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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.
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.

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.)


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.

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.
Birmingham B29 7JA
1 Clark J. Nursing: an intellectual activity. BMJ 1991;303:376-7.
(17 August.)

HIV transmission during

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
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

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

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