It is reassuring to note that majority of doctors and nurses in Nigeria considered the working relationships between the two professions to be cordial, but problems remain. In this study, we found that, proportionally, there were more female nurses than female doctors. Given the role that gender perception plays in doctors-nurses working relationships[7
], we opine that it is necessary to increase the recruitment of men into nursing and women into medicine in order to balance the gender distribution, reduce gender-role-perception based conflicts and enhance nurses-doctors working relationships.
Bad behavior among both doctors and nurses has been linked to poor retention of staff in the health care system and poor clinical outcomes[16
]. While some authors think doctors are the major sources of these conflicts[18
], others have blamed medical training programs that set up a hierarchical model with nurses in a relatively subservient role[16
]. In the opinion of Witz[19
], doctors' behaviors serve as vital demarcation strategies to confirm physicians' autonomy in inter-occupational relationships with nurses. In our study, factors such as inadequate development of interpersonal skills, perception of respect, compliance with advice, personality traits and communication gaps were more commonly reported by nurses than by doctors as having an effect on nurses-doctors working relationships, although these did not reach statistical significance. Nevertheless many more nurses than doctors wished that they could do their work without the other professional group.
Staff shortage was an important determinant of poor nurses-doctors working relationships in our study. This is consistent with findings of other studies that showed that this factor also plays an important role in patients' outcome [17
]. Perennial staff shortage is common in health care institutions in developing countries, including Nigeria, due to decades of economic depression and lack of development[21
]. This situation has been worsened in recent times by the recruitment of health care workers in developing countries by developed countries[22
]. Inadequate staff leads to inefficient health care delivery, perceptions of uncooperative work attitude between health care professionals and further inefficiencies in health care delivery. This may increase the risk of disruptive behavior among health care workers which sets off a feedback mechanism where staffing shortage increases tension in the working environment leading to further exodus of health care workers[16
Another major factor influencing the working relationships between nurses and doctors in our environment was the union activities of professional groups. We found that nurses more than doctors felt that the union activities of the other professional group were inimical to the professional interests of their group. One of the major responses to decades of poor government and economic depression in developing countries has been the radicalization of workers' unions. Withdrawal of services became a frequent tool for negotiating new working conditions and display of grievances about government policies. Such activities tended to polarize workers, particularly in a multidisciplinary environment like health care, where some groups, usually doctors, may be considered more privileged than others[23
]. With return of more stable democratic government (since 1999 in Nigeria) and better labor relationships, the impact of this factor is likely to diminish in future.
Peter reports lack of appreciation of nursing knowledge by physicians and others[20
]. Our study also shows that there was perception of lack of appreciation of the knowledge of the other professional group by both nurses and doctors, but this was more prevalent among doctors than nurses[16
]. Furthermore, more nurses than doctors wanted the post of the chief executive of hospitals to be open to all professionals in the health care system, in the belief that this will positively influence the conditions of service of health care workers and their sense of belonging. Other health care professionals in Nigeria consider government policies such as those related to the headship of public health care institutions discriminatory[13
]. According to Ogbimi[25
], occupational prestige is determined by its sophistication, effectiveness, exclusiveness and accessibility of service to the public. The current situation where headship of hospitals is the sole preserve of doctors arose after series of protracted doctors' withdrawal of services and may account for the overwhelmingly positive response by doctors to government and hospital management policy compared to that of nurses in this study. We also found that the degree of social interaction between nurses and doctors outside the working environment was a predictor of nurse-doctor working relationship, but this may be a reflection of the Nigerian social and cultural structures that are not necessarily generalizable.
Our findings should be interpreted within the context of the limited nature of the development of the instrument used. A more comprehensive sampling of all the doctors and nurses in the region covered by the study would have yielded more information. In addition, we did not keep institution specific information hence could not adjust for the different institutions in the analysis. In addition, responses were voluntary and may have been drawn largely from respondents interested in this issue.