CHAPTER ONE
INTRODUCTION
1.1 BACKGROUND
OF THE STUDY
A system is made up of several parts which functions in
various ways to work as an entity. An example of this is the health care
service delivery system. In this, there are various categories of professionals
and personnel who work hand in hand to perform various specialized duties for
the effective dispensation of healthcare services. These professionals include: doctors, nurses,
pharmacists, radiographers, and medical laboratory scientists etc. they all
carry out their duties which directly or indirectly are related to patients
care (Kalish & Erb, 1987). Where there is friction between any components
of a system, there is a drag. A sustained drag could cause a breakdown of the
system. This research work will examine the inter-relationship between doctors
and nurses as it affects patients care. Doctors and nurses are two major health
workers in the hospital who have continued to attract attention. Nurses are closer
to doctors than all other health workers. Wolinsky (1980), referred to other
health workers as allied health workers. The closeness of doctors and nurses is
brought about by their frequent contact with patients in the hospital.
According to Fagin and Garalick (2004), the relationship
between doctors and nurses is a special one. This is because smooth working
relationship between doctors and nurses is essential for effective and
efficient delivery of health care services. Where this is overlooked, it is at
the detriment of the patient’s care and increased cost to the health care
system. This is sadly the trend in developing countries such as Nigeria
(Albert, Goldman, Kilroy & Pikke, 1992). The relationship that exists
between doctors and nurses has long been the focus of on going debate. In the
past, it was assumed that there was clear agreement between the two professions
that the relationship was hierarchical, with doctors being superior to nurses
(Sheth & Mallipedi, 1997). This was further enforced by Mechanic and Aikan
(1982), who stated that a nurse must begin her work with the idea that she is
only the instrument to which the doctor gets his instructions carried out.
He/she occupies no independent position in the treatment of the sick person.
Kafaru, (1994) argued that no matter how gifted a nurse
may be, he/she will never be a reliable nurse until he/she can obey without
questioning the instruction of the doctor. To her, a nurse is simply an
intelligent machine for carrying out doctors orders. Rosenfield (1992), posits
that, in many countries, doctors determine the scope of nursing practice and
education, and can directly define the limits of nursing knowledge. Also,
doctors head public health care institutions thus affording them additional
opportunities to influence the training of nurses. However, so many others
argue that these working relationships are changing and should be examined
against prevailing development in the profession, society, and work (Ferger and
Shitt, 1979).
Johnson (1983), argued that collaborated work among
nurses and doctors has been found to be very rewarding. This is because some
hospital managements have identified the unique roles each of them plays in the
care of patients. Attempts have been made to change their designation in such a
way that one complements the other. This study examines the form of
relationship that exists between doctors and nurses, and how nurses are coping
with the situation, bearing in mind the differences in status relationship.
There may also be gender bias against the nurses which in turn have negative
effect on their job performance and level of satisfaction which further affects
their care for patients. Elaborating further, Rosenfield (1992) asserted that
collaborative nurse-physician relationships are associated with improved
patient, nurse and physician outcomes. Kohn (1996) asserted that modern nurse
has come of age; hence should be given a rightful place in the health
profession. The nurse’s role is significantly symbolized in “care” for the sick.
Care according to Limm (1994), is the essence and the central unifying and
dominant domain that characterized nursing. It is an essential human need for
full development, health maintenance, and survival of human beings in all world
culture; yet care has not received the same degree of attention by other
professionals as has been given by nurses. As a matter of emphasis, there
cannot be “cure” without “care” and curing is traditionally the doctor’s
function while caring is regarded as primary function of the nurses. Kennedy
and Garvin (2004), stated that the quality of product in the industrial sector
and efficiency of production are dependent on successful teamwork. Therefore,
one assumes that the efficiency and quality of patient care is dependent on the
degree at which interdisciplinary relationships are collaborative and this
shows the importance of teamwork.
Doctors and nurses possess individual expertise, make
individual decisions, hold common purpose and function together in an
egalitarian, cooperative and independent manner, thus, the combined effects of
shared, cooperative decision making are of greater benefit to the patient than
the individual effects on the disciplines on their own. Furthermore,
communication and collaboration are essential elements of good doctor-nurse
relationship. Kallish & Erb (1987) defined collaboration as “nurses and
doctors working together cooperatively to archive shared problem solving, decision
making, conflict resolution, communication and co-ordination”. The research is
therefore motivated to help Federal Medical Centre (FMC) Owerri, find a way of
examining “the effect of doctor-nurse relationship on patient care. It is for
this reason that this research is carried out to determine if patient care has
to do with doctor-nurse relationship and the factors considered here includes
the following;
(a) Medical Team Work
(b) Hospital Administrative Structure
(c) Value Orientations
The
factors listed above will be elaborated upon in the course of this research
work.
1.2 STATEMENT
OF THE PROBLEM
The
lack of collaboration between doctors and nurses in the health care delivery
system has assumed enormous attention. It indeed has posed great challenges to
medical sociologists, medical social workers, health care designers and policy
makers. Today, the health care delivery system is subjected to a state of
social disaster because of the poor relationship that exists between the doctor
and the nurse and this has adversely affected the level of production in the
health care system.
Nurses
and doctors who form the major workforce in the hospital do not see themselves
as partners in progress. Over the years, the doctor-nurse relationship has
tended to be unfriendly perhaps as a result of different value orientations of
doctors and nurses, lower level of interaction between doctors and nurses,
little motivation for them to work collaboratively with each other etc. these
have all contributed to bring about negative influence on the health service
delivery and the general job performance level. The doctors and nurses appear
to have a ritualistic notion about team work. It is based on these note, that
the researcher choose to research on the “The effect of doctor-nurse on
patients care in Federal Medical Centre, Owerri Imo State Nigeria. Thus, the
question that necessarily comes to mind is: To what extent is patient care
influenced by doctor-nurse value orientation, teamwork and administrative
structure?
1.3 RESEARCH
QUESTIONS
The following questions were posed to
guide this study:
1. Is there any
existing relationship between medical team work and patient care?
2. How does
hospital administrative structure relate to patient care?
3. What is the
extent of the relationship existing between doctor-nurse value orientation and
patient care?
1.4 RESEARCH HYPOTHESES
The
following hypotheses were formulated to guide the study.
i. There is
no significant relationship between medical team work and patient.
ii. Hospital
administrative structure has no significant relationship with patient care.
iii. Doctor-nurse
value orientation does not significantly relate to patient care.
1.5 OBJECTIVE OF THE STUDY
The main
objective of the study was to investigate the effect of doctor-nurse
relationship on patient care. Specifically, the study seeks to:
(a) To determine
the relationship existing between medical team work and effect on patient care.
(b) To investigate
the relationship existing between hospitals administrative structure and effect
on patient care.
(c) To examine
the relationship existing between doctor-nurse value orientation and its effect
on patient care.
1.6 SIGNIFICANCE OF THE STUDY
The study and its
findings will be of benefit to different classes of people including policy
makers, medical doctors, sociologists, social workers, nurses, patients and
researchers. The findings of this study will sensitize policy makers in the
Ministry of Health on nurse-physician relationship. The policy makers will
appreciate the need or goal of raising awareness of the importance of positive
nurse-physician relationship throughout the health care system. The Ministry of
Health will understand the need to inform policy and decision makers regarding
initiatives and interventions that strengthens and optimize nurse-physician
relationship. The medical sociologists will equally appreciate the findings of
this study because it will help them to ensure that their clients in the
hospital are receiving proper medical attention. The study will further reveal
the importance of fostering nurse-physician relationship. The medical
sociologists and medical social workers could encourage schools of nursing and
other related allied professional bodies to develop curriculum for their health
discipline programmes to build communication skills and foster optimal
collaboration between nursing and medical faculties, students and graduates.
The medical social workers on the hand will appreciate the findings of this
study because it will make them to understand that for an effective patient
care, there must exist good rapport between doctors and nurses for the overall
well being of the patient.
The
doctors and nurses may find the study useful having fully understood the
importance of doctor-nurse relationship; they will be better placed to mount
pressure on the government to incorporate education models and curriculum for
nurses and physicians. No research is carried out for its own sake as every
researcher is intended to solve one problem or the other in the society.
Through this research, stakeholders in the health care delivery system may
understand the predisposing factors towards poor service delivery. They may understand the vital role effective
doctor-nurse relationship plays in health care delivery system. Perhaps, little
research may have been carried out in this area; this study will further open
new grounds for more researchers to go into this area as well as adding to the
existing knowledge in the field.
1.7 SCOPE
OF THE STUDY
The
study is restricted Federal Medical Centre (FMC) Owerri, Imo State. Therefore,
any generalization of the result should be done in that context on the basis of
other organization having similar characteristics. The study is also concerned
with the ongoing relationship existing between doctors and nurses in hospitals.
The study will not cover all aspects of the relationship rather the aspects
that are covered are as follows:
(i) Value Orientations
(ii) Team work
(iii) Administrative structure. Thus doctor-nurse
relationship is limited to these
three (3) variables.
1.8 DEFINITION
OF CONCEPTS
Doctor:
This refers to a medical professional i.e a person who is skilled or
specialized in healing acts licensed to practice his/her profession. E.g
Surgeon, physician, dentist etc.
Nurse: This is any male or
female who has the stipulated period of training in an institution approved by
the Nursing and Midwifery Council of Nigeria and is duly registered and
licensed to practice nursing in any hospital or place in Nigeria and all over
the world.
Relationship:
The way or manner in which two people, groups or countries behave towards each
other or deal with each other.
Patient:
This refers to a sick individual waiting or under the care and treatment of a
physician.
Care: This has to do with
responsibility for or attention to health, well being and safety.
Team work:
This is referred to as that work done by a group of people who possess
individual expertise, who are responsible for making individual decisions, who
hold a common purpose and who meet together to communicate, share and
consolidate knowledge from which plans are made, Calman (1994).
Health care:
This refers to the maintenance and restoration of health by the treatment and
prevention of disease by trained and licensed medical professionals. E.g
doctors, nurse etc.
1.9 BRIEF
HISTORY OF FEDERAL MEDICAL CENTRE, OWERRI
The evolution and development of Health Institution that
is today known and called Federal Medical Centre, Owerri began rendering
healthcare services in 1903 as a military hospital. The objective was to treat
colonial soldiers, police and other colonial government officials. At
inception, the hospital facilities included three wards: a male ward which
accommodated both medical and surgical patients, a female ward and a maternity
ward. Other facilities available in 1903 included General Out-Patient Department
and a theatre. The staff complement comprises one doctor (general practitioner)
and few nurses. Records show that the patient population of the hospital in
1905 when the Colonial Government of the Northern and Southern protectorate
visited the hospital was between 5 to 15 patients and all were colonial
officials. During the visit, the government observed that the hospital was
underutilized due to the absence of African patronage of the hospital. Between
1905 to 1930, African or native population patronage was visible but still low
for some obvious reasons.
First, there existed in the minds of Africans intrinsic
fear that admission into the Whiteman’s hospital was a sure road towards one’s
death. Secondly, there was a general lack of faith in the efficacy of the
Whiteman’s medicine and there was fear that the hospital was a poly “catching”
Africans to pay tax to the Whiteman’s government. However, the movement for
political agitation for self-rule and self determination between the 1930’s and
1950’s resulted to the formation of government of Eastern Nigeria in 1940. This
phenomenon began a transfer of ownership of the hospital. Furthermore, for
unexplained reasons, Shell-Darcy Company, a major stakeholder in the Colonial
Hospital and whose sole business in Eastern Nigeria was Oil exploration
relocation from Owerri in the late fifties. The Colonial/Shell-Darcy hospital
was handed over to the Eastern Regional Government. Following Nigeria
Independence and under the premiership of Dr. M.I. Okpara, the hospital became
a district hospital and the Shell-Darcy arm was converted to an amenity ward
and known as “Okpara Nursing Home (ONH). The other arm of the colonial hospital
became the ANC Clinics and Administrative block. Other areas of the hospital
involved in this historic perspective include wards 2 and 3 as well as the main
store building extending to the microbiology laboratory. The flower hedge
between ward 2 and the store/microbiology building was the main first entrance
gate into the hospital.
During the East Central State Government, the maternity
unit was extended to accommodate all gynecological/obstetrics patients thereby
bringing the wards in the hospital to four with bed compliment of 44 under a
Divisional Hospital status. Following the creation of Imo State in 1976, the
hospital witnessed further expansion as a result of increased patronage. The
Imo State Government then changed the name of the hospital to General Hospital,
Owerri. Under the Imo State Government, the hospital experienced extensive infrastructural
development in the following areas; a modern Out-Patient Department, six new
wards, Pharmacy Department, Chest Unit, Infant Welfare Clinic, Accident and
Emergency Department, Hospital Canteen and an Mortuary. These infrastructural
achievements brought the bed compliment of the General Hospital to four hundred
and twenty seven (427) in thirteen wards. Since then, each successive Imo Government have worked hard to improve
the facilities and equipment needs in the hospital. Of note is the singular individual
effort in private-public partnership manifested in the building of the
Iwuanyanwu Blood Bank by Chief (Engr.) Emmanuel Iwuanyanwu and the Government
with Mrs. Bridget Nwankwo as commissioner for health.
Following the National Health Policy, the Federal
Government embarked upon the provision of tertiary medical facility in states
where a Federal Teaching Hospital does not exist. Consequent upon this policy implementation, the then Minister
of Health and Social Service Alhaji (Dr.) Dalhatu Tafida accompanied by the
then Minister of State for Health Chief Silas Ib after inspection of the then
General Hospital Owerri on 21st March, 1994 announced Federal
Government take over of the hospital. As a matter of fact, on the 1st
January 1995, the legal life of the hospital as Federal Medical Centre, Owerri
began (online available at: http:/www.fmco.com).