other. They learn from each other. And if they don't work well together it's the patient who suffers. Both professions ought to be mature enough to discuss the problems of the other from time to time without coming to blows over it. Our goals are surely the same. Those listed by Professor Clark are the goals of all health workers, not just of nurses. Certainly you can't be a good doctor if you don't consider the whole patient, as leaders of the medical profession like Lister and Osler emphasised 100 years ago. Secondly, I fear that many doctors will not be happy with either of the suggested "two ways of looking at nursing." Those who are said to look at nursing in the first way (which is described as the more prevalent of the two perspectives) are accused of believing that nurses do not require an understanding of why a task is necessary, how it works, or what its effects will be. But surely nobody thinks this. Anyone with a grain of sense wants each member of a team to have as much understanding as possible of what is being done for a patient. Why else should nurses have lectures from specialists explaining the thinking behind different surgical and medical treatments? As regards Professor Clark's second way of looking at nursing, everyone will agree with much of what she says and with the progress towards an even better trained, understanding, and skilful nursing profession. But it seems to me that to achieve what she would apparently like to see for all nurses (examining and history taking, thought processes identical with those used in medicine, sophisticated cognitive and social skills, and so on) would mean that every nurse would have to go through a course of training very similar to that at medical schools. We have all known nurses who, had they chosen to do so, could have sailed through medical school with flying colours. But there are many othersequally excellent and with equally good skill and judgment in many circumstances-who would be the first to agree that they could never compete or cope at this intellectual level and wouldn't want to. It doesn't help patients or anyone else to pretend otherwise. To be blunt, what is at stake here, it seems to me, is the credibility of those leaders of the nursing profession who brush reality under the carpet and talk as if all nurses were broadly the same in this respect. THURSTAN B BREWIN Bray, Berkshire SL6 2BQ 1 Clark J. Nursing: an intellectual activity. BMJ 1991;303:376-7. (17 August.)
SIR,-IS Professor June Clark suggesting that, though the thought processes in nursing are identical with those in medicine, nursing alone focuses on the "human response" and the "uniqueness of the individual"?' Perhaps she has a vision of care provided by a multidisciplinary team led by nurses, with psychologists providing counselling or behavioural management for problems that the nurse does not have time for and doctors available to sign prescriptions and undertake manual tasks such as pinning femurs and performing tracheostomies. When I become helpless, whether from illness, advancing years, or sheer rage, I hope that there will be someone in this multidisciplinary team to soothe my fevered brow and, more importantly, to keep me clean and dry, thus avoiding the bedsores that seem so common. S BRANDON
University of Leicester School of Medicine, Leicester Royal Infirmary, PO Box 65, Leicester LE2 7LX 1 Clark J. Nursing: an intellectual activity. BMJ 1991;303:376-7. (17 August.)
580
SIR,-Professor June Clarke's editorial on nursing interested me as I am a qualified nurse as well as a qualified doctor. When I decided on a career in nursing I had only two 0 levels. Fortunately, I passed the entrance exam and spent eight happy years as a nurse. My training was intense and stimulating and had a strong element of discipline. I changed my profession not because I didn't enjoy nursing but because I was searching for a different sort of challenge. I am saddened by the standards of nursing care today. Nurses no longer have time to sit and provide that all important emotional support. They say that they are understaffed, but perhaps they are too busy writing care plans and evaluating the care that they have been too busy to provide. I agree that nursing requires a good intellect, but raising the entry requirement means that some real nurses are excluded. After all, had I applied 10 years later to become a nurse I would not have been accepted with my two meagre 0 levels. I believe that standards are falling partly because of this leaning towards academia. It is difficult to see how a degree in nursing produces better nurses when they spend more time in a classroom than at the bedside. Of course good clinical research is needed, but not at the expense of good nurses on the wards, where practical skills are vital. If nurses want to be "clinical specialists" why don't they change professions like I did? Believe me, the grass is not greener on the other side. SALLY-ANN HAYWARD
London NW6 3HP I Clark J. Nursing: an intellectual activity. BMJ 1991;303:376-7. (17 Augist.)
SIR,-As I read Professor June Clark's editorial on recognising nursing's intellectual component' I thought of the women who, on several occasions, have promoted my "physical and mental comfort, healing, and recovery" and wondered what they would have made of it. They would probably have asked, "What on earth is she on about?" Years ago I watched a district nurse restore my badly burnt 80 year old grandfather through convalescence to renewed self confidence. A "considerable intellectual and emotional challenge"? She would have been mystified. She was simply doing her job and doing it superbly; and she was not exceptional. The intellectual component has always been present, and recognised. But we didn't call it that. We called it basic intelligence and common sense. To talk now of "coherent and holistic care" and "extant definitions of quality care" is to use the worst kind of academic jargon. Sadly, this is not an isolated example-the whole article reeks of it. I feel a sense of outrage on behalf of the women who nursed me, some of whom became valued friends of the family. If I was a young woman considering nursing today I would be frightened off by this article. I am afraid that many will be. KATHLEEN NORCROSS Birmingham B29 7JA 1 Clark J. Nursing: an intellectual activity. BMJ 1991;303:376-7. (17 August.)
HIV transmission during surgery SIR,-We should like to clarify certain issues raised by Dr A G Bird and colleagues.' These remarks concern the case of the HIV infected gynaecologist who agreed that the 1000 patients he had operated on should be contacted.
Letters were sent to patients in the three districts. They were offered initial counselling by telephone helpline and then encouraged to attend for further counselling and discussion at convenient centres. Alternative arrangements for counselling were also catered for, including home visits for those unable to take time off work or with transport difficulties, and an option of attending their own general practitioner instead of the organised counselling sessions. The general practitioners had been advised separately about the nature of the incident. No patients were discouraged from having a test, and the genitourinary clinics were used only for counselling and testing within one district, where other facilities were not readily available. That many patients chose to have a test after counselling was in part related to their level of anxiety on receipt of the letter. The role of the counsellors was to offer impartial information and not to persuade or dissuade patients from having a test. The Association of British Insurers, by recommending a waiver note for patients taking the test, may have only confused its prevailing message. In April 1991 a "statement of practice" was produced by the association, reiterating that a negative HIV test in the absence of lifestyle risk factors would not jeopardise insurance premiums on any occasion. A waiver notice was therefore not strictly necessary, but the machinery to produce this had in any case been put into operation well before the events became public. Whereas it may be claimed that the exercise illustrated could have been used to provide even greater epidemiological information, there is no evidence from the evaluation of work carried out locally in the health authorities of any "collective denial" hindering epidemiological assessment. Indeed, our objectives included acknowledgment of the potential risk (however small), sympathetic and confidential management of the individuals concerned, and delivery of unbiased and correct information to the public. The success of the exercise cannot be judged by the level of HIV testing achieved, but rather by the dissipation of anxiety and uncertainty of all those involved. S C CRAWSHAW R J WEST
West Suffolk Health Authority,
Bury St Edmunds, Suffolk IP33 I YJ 1 Bird AG, Gore SM, Leigh-Brown AJ, Carter DC. Escape from collective denial: HIV transniission during surgery. BMJ 1991;303:351-2. (10 August.)
Guidelines for doctors with HIV infection SIR, -In DrMichaelMorris'seditorialonAmerican legislation on AIDS' the tired old guidelines from the General Medical Council are repeated yet again: "It is unethical for physicians who know or believe themselves to be infected with HIV to put patients at risk by failing to seek appropriate counselling or act upon it when given." This will not do. AIDS may eventually kill the unfortunate surgeon who is HIV positive, but if he abandons his livelihood poverty, loneliness, depression, and debt will kill him sooner. His family surely have enough to cope with without losing their house and facing a mountain of debt. If those eminent people who formulate such guidelines truly believe them then we must pay those whose counselling leads them to give up their profession the full rate for the job they are leaving. When the Ministry of Agriculture, Fisheries, and Food destroys livestock to control an outbreak of foot and mouth disease it pays the full market rate for the animals it destroys, otherwise the farmers would not always cooperate. If we really want to
BMJ VOLUME 303
7 SEPTEMBER 1991
SIR,-IS Professor June Clark suggesting that, though the thought processes in nursing are identical with those in medicine, nursing alone focuses on the "human response" and the "uniqueness of the individual"?' Perhaps she has a vision of care provided by a multidisciplinary team led by nurses, with psychologists providing counselling or behavioural management for problems that the nurse does not have time for and doctors available to sign prescriptions and undertake manual tasks such as pinning femurs and performing tracheostomies. When I become helpless, whether from illness, advancing years, or sheer rage, I hope that there will be someone in this multidisciplinary team to soothe my fevered brow and, more importantly, to keep me clean and dry, thus avoiding the bedsores that seem so common. S BRANDON
University of Leicester School of Medicine, Leicester Royal Infirmary, PO Box 65, Leicester LE2 7LX 1 Clark J. Nursing: an intellectual activity. BMJ 1991;303:376-7. (17 August.)
580
SIR,-Professor June Clarke's editorial on nursing interested me as I am a qualified nurse as well as a qualified doctor. When I decided on a career in nursing I had only two 0 levels. Fortunately, I passed the entrance exam and spent eight happy years as a nurse. My training was intense and stimulating and had a strong element of discipline. I changed my profession not because I didn't enjoy nursing but because I was searching for a different sort of challenge. I am saddened by the standards of nursing care today. Nurses no longer have time to sit and provide that all important emotional support. They say that they are understaffed, but perhaps they are too busy writing care plans and evaluating the care that they have been too busy to provide. I agree that nursing requires a good intellect, but raising the entry requirement means that some real nurses are excluded. After all, had I applied 10 years later to become a nurse I would not have been accepted with my two meagre 0 levels. I believe that standards are falling partly because of this leaning towards academia. It is difficult to see how a degree in nursing produces better nurses when they spend more time in a classroom than at the bedside. Of course good clinical research is needed, but not at the expense of good nurses on the wards, where practical skills are vital. If nurses want to be "clinical specialists" why don't they change professions like I did? Believe me, the grass is not greener on the other side. SALLY-ANN HAYWARD
London NW6 3HP I Clark J. Nursing: an intellectual activity. BMJ 1991;303:376-7. (17 Augist.)
SIR,-As I read Professor June Clark's editorial on recognising nursing's intellectual component' I thought of the women who, on several occasions, have promoted my "physical and mental comfort, healing, and recovery" and wondered what they would have made of it. They would probably have asked, "What on earth is she on about?" Years ago I watched a district nurse restore my badly burnt 80 year old grandfather through convalescence to renewed self confidence. A "considerable intellectual and emotional challenge"? She would have been mystified. She was simply doing her job and doing it superbly; and she was not exceptional. The intellectual component has always been present, and recognised. But we didn't call it that. We called it basic intelligence and common sense. To talk now of "coherent and holistic care" and "extant definitions of quality care" is to use the worst kind of academic jargon. Sadly, this is not an isolated example-the whole article reeks of it. I feel a sense of outrage on behalf of the women who nursed me, some of whom became valued friends of the family. If I was a young woman considering nursing today I would be frightened off by this article. I am afraid that many will be. KATHLEEN NORCROSS Birmingham B29 7JA 1 Clark J. Nursing: an intellectual activity. BMJ 1991;303:376-7. (17 August.)
HIV transmission during surgery SIR,-We should like to clarify certain issues raised by Dr A G Bird and colleagues.' These remarks concern the case of the HIV infected gynaecologist who agreed that the 1000 patients he had operated on should be contacted.
Letters were sent to patients in the three districts. They were offered initial counselling by telephone helpline and then encouraged to attend for further counselling and discussion at convenient centres. Alternative arrangements for counselling were also catered for, including home visits for those unable to take time off work or with transport difficulties, and an option of attending their own general practitioner instead of the organised counselling sessions. The general practitioners had been advised separately about the nature of the incident. No patients were discouraged from having a test, and the genitourinary clinics were used only for counselling and testing within one district, where other facilities were not readily available. That many patients chose to have a test after counselling was in part related to their level of anxiety on receipt of the letter. The role of the counsellors was to offer impartial information and not to persuade or dissuade patients from having a test. The Association of British Insurers, by recommending a waiver note for patients taking the test, may have only confused its prevailing message. In April 1991 a "statement of practice" was produced by the association, reiterating that a negative HIV test in the absence of lifestyle risk factors would not jeopardise insurance premiums on any occasion. A waiver notice was therefore not strictly necessary, but the machinery to produce this had in any case been put into operation well before the events became public. Whereas it may be claimed that the exercise illustrated could have been used to provide even greater epidemiological information, there is no evidence from the evaluation of work carried out locally in the health authorities of any "collective denial" hindering epidemiological assessment. Indeed, our objectives included acknowledgment of the potential risk (however small), sympathetic and confidential management of the individuals concerned, and delivery of unbiased and correct information to the public. The success of the exercise cannot be judged by the level of HIV testing achieved, but rather by the dissipation of anxiety and uncertainty of all those involved. S C CRAWSHAW R J WEST
West Suffolk Health Authority,
Bury St Edmunds, Suffolk IP33 I YJ 1 Bird AG, Gore SM, Leigh-Brown AJ, Carter DC. Escape from collective denial: HIV transniission during surgery. BMJ 1991;303:351-2. (10 August.)
Guidelines for doctors with HIV infection SIR, -In DrMichaelMorris'seditorialonAmerican legislation on AIDS' the tired old guidelines from the General Medical Council are repeated yet again: "It is unethical for physicians who know or believe themselves to be infected with HIV to put patients at risk by failing to seek appropriate counselling or act upon it when given." This will not do. AIDS may eventually kill the unfortunate surgeon who is HIV positive, but if he abandons his livelihood poverty, loneliness, depression, and debt will kill him sooner. His family surely have enough to cope with without losing their house and facing a mountain of debt. If those eminent people who formulate such guidelines truly believe them then we must pay those whose counselling leads them to give up their profession the full rate for the job they are leaving. When the Ministry of Agriculture, Fisheries, and Food destroys livestock to control an outbreak of foot and mouth disease it pays the full market rate for the animals it destroys, otherwise the farmers would not always cooperate. If we really want to
BMJ VOLUME 303
7 SEPTEMBER 1991
