Who cares? Who cures? The ongoing debate in the provision of health care

Who cares? Who cures? The ongoing debatein the provision of health care

Andrea O. Baumann RN PhD

Professor, Faculty of Health Sciences, McMaster University

Raisa B. Deber RN PhD

Professor, Faculty of Medicine, University of Toronto, Toronto

Barbara E. Silverman MSc

Research Projects Coordinator, Faculty of Health Sciences, McMaster University

and Claire M. Mallette RN MSc

Lecturer, Faculty of Health Sciences, McMaster University,

Hamilton, Ontario, Canada

Accepted for publication 4 October 1997

BAUMANN A.O., DEBER R.B., SILVERMAN B.E. & MALLETTE C.M. (1998) Journal of

Advanced Nursing 28(5), 1040±1045

Who cares? Who cures? The ongoing debate in the provision of health care

In the debate about the role of health professionals, two normative models have

been placed in opposition Ð `care vs. cure'. To many, the cure model has been

associated with physicians, and the care model with nursing and the other

allied health professions. As the shortcomings of a cure-orientated model have

been recognized, particularly in dealing with chronic disease, more attention

has been focused on care, with many writing as though the two were mutually

exclusive. In this paper, we suggest that these models are instead end-points on

a continuum which ideally should be used by all health providers, rather than

being characteristic of different clinical professionals. This conceptualization

places less concern on what should be done by doctors as opposed to nurses,

and more on the needs of the particular situation. The resulting convergence

among roles should not imply that nursing and the allied health professions will

adopt the medical model, but that medicine, nursing and others will work

together with patients for all members' mutual bene®t. In this expanded

continuum, the focus for decision making becomes the patient and family in

partnership and collaboration with health professionals.

Keywords: care, cure, continuum, nurse, physician, health care providers,

patient, roles, collaboration

CONVERGING ROLES OF PHYSICIANS,NURSES AND HEALTH CARE PROVIDERS

In the debate about the roles of various health profession-

als, two normative models have been suggested Ð `care'

vs. `cure'. To many, the cure model has been associated

with physicians, and the care model with nursing and

Correspondence: Andrea Baumann, McMaster University,

HSC 2J17, Faculty of Health Sciences, 1200 Main Street West, Hamilton,

Ontario, Canada L8N 3Z5.

Journal of Advanced Nursing, 1998, 28(5), 1040±1045 Philosophical and ethical issues

1040 Ó 1998 Blackwell Science Ltd

other allied health professions. As the limitations of the

medical model have been recognized, particularly in

dealing with chronic disease, more attention has been

focused on care. Many authors have written as though care

and cure were mutually exclusive. In this paper we

suggest that these models are instead end-points on a

continuum that ideally is used by all health providers, and

different combinations of the two models are appropriate

under different clinical circumstances, rather than being

characteristic of different clinical professions. Implica-

tions for the roles of providers and patients are also

explored.

THE CURE MODEL

Traditionally, the focus for the physician has been the

cure model. This medical model focuses on the `biomed-

ical or technological approaches' (Webb 1996 p. 960). As

noted in Table 1 the goals of this model are the identi®-

cation of pathophysiology, leading to a diagnosis, and

reduction of symptomatology through the treatment of

pathology. To achieve these goals, physicians have been

taught to apply a sequential model in which the practi-

tioner ®rst diagnoses the problem (disease) and then

examines a series of clearly de®ned treatment alternatives

to select the optimal choice. Encounters between clinician

and patient are often initiated as a result of the appearance

of symptoms, and accordingly tend to be episodic rather

than continuous (Table 1).

One of the attributes of the cure model is that it is

amenable to application of such techniques as decision

analysis, in which the clinician can choose among clearly

de®ned interventions (e.g. surgery or pharmacotherapy)

(Lawler 1995). Such interventions may be highly technical

and require expert knowledge on the part of the clinician.

The effects of these medical interventions can be evalu-

ated using objective indicators such as mortality rates,

laboratory values, or degree of pathology.

In decision analysis, a decision tree, which indicates

choices and chances, is used to provide a simpli®ed

description of the otherwise complex clinical problem

(Lawler 1995). A model is used to outline the worth of the

options available and to provide a decision analysis

pathway which computes the best possible outcome by

evaluating each of the options and multiplying the

probability of each possible outcome by its expected

value. For example, a particular decision might lead to

cure (best outcome), minor complications, major compli-

cations, or death. The probability of each possibility is

assessed, and a value af®xed to each. Classical decision

theory would then select the option with the highest

expected value, although this approach has been criti-

cized as inadequate under some circumstances (Goel

1992). `Good' cure decisions are thus viewed as related

only to patient outcomes, and dependent upon the

clinician's level of knowledge and experience, and avail-

ability of necessary information.

In addition, curative activities are often dramatic and

carry high prestige Ð Hollywood movies and popular

novels glorify the `miracle curer' function. However,

heroic technically orientated cure activities are now being

questioned by many for their high cost and often poor

outcomes.

THE CARE FOCUS

Both cure and care centre on sustaining an optimal level of

health for patients. Curative activities can be readily

assessed, whereas care interventions are not as amenable

to measurement (Baumann & Deber 1989a). `The concept

of caring is one of the least understood ideas used by

professionals and remains a poorly de®ned concept in

nursing practice and education' (Kyle 1995 p. 506). Caring

is an èlusive and imprecise concept' (Kyle 1995 p. 506).

There are numerous characteristics associated with care,

Table 1 Dimensions of care and cure.

Dimension Cure Care

Goals of treatment Identi®cation of

pathophysiology,

diagnosis, and

subsequent

reduction

of symptom-

atology and treat-

ment of pathology

Achieving or main-

taining optimal

health or well-being

Basis for encounters Episodic, sparked

by the appearance

of symptoms

Continuous, often

evoked by a chronic

condition

Treatment options Clearly de®ned,

mutually

exclusive*,

often invasive

Often overlapping,

rarely mutually

exclusive, rarely

invasive

Clear relationship

between

interventions

and outcomes

Yes No

Outcomes

measurable

Yes (e.g. decreased

tumour growth)

Not directly (e.g.

anxiety is measured

by a number of

related constructs

such as decreased

negative affect)

Criteria for team

membership

Expertise Variable (may

include proximity,

willingness)

Provider of care Expert (usually

physician)

Variety (often

including family)

*In the context of decision analysis.

Philosophical and ethical issues Who cares? Who cures?

Ó 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 28(5), 1040±1045 1041

some of which include honesty, patience, courage, know-

ledge, skills, feeling, compassion, empathy, respect, and

closeness (Webb 1996). Other elements to care are that it

requires the carer to be responsive to the needs of the

person cared for, the resources available and the context in

which care occurs. This involves skilled assessment,

planning, action and evaluation of the implications and

nuances of all of these factors (Webb 1996).

In recent years, there has been a close examination of

what constitutes care. `The term carative is used in

contrast to the more common term curative in order to

differentiate between medicine and nursing' (Kyle 1995

p.507). The relevant literature focuses both on what care

entails, and on who should or can provide it. Care

interventions can go from the very simple (e.g. listening

to the client) to highly technological (e.g. managing

cardiac monitors) with varying requirements for profes-

sional skills. Indeed, care interventions cross over into

activities of normal life, and as such have far less prestige

and are less likely to be lucrative. There are minimal

regulatory controls, and there is a perception that ànyone

can do it' Ð that is, anyone can `care' (e.g. compassion,

empathy, respect).

Care is dif®cult to evaluate for several reasons. First,

these interventions are often hard to de®ne (Table 1).

Unlike cure interventions in the medical model where

some are mutually exclusive, for example to operate or not

to operate (Weinstein et al. 1980), care interventions are

rarely mutually exclusive. The caring intervention of

taking vital signs does not preclude reassuring patients,

or making them more comfortable (Baumann & Deber

1989b). In addition, many different care givers may

simultaneously take many different actions. As a result,

there is often no clear relationship between a particular

intervention (e.g. empathy) and speci®c health outcomes

(e.g. improved health status) as is seen with attempts to

evaluate health promotion care focused activities (Goel

1992). Another dif®culty in evaluating care outcomes by

traditional methods of inquiry is the existence of multiple

`soft' dependent variables (e.g. comfort, patient satisfac-

tion, coping, levels of wellness), which are often dif®cult

to measure (Baumann & Deber 1989b). Watson & Lea (1997)

have attempted to quantify these constructs using a core

set of 25 questions derived from a review of the literature

and other care questionnaires to gather nurses' percep-

tions of caring. Although the testing of this tool indicates

that it may be useful in measuring nurses' perceptions of

caring, further analysis of the preliminary data and testing

of the tool is required (Watson & Lea 1997).

Although care is often seen as synonymous with `nurs-

ing', much of primary health care involves similar pro-

cess-orientated interventions aimed at such goals as

àssessment' and èducation', and helping the patient

and family stay healthy or cope with illness. For example,

treatment of a patient with diabetes involves more than

maintenance of an appropriate blood sugar level. It also

stresses the importance of hard-to-measure goals as em-

powering the patient to take responsibility for his or her

own care, encouraging independence in activities of daily

living, or increasing patient satisfaction with his or her

own life highlighting that, `caring is a complex phenom-

enon involving more than a set of caring behaviours' (Kyle

1995 p. 512).

As suggested, the care model encompasses a host of

potential providers, including physicians, with varying

levels of expertise. Indeed, much care will be provided

outside of the formal health delivery system, for example,

self care and care by family. Cure is generally episodic,

whereas care is continuous, varies in intensity, and

consists of a host of interdependent actions. Care is often

measured by maintenance of a satisfactory level of func-

tioning in several dimensions, rather than by attainment of

a particular outcome (e.g. decreased blood pressure). There

is a need for research to evaluate outcomes of both care and

cure interventions within interdisciplinary practices.

HEALTH CARE PROVIDERS' ROLES

In recent years, the public dimension has been added to

this care±cure continuum debate as nurses and other non-

physician health providers, as well as some physicians,

have sought to identify their activities with the `care'

focus. As medical paternalism declines, there is an

increasing recognition that patients must be the ultimate

arbiters of their own treatment.

There is a blurring of the care±cure continuum among

physicians, nurses, and other health care providers,

including family members. For example, special know-

ledge may be essential in educating patients on how to

manage everyday care, as well as in coordination/moni-

toring to detect situations in which more aggressive

intervention is required. The skills required to perform

these tasks, however, do not clearly fall within the domain

of any health profession, particularly because they require

not only technical knowledge, but also the interpersonal

skills to be effective in empowering patients and their

families. In a cost-conscious environment tasks may be,

and increasingly are, performed by individuals with far

less formal training than physicians or nurses.

There has also been a demysti®cation of the health care

provider's role and a movement towards self-maintenance

of health (e.g. family members responsible for orthopaedic

traction while at home). This shifting of responsibility to

patients and families has lead to increased reliance on self

care.

FRAMEWORK OF PRACTICE

Within the care±cure continuum or framework of practice,

physicians have traditionally been assigned the role `gate

A. Baumann et al.

1042 Ó 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 28(5), 1040±1045

keeper' of patient care, making decisions as to which

interventions would be delegated to other professionals

and which services would be used. The cure±care struggle

has become entangled with efforts to redistribute power

between health providers and patients. The resulting

battles pitting `care' against `cure' have served to empha-

size the extent to which traditional depictions of the roles

of different health care providers have led to an arti®cial

distinction between `cure' as being a physician's respon-

sibility, and `care' as being the responsibility of the nurse

and/or other health care workers.

Physician professional self-regulation has assumed that

physicians would be judged only by their peers, by

standards mutually agreed upon by physicians. However,

few mechanisms existed to scrutinize the decision-making

of physicians in solo of®ce-based practice. Physicians

have thus enjoyed considerable autonomy; their role, as

independent experts, had been to employ the resources

available to diagnose and `cure' the patient if possible.

Nursing and other allied health professionals, in con-

trast, were practising within a bureaucracy (usually, the

hospital), with considerably less autonomy. Relationships

between nurses and physicians have been described as

`the doctor and nurse game', requiring nurses to assert

themselves indirectly in a manipulative rather than direct

manner in the planning and coordination of care (Pilliteri

& Ackerman 1993, Stein et al. 1990). In some situations,

nursing practice had been bounded by rules and regula-

tions, and subject to hospital policy, whose nursing

structure assured considerable scrutiny over activities of

individual nurses. Nurses could not independently decide

to allocate resources or change treatment plans; their role

was to administer treatments de®ned by physicians, and

to `care' for patients, usually by performing speci®c

physical-care tasks.

This categorical division between physicians and other

health workers has become blurred in recent years. The

increasing complexity of medical care has encouraged the

growth of multidisciplinary clinical teams. With the

expansion of specialized knowledge, physicians have

recognized that they cannot be all things to all people

(Stein et al. 1990) and are more willing to work within

such team settings. The hospital milieu is characterized by

the presence of a multidisciplinary team, sets of policies

and procedures readily available, and ready access to

supervisory personnel (Prescott et al. 1987). Working in

the client's home and performing a variety of interven-

tions, without direct supervision, has resulted in greater

decision making independence for nurses and, in turn, a

different role for patients has evolved.

At the same time, nurses are attempting to liberate

themselves from their old role as `physician handmaiden'

and in many cases are incorporating more `cure' functions

into their roles. Lipsky (1980) has noted that what he

terms `street level bureaucrats' have high degrees of

discretion and relative autonomy from organizational

authority. Community-based nurses may ®t this model.

They work in clients' homes quite isolated from tradition-

al medical teams and have a choice about the nature and

quality of the service which does not exist in the hospital

sector.

Nurses have also attempted to elevate the status of

traditional `care' activities, and to increase emphasis on

the `cure' tasks performed by nurses. To some extent,

many nurses have seen the shortest route to increased

status as taking over physician tasks or as de®ning nursing

tasks to better ®t a medical model. An example of this

could be the nurse practitioner or independent practice

role. The nurse practitioner provides holistic client care

through the implementation of supportive, educative,

curative, rehabilitative and promotive roles (Watson

1994). Although these new nursing opportunities are

often positive ones, the danger exists that the practice of

nurse practitioners could be seen as `medicalization' of the

nursing profession with the focus more on medical tasks

and keeping clients free from disease (Birenbaum 1994).

WHAT IS THE ROLE FOR THE PATIENT?

Medical sociology has recognized that most health prob-

lems, as broadly de®ned, are never brought to the health

care system (Spitzer 1984). Indeed, one topic of study is

the circumstance under which patients will de®ne symp-

toms as requiring medical attention. Accordingly, any

attempt to de®ne roles must include the recipient of care

who will only become a `patient' if contact is made with

the formal system of care.

Clearly, health goes far beyond mere treatment of

disease. It does not follow, however, that health profes-

sionals are required to assist in all parts of the care±cure

continuum. Indeed, one could argue that they are primar-

ily required at the `cure' end of the spectrum, where

special knowledge and training are needed. Even then,

there are limitations on a professional's role. The cure

model has traditionally viewed the patient as a passive

recipient of care, amenable to interventions that can be

quanti®ed. This has arisen in large part from the heavy

emphasis placed on the necessity for expertise in order to

make wise decisions, and the accompanying assumption

that the patient will rarely possess such knowledge.

Accordingly, the focus has been on the clinician to act

as the àgent' of the patient, with the assumption that

professional responsibility will ensure that he or she

would act in the patient's best interests.

Kassirer (1983) has written about ùsurping patient

prerogatives' and cautioned against presuming that ex-

perts should make decisions for patients, rather than

advising them and implementing their mutual decisions.

Deber et al. (1996) have found that most patients do not

wish to perform problem solving tasks (i.e. diagnose a



health care problem, or identify the possible treatments

and their risks and bene®ts), although many wish to be

involved in the decision making process (e.g. determine

how they value potential outcomes, and decide what

treatment they wish to receive.). This conceptualization

recognizes the possibility of a partnership between patient

and provider, which can apply to both the care and the

cure components (Deber 1994a, 1994b).

The continuing evolution of professional role de®ni-

tions appears to leave the ownership of a growing propor-

tion of the care-cure continuum in question.

Technological developments, for example, may allow

patients and their families to perform intricate treatments

(e.g. dialysis, home respirators, tube feeding). With many

chronic diseases, patients now take responsibility for most

of the daily care requirements, with the role of the health

professional restricted to episodic crisis intervention and

overall education and monitoring. Trends to shorter

lengths of stay have also shifted more care activity to the

home and lessened the claim of professionals to `control'

their patients' needs.

Patient care originally started off with health care

professionals assuming care in a hierarchical manner.

With the advent of multidisciplinary care, the hierarchy

becomes less evident. As such, there is a predisposition to

a blurring of roles. The skill mix required within institu-

tions has also shifted to include an increased number of

unregulated care providers and volunteer workers. Coor-

dination and management of patient care becomes dif®-

cult when roles are blurred, let alone when there is an

increased requirement for evidence-based cost effective

delivery of care and skill mix ratios.

THE EFFECTIVENESS DEBATE

Nurses are paying more attention to nursing outcomes and

evaluation, and to the decision making and problem

solving aspects of their role (Baumann & Deber 1989b). An

example of this is when Ciliska et al. (1994) assessed the

effectiveness of public health nursing interventions and

outcomes. Positive outcomes, including improvement in

children's mental development and physical growth,

reduction in mother's anxiety, depression and tobacco

use, reduced level of care required for the elderly and

government cost saving, were identi®ed (Ciliska et al.

1994). The search for increased professional status and

clearer measurable outcomes for nursing has also shifted

attention to nursing activities which fall closest to the

`cure' end of the spectrum as they are easier to quantify.

To the extent that care activities do not ®t an outcome-

orientated model, they have been downplayed. Indeed, as

the costs of nursing care become higher, cost-conscious

institutions are no longer willing to pay nurses to perform

important `care' functions which do not necessarily

require the skill level of a registered nurse. However,

these functions must still be performed; ignoring `soft'

outcomes which are dif®cult to measure may in turn

imperil our ability to improve the health and well-being of

patients. In our judgement, there is an urgent need for

better understanding of the care components, their impact,

and how best to ensure they are accomplished.

CONCLUSION

It is commonly agreed that delivery of care should be

viewed as multidisciplinary and continuous. Acceptance

of this viewpoint implies a need for a focus on the merging

of roles rather than maintaining the division (i.e. not

cutting the patient into pieces). In reality, today's effec-

tiveness-based health care environment requires the needs

of the particular situation to dictate which member(s) of

the health care team will provide the curing or caring

necessary to achieve the speci®c health outcome. At one

end of the continuum there is an autonomous functioning

client who has little need for either care or cure. At the

other end there is an acutely ill patient requiring massive

interventions both with a care and cure focus. In the

middle is a person who may require mainly supportive

and preventive interventions.

The recognition of the importance of care has been

offset, to a large extent, by nursing's search for profes-

sional growth and the emphasis on evaluating outcomes in

order to control escalating health care costs. Quality of

care is a complex issue, and measurement of quality

requires attention to `softer' or subjective outcomes of care

(e.g. decreased anxiety) as well as the sometimes more

objective outcomes of curing interventions (e.g. mortality

and morbidity). If the economic circumstances of the

health care system require that professionals take primary

responsibility only for the `cure' dimension, education,

and coordination/monitoring, and not for the dimension

of `care', then a partnership with patients and families

becomes of paramount importance; however, care need

not be the exclusive domain of any one group or profes-

sion.

In the expanded care±cure continuum the focus for

decision making becomes the patient, the family and

indeed the population, in partnership and collaboration

with health professionals. The key question then becomes

less `who' and more `what is to be done in the name of

optimal treatment'? Less focus should be placed on what

should be done by doctors as opposed to nurses, and more

on how both groups can assist patients, and when patients

should be allowed to assist themselves (Deber 1994a,

1994b). Ideally, the roles of the various health profession-

als should begin to converge. This convergence of roles

and the recognition of partnerships (Byrne 1991) should

not imply that nursing and allied health professions adopt

the medical model, but that medicine, nursing and others

work together with patients for their mutual bene®t. Às

A. Baumann et al.

1044 Ó 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 28(5), 1040±1045

the future unfolds, it will probably be less advantageous to

narrowly de®ne the scope of practice, as is the case today

for most health disciplines' (MacLeod 1994 p. 46).

Acknowledgements

The authors would like to acknowledge the assistance of

Dr Stuart MacLeod, Professor of Clinical Epidemiology

and Biostatistics at McMaster University, in the editing of

the original manuscript as well as Jennifer Mercer RN

BScN for her assistance with the review of the literature.

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Documents

Who cares? Who cures? The ongoing debate in the provision of health care