Independent judgement may count for squat if the doc doesn’t listen to you. One of my spies in the Ontario health care system tells me the story of a 60ish year-old woman, a known drinker, who came into an Emergency Department with an altered level of consciousness. Ethanol level comes back elevated, so end of story, right?
Unfortunately no. The primary nurse advocates for this patient. She’s seen cerebral bleeds, and she’s seen drunks, and she’s seen bleeds and drunks in the same person, and moreover, she has watched this patient subtly deteriorate for the last three hours. She tells the Emergency Physician, “Hey, this patient isn’t right. Her neuros are whacked. She needs a CT of the head.”
The EP is the sort of doc who, if a nurse said “Feces”, would say “Fudge, and please pass the plate.” He refuses to order the CT, and instructs the primary RN to discharge the patient.
The nurse absolutely refuses. The patient needs a CT, the nurse says.
The EP gets all huffy. Fine, he says. I’ll pull the IV and discharge the patient myself. Take that, you dumb know-nothing nurse!
Of course, you know the sequel. Patient returns a short time later, twenty times worse, coags are screwed, finally gets the CT, which (naturally) shows a cerebral bleed; she’s shipped to a Big Toronto Hospital, and blah, blah, blah — hemorrhagic stroke.
Independent judgement — where a nurse can effectively advocate for their patients — will only work in environments where there is a culture that treats the professional opinion and judgement of nurses (and other health care professionals) as valuable and meaningful in effecting good patient outcomes. Unfortunately, in many health care settings (the majority?), such as perhaps this Emergency Department, this isn’t the case. The quality of patient care accordingly directly suffers as a result.
I’m also reminded of an article I saw the other day about moral distress — the anxiety and suffering caused by being unable to act upon one’s own ethical values — and the risks it poses to nurses personally and professionally: dissociation, apathy, leaving nursing altogether. I suppose moral distress would include being discounted and minimized, advocacy being at the heart of ethical nursing practice. I wonder if there have been any studies linking patient outcomes specifically with moral distress in nurses, and if not, whether this would be a fruitful topic for investigation.