Examining Professional Boundaries between Nurses and Physicians

Medical and technological developments, financial constraints and a shortage of physicians have made it necessary to re-examine professional boundaries in health, particularly between physicians and nurses. Israel’s manpower shortage in Neonatal Intensive Care Units (NICUs) has changed the responsibility and authority of ward nurses. However, these changes have not evolved into a uniform policy defining the division of responsibility and authority of physicians and nurses. Moreover, to date, there has been no systematic investigation of the steps required to broaden the authority of nurses.

The study was designed to survey and document the work processes and actual division of labor between NICU physicians and nurses; examine the attitude of physicians and nurses to their shared work and to the greater empowerment of the nursing role; review the worldwide situation of Advanced Neonatal Nurse Specialists; and suggest a model to regulate work processes and develop the role of neonatal nurse specialists in NICUs.

From the in-depth interviews with NICU physician-directors and head nurses and from a survey of some 50% of the physicians and nurses at 22 hospital NICUs (about 430 physicians and nurses), the following issues emerged:

  • The main problems of the NICUs are a shortage of physicians and overcrowding, a shortage of auxiliary staff and fragmented work processes.
  • A large part of the tasks permitted to nurses by law and government regulations are not performed by them. The main barriers to this are the need for organizational approval and a lack of knowledge by nurses of the tasks they are permitted.
  • Concomitantly, in some situations, nurses are compelled to perform tasks and make decisions that they are not authorized to do, mainly because of the unavailability of physicians and the workload in the NICUs.
  • Most physicians and nurses agree that nursing graduates of post-basic training courses should have the authority to perform certain tasks, such as resuscitation and medication balancing. They also agree that invasive procedures should remain the physicians’ responsibility.
  • It is widely agreed that broadening the authority of nurses would improve the quality of NICU care even though it would increase the nursing workload.

The study provides policymakers with important input into decisions on whether to authorize nursing care for complete areas rather than the performance of isolated tasks; on whether to remove institutional restrictions on tasks currently permitted to nurses; on whether to organize work within the NICU on the basis of full-time/dedicated staff, and on whether to expand the nurses’ decision-making and empowerment. In addition, the study revealed that there is a basis on which to build up the role of neonatal nurse specialists since most NICU nurses have the suitable academic and clinical training.

The study was funded with the assistance of a research grant from the Israel National Institute for Health Policy Research.

Citing suggestion: Toren, O., Nirel, N., Tsur, Y., & Toker, A. (2013). Examining Professional Boundaries between Nurses and Physicians. RR-641-13. Myers-JDC-Brookdale Institute. (Hebrew)