they have to have a nurse to provide that care. That is what a nurse does; that is our profession. We provide direct care (tx, toileting, feeding, etc.), medication administration, pt education, and rehabilitation. The modern health care paradigm requires both MD and RN. When the modern healthcare paradigm falls apart, such as in some African countries, nurses become ultimately more useful than MDs, and when they all leave or die off, it reverts back to a "wild" caveman system of health care (see the NY times article today on the exodus of nurses from Africa).

MDs cure people.

Nurses care for people.

There is no debate.

MDs have NPs and PAs and IAs as assitants--and thank God for them.

Nurses have LPNs, IAs, CNAs, PCAs, housekeepers, laundry workers, and cooks for assistants--and thank God for them.

Some MDs think that nurses are sub-doctor; they are idiots, because nurses are not MDs at all. We occupy the other side of the health care coin. And let's face it: most nurses are just as arrogant and consider what they do to be more important than what MDs do. But the two feilds are completely different professions.

Nurses should not seek to increase their status by becoming more like MDs. They should seek to provide the most efficient and effective care for debilitated patients.

When I call an MD because a pts cardiac rhythm has changed. I tell him/her the VS, the EKG interpretation, what the previous stips have read, the recent lab values (esp. K+) and the symptoms the pt is experiencing. I don't tell the MD "My patients potassium is low, she needs to go on the K+ protocol." It is not my job to tell the physician that. It is the physicians job to tell me that. Implementing the potassium protocol is my job. It is not my job to dx a cardiac condition r/t low potassium, and frankly, I would be offended if a dietician came up to me and told me: "The patient is due for her potassium IV." So why would I do the same thing to an MD?

I call MDs "sir, ma'am or Dr." But then I also call the houskeepers "Sir or Ma'am" And when my patient comes back from an x-ray and I call for a late lunch tray, I show more servile respect and undeserving gratitude to that kitchen worker on the phone than I ever show to MDs (But I should show MDs the same respect, and I'm working on that.)

TennRN2004 · Jul 12, 2004

"Nurses have the duty and the obligation not to be complicit in providing treatment that would harm a patient. However, I think the burden on any nurse who decides not to execute a physician's order is fairly high. Refusing to provide treatment for a patient based on a physician's order because the nurse doesn't feel that is the best treatment is not a valid reason. That is a medical decision, and if you want to make those sorts of decisions, it is time to go to medical school. In order to withold prescribed care, the treatment must likely be harmful to a patient."

You can't have it both ways PA-C in Texas. On one hand, nurses have the "duty and obligation not to be complicit in providing treatment that would harm a patient". I agree with you on that point. On the other hand, "refusing to provide treatment for a patient based on a physician's order because the nurse doesn't feel that is the best treatment is not a valid reason" is not a credible statement in regard to a RN. What you're saying is that nurses should not do anything to harm a patient, but they can't question a treatment a doc writes (even if it may harm the patient) because that's a medical decision. NOT TRUE! If I carry through with an order I question and the patient is harmed I can be SUED FOR MALPRACTICE, which is described for nurses as doing something another nurse with same education and experience would have done or not done, and the patient was harmed by the direct action of the RN. That is in no way an inferiority complex. It is simply a responsibility our profession places on us when we are licensed. With that in mind, put yourself in the patient's place. Do you know how often nurses catch errors or potential errors from MDs in the hosptial? It happens almost on a daily basis in my unit. The nurses are respectful about questioning doctors, but you better believe I will not carry out an order I think is irresponsible and rightly so. I will check with that MD first. If your mother was in my unit PA-C in Texas, and I gave her a medicine I thought was unusual with her diagnosis, and she codes or has major problems, would you blame me or the doctor who wrote the order for the medicine? Same goes for any type of treatment orders from respiratory to ambulatory orders. If something happened to your mom and I was carrying out a MD order, does that absolve me of blame becuase I was just doing what the doctor said? NO it does not. I, as the RN, am the final check for patient safety, which is always my concern. It is not about questioning a doctor, or thinking I know as much as a doctor, it is a matter of professional judgement, which like it or not we RNs do have professional judgement. Our patients, our employers, and our state boards hold us to a much higher acountability and standard of care than you are implying in your post.

As far as the differences between medical and nursing models, both are complimentary to the other. Both must exist for patient welfare. It is not a queastion of who is smarter or who is better, but rather a necessity to ensure that any healthcare worker, be it doctor or nurse, be educated and mindful at all times of what is best for the patient. I don't know if you are aware of the "nurses intuition" PA-C, but many a patient has been saved by the feeling that something is not right with the patient. The nurse calls the doctor and says "come check out the patient in Room 101." The doctor asks "what's wrong?" The nurse says I'm not sure, VS..labs ok, but the patient does not look good." A doctor who knows and respects the nurses judgement will say "okay I'll be there." **Now at this point, the nurse has no idea of the disease process going on inside the patient, just that there is a minute change, be it in LOC, pallor, etc. and has a bad feeling. So, she calls the MD to come examine the patient.** The MD comes in and does diagnose a problem and a major complication was prevented for the patient. For this patient, it took the nurse to recognize a problem and a doc to come in and diagnose. He could not have diagnosed if he was not notified of a potential problem, just as the nurse could recognize the problem, but she could not diagnose it. This is an example of why both medicine and nursing exist, and function together. This actually happened (quotes not verbatim, but pretty close) when I was in nursing school at a level 1 Trauma hospital where we have residents on call 24/7. The residents respect and learn from the nurses and vice versa. Many a doc helped me as a nursing student and I am grateful for that, just as the residents were to the nurses who helped them. It doesn't have to be a competition between nursing and docs if we respect each other and work together. I know my scope of practice and I am comfortable with that. I don't feel inferior to any doc because I'm not. Nor is any RN subordinate to a doctor. If people don't like us labeling nursing and medicine as "different" rather than labeling doctors as "superiors" then you don't have an understanding of the healthcare team today and no post here will help you to get it.