Peers or Sub-Ordinates?
Although changes in health care and practice settings have induced new roles for nurses like Advanced Practice Nurse, Clinical Nurse Specialist, Nurse Practioner, Certified Registered Nurse Anesthetist and Nursing Administrator, studies show that the nurses are often in role ambiguity, where there is always an uncertainty regarding others' expectations and role conflict arising out of incompatible demands from various role senders or from multiple roles held simultaneously. These factors of role conflict and ambiguity have been shown to significantly contribute to job stress resulting in reduced organizational commitment, job satisfaction, and enhanced intentions to quit (Rosse, 1981).

The Role Confusion and Conflicts
The frustrations of nurses are due to a range of structural and ideological features which conspire to limit the professional autonomy of the nurse at the bedside and is a clear case of medical dominance (Turner, 1986). The nurse is always at a disadvantage when there is no role delineation and this often results in an ineffective use of resources and personnel (Glover et.al, 2006). Further, the nurse-physician relationship is usually perceived as one of nurse deference to physician authority. Disruptive physician behavior such as verbal abuse to physical and sexual harassment, the healthcare organization's response to such behaviors, is seen as an important factor in nurses' decisions to leave their positions and role confusion (Rosenstein, 2002). Nurse conflict with physicians has been identified as a stressor in the work environment and nurses have been found to lack the assertiveness to communicate their opinions and contributions when interacting with physicians (Nelson et.al, 2008). Physician-nurse relationship has also been identified as one of the five important stress factors affecting nurses in heath care organizations (Leatt and Schneck, 1985).A recent study to measure and compare critical care physicians' and nurses' attitudes about teamwork has shown that critical care physicians and nurses have discrepant attitudes about the teamwork with suboptimal conflict resolution and interpersonal communication skills due to the differences in authority, responsibilities, gender, training, and cultures (Thomas et.al,2003).Nurse -physician conflicts do occur in intensive care settings, end of life decisions (Ferrand,2003), clinical trials and palliative care. A survey conducted among registered nurses and primary care physicians in south eastern Pennsylvania to define the role of the nurse practitioner as a new health care provider and to determine nurses' and physicians' conceptions of the NP's role has shown that significant differences exist between nurses and physicians with respect to both of the issues. Nurses have been found to assert that a nurse practioner should be allowed independent practice and exhibit a higher appraisal of the NP's capabilities (Burkett et.al, 1978). A typical conflict in Wisconsin over expansion of APNs' diagnostic test ordering and interpretation authority has generated an administrative rule that actually clarifies the important relationship that must exist between APNs and physicians (http://www.wafp.org/).The physician organizations seek to control nurse practice through mandatory supervisory relationships, keeping responsibility for patients, and limiting direct reimbursements (Butler, 2000). Although, nurse practioners have prescriptive authority in all fifty states, there is considerable variation and the prescriptive authority represents less than 0.01 percent of all prescriptions (Galewitz, 1999).

Role Clarity of Nurses
Nurses define caring as their function and have been found to defend this exclusive care role (Riska et.al, 1993). Expectations, conception and performance have been identified as the three important factors needed to define a specific role using the role theory as a framework. Role expectations can be defined as the attributes that members of an organization believe an individual will display. Role conception is the individual's definition of the role. Role performance depends on these two factors (Glover et.al, 2006). Thus, a modern day nurse is burdened with a political-ethical conflict.Political-ethical conflict can be defined as the conflict between one's ethical belief system and what he or she feels compelled to do or is told to do by someone in a position of power (Jardin, 2001).The difference between traditional ideas on nursing and the new image of what nursing has become, the perceived weakness of the female gender and contrast in goals of physicians-institution-nursing profession triangle are some of the conflicting issues that affect nurse's role clarity(Jardin, 2001).

Neo Nurse Redefined
Although the nurse practitioner role was created in 1965, due to the efforts of Loretta Ford and Henry Silver (Ford, 1997), it should be recognized that the role of the NP has changed to that of a more independent provider who can substitute for physicians in primary care (Mundinger, 2002) and nurse practioners now seek to expand practice autonomy and get independent reimbursement (Cooper et.al, 1998). It should be noted that the laws for nurse practioners have moved steadily away from requiring physician supervision and protocols with forty-three states and the District of Columbia authorizing NP practice through a state board of nursing (Mundinger, 2002) with only a half having the statutory requirements for physician collaboration or supervision. The definitions, roles, and expectations for the new roles for nurses like Advanced Practice Nurse, Clinical Nurse Specialist, Nurse Practioner, Certified Registered Nurse Anesthetist and Nursing Administrator need to be well documented in the literature with no room for role confusion. For example, researchers report that CNS and NP roles are similar in some aspects but distinctly different in others. (Glover et.al, 2006). Further, patient advocacy is an essential component of nursing and this patient advocacy does not end in just supporting professional nursing goals that relate to health care for consumers but runs into nurses getting involved in the political process to determine public health policy issues (Jardin, 2001, Ennen, 2001). Barriers to the use of research findings in practice must be modified (Thompson and Bonnes, 2005).

Action research, an elaborate process of enquiry that helps to solve problems in a collaborative context and to understand underlying causes (Reason & Bradbury, 2001) will help stimulate and evaluate nursing practice. A study on the social order in medical and surgical wards between nurses and physicians has shown that the social order on the wards today is a negotiated order on account of a continuous negotiation between doctors and nurses (Svensson, 1996). The nurse-physician collaborative model is a model which shows a radical shift from the past. In such a model, the health care organizational structure is decentralized and the nurses and physicians function collaborately to make clinical decisions.  A joint practice committee, with equal representations functions at the organizational level to monitor and support those professionals (Potter, 205).  The clinical records are integrated with joint patient care record views to foster collaboration. A study to describe the benefits of a physician-nurse practitioner (NP) collaborative tandem practice model has shown that a collaboration of the physician specialist and primary care NP provides a holistic approach to the care of diverse and challenging patient populations(Herrmann and Zabramski,2005).  A survey to explore the relationship between interdisciplinary teamwork and nurse autonomy on patient outcomes has also shown that a strong association exists between teamwork and nurse autonomy suggesting a synergy rather than conflict taking us to the conclusion that nurse autonomy should be encouraged without any apprehensions that nurse autonomy might undermine teamwork (Rafferty et.al, 2001).

Conclusion
The nurses are often in role ambiguity in spite of changes in health care and practice settings. A lack of role delineation has led to nurse-physician conflicts. Physicians should work with nurse organizations like ASRN to develop collaborative models of integrated patient-centered care.

 

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