Is The "Doctor-Nurse" Game Still Being Played?

  1. The doctor-nurse game first described 40 years ago is still relevant to modern nursing, despite many changes to the profession. Is nursing partly to blame?
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  3. by   samirish
    I could not gain access to the article but I googled the Doctor Nurse game and came up with this:

    god, it sounds just like the silly games I have to play with my husband or father to get them to do something I want them to do. If I make it so it seems like they are the ones that came up with the idea then I am much more likely to get what I want instead of coming right out and asking or telling them what I want.

    It just reeks of patriarchal sexist BS and one has to wonder if part of the reason behind the behavior is because traditionally doctors have been male and nurses female. An interesting topic for sure and I wish we will see a day where we don't have to play such silly games any longer for the sake of stroking egos.
  4. by   threelittlebirds
    WOW, that was interesting...I still see remnants of those attitudes every time I'm in the hospital.

    My favorite lines:

    One nurse described that premise [nursing attitude towards doctors] as, "He's god almighty and your job is to wait on him. "

    Some nursing instructors explicitly tell their students that their femininity is an important asset to be used when relating to physicians (703)
  5. by   talaxandra
    I like the idea of a nurse/doctor dynamic where this wasn't necessary, but we're not close yet. I've consciously played the game since I first read the original article a couple of years after I registered - prior to that I'd absorbed it unconsciously by watching more experienced nurses.

    I was talking about in on ND several years ago, with a couple of nurses (including a grad) and two female doctors. I think it has nothing to do with gender per se and everything to do with prestige and role, which while certainly gendered and rooted in gender, is no longer clearly gender differentiated.

    Back to that night - the way I explained it was that, rather than directly expressing an opinion to the medical staff, a nurse playing the game neutrally offers information as though on a serving platter: I bring you this information on behalf of the patient, and you can do with it what you will *bowing and backing away.*

    One of the doctors said she thought the nurses she worked with had no trouble expressing what they thought.

    The following night one of my patients had an elevated BGL. I paged that resident, typing "Mrs X's BSL is Y - insulin?" and said to the grad next to me "If I wasn't playing the game, based on my experience, her usual insulin doses, and how she's responded to stat doeses in the past, I'd write 'Mrs X's BSL is Y - I think she needs 4units of Actrapid' or even 'can I have a prescription for 4units of Actrapid?'"

    When the resident rang back she gave me a phone order for 4units of Actrapid. I repeated it back and the grad laughed, prompting the doctor to ask why. When I told her, I could feel her wanting to change her order to another dose. I know it was partly because she felt manipulated, but mostly because I had the temerity to have an opinion, and it was right. Forget that I'd worked on the endo unit for over a decade and was a CNS in endocrinology, she was the doctor and I was only a nurse. She also avoided me as much as possible for the rest of her night rotation.

    I've had doctors ask for my opinion about many things, including stat doses, and it's happening more often than it used to. For an increasing number of doctors I can have a discussion among equals - I respect their level of education and they respect my experience.

    I don't have to play it, but if I don't then my patients are less likely to get the best interventions and care. I think that as long as there are doctors who think their role is to give orders and ours is to follow them the doctor/nurse game will have a role.
  6. by   llg
    One of my favorite conversations as a staff nurse many years ago:

    Me: "Baby X's midnight labwork showed that the bilirubin is up to YY."

    Resident: Bewildered look (as in "OMG, that's high. I don't know what to do." -- but not able to verbalize that.)

    Me: (offering a lifeline and trying to appear helpful) "That's about the same as it was last night."

    Resident: "What did they do last night?"

    Me: "They added a 3rd bililite and ordered a repeat level drawn at 0400. They decided not to do an exchange transfusion unless it reached YY + 3."

    Resident: "Does that seem reasonable to do again tonight?"

    Me: "Yes."

    Resident: (looking relieved) "Thank you"

    Me: (appearing old, wise, and gracious at age 22) ..."You're welcome."
  7. by   DoGoodThenGo
    is the doctor-nurse game still being played?
    is the doctor-nurse game still being played?

    28 october, 2011
    the doctor-nurse game first described 40 years ago is still relevant to modern nursing, despite many changes to the profession. is nursing partly to blame?

    in this article…

    • how the doctor-nurse game was first described 40 years ago
    • why some believe changes to the nursing profession have rendered the game obsolete
    • how the game between medicine and nursing may still be very much on


    dean-david holyoake is a senior lecturer in the school of health, university of wolverhampton

    holyoake dd (2011) is the doctor-nurse game still being played? nursing times; 107: 43, early online publication.
    forty years ago, leonard stein outlined his theory of the doctor-nurse game. in 1990, he revisited his theory and found that the game he had described no longer existed, mainly because nurses were no longer willing to play.
    since the publication of the original theory, attempts have been made to professionalise nursing and to negotiate a sense of identity within the somewhat patriarchal doctor-nurse relationship.
    i believe, despite denials from the nursing establishment, the doctor-nurse game continues, and changes to the profession have not been as far-reaching in this respect as hoped.
    keywords: professional relationships/game theory/multidisciplinary working
    • this article has been double-blind peer reviewed
    • figures and tables can be seen in the attached print-friendly pdf file of the complete article

    5 key points

    1. the doctor-nurse game says that doctors and nurses share a special relationship founded on role expectations based on power, influence and territory. the nursing role showed respect, acted passively and never disagreed with the doctor
    2. in recent years, nursing has aspired to be a profession and take on greater responsibilities
    3. by 1990, the author of the doctor-nurse game said it was no longer being played because nurses were no longer competing
    4. yet many of those working on the front line believe the doctor-nurse game is still being played
    5. nursing is more dependent on medicine than ever before and medicine still holds all the cards

    in 1967, leonard stein wrote an article called “the doctor-nurse game” discussing the relationship between the professions (box 1).
    the notion of the game can be thought of as a metaphor for understanding the dynamics of how the two professions were expected to relate in everyday practice. as such, both doctors and nurses interacted with one another in pre-prescribed and historical ways in which the nurse was always aiming for approval. as noted by keddy et al (1986) “worthiness was equated with helpfulness to the doctors”. these unspoken about and often-hidden traits, behaviours and expectations determined the nature of nursing identity. likewise, the idea of a game illuminated the possibility that there are winners and losers.
    the historical baggage implicates the fine balancing of the game and imagery from the times of nightingale’s victorian housewife through the house maiden in pre- and interwar periods to the sexually liberating 1960s. thus, the space was set for stein to think about the nature of the game.
    in 1990, stein and colleagues revisited their theory and concluded that the contest they had originally described had changed largely because, among other reasons, nurses had given up on it.
    the nursing establishment also promotes the idea that “the game” is over and no longer relevant in modern clinical practice. nursing has become more educationally focused, politically aware and eager to raise its perceived status.
    according to closs (2001), stein et al’s revisiting of the doctor-nurse game in 1990 showed nursing had unilaterally given up the game in what is described as a “hostile” and “stubborn” manner. this suggests the nursing professional did some kind of educating rita rags-to-riches turnaround. rita got educated and refused to play. yet many patients and nurses i have spoken to do not feel this to be an accurate description. for them, the denial of multidisciplinary conflict conceals the true experience of many frontline nurses when it comes to the nature of the doctor-nurse relationship.
    box 1. the game conditions

    • it is against medicine that nursing is determined, objectified and always represented.
    • the game is about systems and discourses as well as the interpersonal. boundaries and rules are tied up with roles and gatekeeping resources. it suits certain groups to maintain a particular status quo.
    • ultimately, medicine holds all of the cards.

    the history of relational games

    during the 1960s, there was an increasing belief that social psychology could offer insights into the way human beings behave in groups.
    game theory is an approach used to try to understand how individuals and groups of people relate. its principle facets are competition and cooperation. in game theory, participants or groups (called players) engage in some sort of theoretical conflict such as a shortage of resources or an ethical dilemma. this conflict sets up opportunities for chance occurrences, but mostly players make choices that then affect the outcome or payoff.
    this sort of analysis has been used to explore aspects of nursing practice (reeves, et al, 2008; sweet and norman, 1995). game theory has also been used to explore how people are motivated to make moral choices (axelrod, 2006), and communicate and signal understanding as in the work of skyrms (1996) and bicchieri (2006). theorists such as sober and wilson (1998) and mckenzie (2000) have argued that the emergence of group norms or, in the case of nursing, professional standards, are founded on the bargaining and development of attitudes about morality.
    these all too very human conditions make the issue of the doctor-nurse game a very real practical concern for discussion in the modern era of healthcare reforms. i believe that the game is far from over and that it is very much game on. in fact, it can be argued that the nursing profession is driven by a number of competing discourses and professional values that substantiate and perpetuate the game.
    knowing each other’s role does not end the game

    as noted by keddy et al (1986) “a look into nursing history confirms there has been an evolution of conflict between the medical and nursing professions”.
    i see the present-day game as simply part of that evolution - just more sophisticated and hiding itself. in stein’s 1967 study, the “culture” was always ordered and binary, black and white. the male doctor always knew best and the nice lady nurse (if she was any good) would follow orders.
    keddy et al cite hoekelman (1975), himself a physician, who states “the key problem in the nurse-physician relationship is the basic lack of understanding each discipline has for the other’s role in the provision of healthcare”. here we are 35 years later and this explanation appears to still be perfectly satisfactory.
    when stein (1967) intimated that doctors and nurses played a game that had the aim of maintaining a status quo in the perceived social relationships of both professions, he seemed to be suggesting that it was within the interests of both professional groups to perform in an expected fashion.
    and all was well with the game until nursing, as stein et al (1990) concludes, decided it did not want to play anymore. when they revisited the game, they found nurses had shed some of the handmaiden duties, improved their education and were in a process of redefining themselves. new nursing is too sophisticated to play games - or at least that is how it appears.
    in short, nursing seemed to be in a type of identity crisis stemming from an inferiority complex and the illusion that equality was easily within their grasp (department of health, 2000a). nursing extended, expanded and took on duties that previously would have been performed solely by junior doctors. taking bloods, prescribing and consulting with clients signalled a redistribution of power, influence and game strategy.
    but does this really show a reluctance to play the game or rather act as a reminder that medics have happily let go some of their grip in favour of taking a stronger hold of the more sophisticated issues of care - such as commissioning, research, and new technologies?
    manias and street (2001) highlighted that nurses felt their medical counterparts did not listen to them during ward reviews. bucknall and thomas (1995) surveyed 230 australian nurses and concluded the potential for conflict was due to the physical and cognitive closeness of nursing and medical spheres.
    others have pointed to the need to look at gender power relations (gatens, 1996; butler, 1990) to better understand the doctor-nurse relationship.
    sweet and norman (1995) did a literature review of the doctor-nurse relationship and argued there is much “anecdote and opinion”, but not much empirical research to “establish an evidence base around the impact of patriarchy” on the doctor-nurse relationship (goodman and clemow, 1998).
    this insistence on empirical truths and a belief that it is both possible and beneficial to establish correct questions is itself an example of patriarchy because it reinforces the larger discourses that promote role expectations and construct the game. if you were to ask nurses about their experiences, they would more than likely say - as they did in the work of adamson et al (1995) - that they are more dissatisfied with their professional status than doctors.
    the difference debate

    discussions of the doctor-nurse game may appear a fun distraction but it goes some way to show how nursing has squandered opportunities. for every nurse who has learnt to take bloods, prescribe medication, become a graduate or argued with colleagues to be called nurse consultant, there are 1,000 who simply see the profession as a practical hands-on affair concerned with care.
    the opportunities and career ladders that replicate those of medicine are reminders that the didactic nature of the game is still very much ongoing.
    the wanless review (welsh assembly government, 2003) assumes that 20% of work undertaken by physicians will eventually be taken up as nursing duties. the nursing profession is still committed to emulating the medical profession by raising its status through the extension of role as opposed to an expansion of its caring definition. the need for association, even acceptance, is a marker of the fact that the game continues.
    who are the players? at the micro and interpersonal level is every nurse, healthcare professional and service user. as just discussed, these people compete against one another within a nursing establishment that includes the governing bodies, media, unions and collaborative organisations. these sectors are not neutral, but rather sustain the game through a process of naturalising, maintaining and manipulating the signs, apparatus and symbols of nursing.
    farrell (2001) describes how aggression and hostility between nurses have undermined their position in relation to other groups. for every nurse manager who argues the game is over, there will be a number of patients and an equal number of newly qualified nurses who will show you exactly how it is for them. according to closs (2001), it should be possible in the present climate “for doctors and nurses (and other healthcare professionals) to collaborate in a range of activities more often and more successfully”. but any nurse who has waited patiently for the consultant to arrive will tell you that the notion of collaboration is patchy at best and about power.
    nursing has been so intent and fixated on mirroring medicine that it has turned itself into little more than a clone. like a third-generation photocopy, nursing has strived to be accepted as equal but faded in the attempt. this is because, in the grand scheme of things and put bluntly, nursing is not medicine and, if it was, it just would not be as good.
    the effects of redefining

    it is true to say that perceptions of the nursing role have changed. there is much literature regarding the power dynamic debate and the assumption that interprofessional working is beneficial for the patient (zwarenstein and bryant, 2001; dh, 2000b).
    this, of course, is part of the power dynamics that maintain the doctor-nurse game. attempts to erase difference turn nurses into mini-doctors as opposed to developing nursing.
    the game continues to project nursing as being clinically minded like medicine and inadvertently wanting to be more like medicine than medicine itself. it appears that nursing aims to achieve the same status by adopting and adapting to the same values, skill sets, education and career frameworks at the expense of more authentic nursing identities.
    the end game

    i believe, despite denials from the nursing profession, the doctor-nurse game continues.
    Last edit by TheCommuter on Oct 30, '11 : Reason: copyright issues
  8. by   CCRNDiva
    I had trouble with a neurosurgeon but who hasn't, lol? Frankly, though, I seem to have more trouble from female residents than any other group. I work in critical care and I serve as a code blue and RAT responder. Residents are required to respond to all codes too. The male residents and I collaborate and they frequently ask my opinion. I usally get a "wow, you really know your stuff" or a big thank you response from them. But every year I end up butting heads with at least one female resident.

    For example, we were coding a pt in the unit and we had just ran Chem 8s and the K was 7.6. The resident ordered kaexalate per NG. I'm not kidding. I said, "this pt is dead, ACLS protocol is 10 units insulin IVP and an amp of D50, recheck levels and repeat if necessary." She asked for his glucose level which was 369. She ordered 20 units of insulin and a half amp of D50; to which I responded, "we are not treating the glucose level, we are treating the high K, the insulin will push K into the cell and the D50 helps prevent hypoglycemia. 20 units of is too much and a 1/2 amp of D50 will not cover that. His levels could drop too low and we may never revive him." Now I'm in a room full of new RNs who are looking back and forth between us when a seasoned RN actually pushed the 20 units. (Now would you ever give 20 units of insulin IV for a BG of 369?) I tell another RN to put the kaexalate away because we don't give kaexalate to dead people. In walks our intensivist and he asks we what we've done so far. I let the resident have the floor and she rattles off her list of orders. Our great intensivist then gives order to reverse the mess she started (including another 1 and 1/2 amp of D50) told her the same thing I had just told her. She couldn't even look me in the eye. She high-tailed it out of there as soon as she signed the code blue record.

    I told our intensivist about our interaction prior to his arrival and he laughed and said, "I guess we should have brewed a pot of coffee so we could keep compressing until he **** **** the K out. Don't worry, I'll have her in class next week, and I'll be sure to address it." That resident avoided me like the plague after that, lol. Look, I know I'm not a physician but I can run a code in my sleep. I deal with critical labs on a daily basis but I guess being a RN makes me too dumb to follow ACLS protocols.
  9. by   msn10
    Do Good then Go:

    You apparently were spying on me this week . I attended a meeting where I am creating a curriculum for new rural nurses. In some hospitals, nurses perceive this hierarchy environment to be happening to a higher degree than in urban hospitals where there are more doctors and so the BS is spread around more than in rural where there are fewer doctors. If these rural docs are alpha males or just jerks, then nurses have more dominance they feel they have to submit to :bowingpur. The curriculum committee and I were even talking about doing a study on that particular issue. Thanks for all your work with literature retrieval, I will be examining it for the study.

    As from personal experience, I do not mind confrontation and I have no problem telling a doctor my opinion. I think part of the issue is communication for new nurses especially. If we can help them when they are in school and in their orientation and residency (if they have one) then we will better prepare them to be on the floor.

    According to the '36 Competencies' that nurses are required to have, delegation, time prioritization, and talking with physicians are some of the lowest rated (nurses are least prepared) in these areas when they graduate. By purposefully increasing their competence and confidence, experienced nurses can help create a culture without bullying and horizontal (or vertical in this case) violence that seems to be so prevalent in health care.
  10. by   msn10
    Frankly, though, I seem to have more trouble from female residents than any other group.
    That is an interesting dynamic. You wonder if they feel they have to be better than the males and they themselves try to become the alpha males!!!!! Although when women gain leadership positions, and then they become assertive are labled the bi***es. Although, sometimes they do definitely earn that name.
  11. by   threelittlebirds
    I happened across this article today. While it doesn't necessarily pertain to the healthcare field, I do see this in many interactions and I did think about the doctor-nurse game as I was reading...

    It's a whole lot easier to emotionally manipulate someone who has been conditioned by our society to accept it. We continue to burden women because they don't refuse our burdens as easily. It's the ultimate cowardice.

    I wonder if these attitudes contribute to the game....Because really, when you're forced into a passive role for fear of repercussions (personal ones, like being branded a crazy *****; and fear of compromised patient care due to ego), isn't that emotional manipulation? Especially considering the historic gender disparity...The game isn't a far stretch from what is described in this article.
  12. by   Rodoon
    Hopefully, this game will die out when the doctors/nurses trained on it retire. I remember setting up a hemodynamic clinic outside the critical care unit for ICU nurses and the medical students and interns were first in line. They said, and I hope its changed, they didn't have any practice time in labs. Knowing how to zero an ICP line, sure takes some of the stress away when putting one in.
  13. by   talaxandra
    I think change is possible - I've seen medical practice evolve in my time thus far at the coal face. As I posted earlier on this thread, I work with many doctors who solicit and are interested in my opinion - in a few instances I get called about what I think they should do about patients on another ward, which is always flattering

    It's also the exception. I'm an exception - I've not only given the Game a lot of thought, I have enough feminist, sociology and history & philosophy of medicine education to unpack it. Doctors who listen to my opinion as seriously as they'd listen to another doctor do so partly because their outlook's flexible, partly because thet have an underlying respect for nurses (there's often a nurse in their lives), and partly because my previous interactions with them have been influenced by my knowledge of nurse/doctor interaction, including the Game.

    My aim is to get the best care for my patients. Often that means following the lead of skilled, educated, experienced colleagues. Sometimes it means working out how to stop idiots doing (or failing to do) something that will harm or even kill my patients. I can go balls to the wall and have antagonism in every future interaction, or I can use diplomacy, game play and experience to not only get the outcome I want but possibly mould a better practitioner.
  14. by   talaxandra
    Quote from Rodoon
    Hopefully, this game will die out when the doctors/nurses trained on it retire.
    I read an article exploring junior doctors' ethical decision making: the biggest contributing factor - outweighing ethics classes, previous experience, cultural beliefs, upbringing and family ethos combined - was the opinion of the consultant.

    As the OP pointed out, the original article was publihed in 1967, well before the majority of nurses and junior doctors now working were born. I don't think it's going anywhere any time soon.