Archive for category What Nurses Really Want

Doctors Are From Mars, Nurses Are From — Oh, To Hell With It

News flash! From Fierce Medical News, here’s the shocking headline:

Docs, nurses miscommunicate on respect, job role

When you guys pick yourselves off the floor from laughing, here’s the money quote:

In particular, the survey found differing views of how doctors treat nurses. According to 42 percent of nurse leaders, physician abuse or disrespect of nurses was common, whereas only 13 percent of physician leaders said it was common. Fifty-eight percent of nurse leaders considered disrespect for nurses uncommon, while 88 percent of physician leaders said it was uncommon at their healthcare organizations.

“I do believe nurses and physicians are on two different pages when it comes to communication,” Pam Kadlick, vice president of patient care and chief nursing officer for Ohio’s Mercy St. Anne Hospital, said in a HealthLeaders Media article. “Nurses have a tendency to give a very detailed report, more than what a physician may want to hear; hence, the physician may interrupt, seem to be abrupt, even rude at times.”

But most physicians don’t consider such behavior to be disrespectful, she noted.

You’re telling me abuse of nurses is all about physicians being insensitive, maybe, and nurses having too many hurt fee-fees? Really? And nurses are supposed to be surprised that physicians “don’t consider such behavior to be disrespectful?”

Why does this sound like a ’80s sitcom?

Why does this sound like this report is trying to validate abusive physician behaviour?

You can only shake your head. And you just know, somewhere, in a darkened office maybe, in an obscure corner of a mega health care corporation, a manager is reading this report and exclaiming, “I knew nurses were to blame!”

I will very happily concede abusive behaviour of all kinds has declined markedly in my own time as a nurse, though I will say I work in an institution that enforces a zero tolerance policy against abusive behaviour. Moreover, the physicians I work with, shoulder to shoulder, are lovely and professional, and there is a true sense of collaboration. This makes for excellent patient care.

However, by no means is this true everywhere. So let’s not pretend the brow-beating, the mocking, the chart-throwing, the patronizing  — to be blunt, treating nurses like you wouldn’t treat your mother, daughter, wife, bank clerk, Wal-Mart greeter, housekeeper, or dog — still doesn’t go on. Denial will never fix the problem, either from physicians — or nurses.

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The Cure for the Post Below

Shamelessly stolen from Head Nurse who shamelessly stole it from Jezebel.

My question: where can I get some, and how soon can they be delivered?

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Nursing Malaise

Not Nurse Ratched has written compellingly on her blog about the seemingly chronic and unfixable malaise in nursing:

I maintain that currently registered nurses work in an environment perfectly engineered to create and perpetuate anxiety, hostility, and eventually depression. Why do we eat our young? Because we are anxious, hostile, and depressed. Healthcare today is a society of witch-hunting, and someone has to be burned. In all likelihood it will be “the primary nurse.” The primary nurse currently has responsibility for nearly everything, including ensuring physicians are correctly entering computing orders and ensuring that all the electronic pieces of the chart are present and correctly uploading to the main system. We now must double-check ourselves, our aides, our secretaries, and our physicians. If any part of the system goes down, you’re the one responsible. This is in addition to heavy patient loads. Speaking of which: you’re assigned too many patients for safety? Complain, and you’re written up for being a bad team player. Don’t complain and make an error, and you run a real risk of losing your job and/or your license.

She then adds:

I don’t know what can be done about that part of the job. It’s a hard job, we choose it, and we figure out how to cope or we quit and find something else. This other stuff…I can’t give up believing that this bureaucratic terrorism is not a necessary part of the profession. I feebly cry out to my nursing brothers and sisters: what can we do? Is there a solution? Can we not stop the environment of fear?

What’s appallingly obvious about this present malaise NNR describes so vividly that it is nearly always the result of nurses abusing other nurses. This, I think, is the elephant in the room. We can talk at great length about hospital policies, regulatory requirements, the exercise of power in hierarchies, horizontal violence, corporate culture and all the rest and how they negatively affect the quality of nursing work-life. But strip away all that, and you’re left with nurses formulating policy, making decisions and giving direction which adversely and sometimes abusively impact other nurses. In short, we do it to each other, and then we blame some impersonal force, like “the hospital;” for some unfathomable reason, we think that is A-OK.

I’ve argued on this blog before that there is a spurious belief out there that once a nurse becomes management he is somehow exempt from the professional duties and responsibilities which bind all nurses, and hospital policy or the demands of human resources takes precedence over these obligations. This pretense needs to stop: it’s damaging to the profession and it harms patients. Nurse managers who create an unsafe or hostile working environments are responsible in turn for increased patient mortality and morbidity. The evidence is pretty strong for the link between quality of nursing work-life and patient outcomes. By the nursing standards of practice here in Ontario — like most places — abusive behaviour and  harming patients is surely a matter for professional discipline. Do we need to start reporting a manager’s “bureaucratic terrorism” to our respective colleges/state boards of nursing? Maybe it’s time we called them on it. There is clear sense among frontline nurses that we need managerial accountability for poor practice, and evidently hospitals aren’t providing it.

But ultimately (and I speak from personal experience here) the best answer is to speak truth to power, take care of ourselves and our profession, and walk away. Toxic workplaces are beyond the ability of any single nurse to fix, and the clearest (and most financially damaging, for it costs big money to fill a nursing vacancy) message we can send to abusive employers is to vote with our feet.

Nursing is a hard job, physically, intellectually and emotionally challenging. But no nurse signed up for working in an environment of fear and hostility. Coming home from every shift emotionally drained and numb for anxiety is not sustainable, not for patients, not for nurses personally, nor for the profession as a whole.

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Maxims for New Graduates

Courtesy of Will Hardy

Will Hardy over at Drawing on Experience wanted advice for new grads.  My two cents.

Learning never ends.

Learn by doing.

See one, do one, teach one.

Pay attention when a patient complains of imminent death.

Go to codes.

Never pass up the opportunity to see a procedure.

Not everything can be fixed.

Eat.

Pee.

Breathe.

Patients die unexpectedly for reasons unrelated to the quality of your care.

Don’t think you know more than you do. You don’t.

Ask for help.

Ask questions.

More importantly, know when you must ask questions.

If you still don’t understand, ask more questions.

Advocate. For your patients. For your profession. For yourself.

Be skeptical.

Critical thinking is not optional.

Bedbaths are an essential skill, even for RNs.

Chart. Then chart some more.

Read Notes on Nursing.

Walk before running. Basic nursing before Swan-Ganz catheters.

Listen. Carefully. When someone offers you a piece of chewing gum, you’re not thinking your breath stinks, right?

ABCDs.

Wash your hands.

Foley catheters are not a substitute for good nursing.

Housekeepers and ward clerks are your best friends. Treat them as such.

Bring chocolate.

Your most recent assessment is the most important one.

Find a mentor.

Sixth sense counts. Ignore it at your peril.

Five rights. Three checks. Always and forever. No exceptions. Ever. Amen.

If you’re giving more than two of anything — tablets, capsules, vials — you’re giving too much.

If your colleague is drowning, throw her a life ring.

Specialize in a skill. Be the go-to guy for hard IV starts.

Make it your rule: take no shit from anyone.

Feel free to add your own: I’ll make a page for them.

[Update: Will’s cartoon added]

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How Hospitals Punish Nurses for Being Sick

I admit it: I’ve gone to work sick when I should have stayed at home. I’ve gone with hacking coughs, sore throats, Fevers Not Yet Diagnosed, and probable gastroenteritis. I’ve gone in with migraines. Once when I was being treated for an I & D’d abscess, I went in with a saline lok, a kind of intravenous access to give me antibiotics. Should have stayed home, I confess, I know better, but there it is.

So I listened attentively to Brian Goldman’s CBC Radio show White Coat, Black Art this week (you can hear it at the link) on health care professionals coming in to work sick. We do it for reasons perhaps not unique to health care: we don’t want to let down the team, there’s no one to replace us, we’re indispensable. He mentions physicians being expected to show up unless dead or nearly so; nurses, when I was a student at least, were inculcated from our first clinical day that calling in sick was tantamont to being a bad nurse.*

However, the consequences of having sick health care professionals are, of course, unique: we tend to infect patients who are already compromised. As bad, or worse, we compromise our judgement: who can think clearly with a temperature of 39.8C, or while having to run to the toilet every ten minutes? Goldman suggests that a massive culture change in hospitals is necessary to let health care workers take sick days as needed. I agree. But it’s not going to happen any time in the near future: hospital administration itself is the biggest obstacle. There are clear choices in creating a culture that gives permission for nurses in particular to take sick time. I don’t believe hospitals have the will to make that cultural shift.

Let me explain: the problem of sick nurses, other health professionals and ancillary staff coming to work — I’m leaving out physicians, because in Ontario hospitals, they aren’t subject to the same scrutiny as nurses — highlights an internal conflict within hospital administration. In an ideal world, Infection Control in all hospitals would dearly like nurses and the rest to stay home if they’re sick. Patient safety, after all comes first. In the real world, however, hospital Human Resources departments do not consider infection control as a priority. Human Resources views sick time as a controllable cost, and frankly, sick nurses a problem to be managed.

It’s true in general that nurses take higher than average rates of sick time. The reasons for this are complex: we are, after all, exposed to infection on a daily basis, the nature of our work is highly stressful (which in of itself has health consequences), and sick time is an indicator of nursing morale which in many hospitals is quite poor. The job of human resources is to provide strong disincentives to nurses (and others) calling in sick. They d0 this in a couple of ways. In Ontario, hospitals cut sick pay for nurses by up to a third, depending on seniority. If you’re a sole-wage earner living paycheque to paycheque, it’s a substantial amount. Pragmatically speaking, if it’s between feeding your kids, and coming in sick, even if you are a conscientious nurse, guess which will win.

Further, nurses must cope with attendance management programs. In Ontario, and I know this is true in many American hospitals, nurses are subject to punishment if they take as few as three sick days, and made (with union acquiescence) to attend humiliating, disciplinary “attendance-management” meetings. For their part, hospital management and the union — the Ontario Nurses Association — will vehemently deny the attendance management process is disciplinary in nature. Personally, I have never been subject to attendance management. But I have seen nurses leave these meetings distressed to the point of tears, and I know of one nurse who left her position and the hospital because of Human Resource harassment. It’s discipline by other means and it’s a strong deterrent to taking sick leave. I’ve come in sick myself knowing I was close to the threshold of being put on “The Program.”

A conversation I had a few months ago with the Infection Control Nurse illustrates quite nicely this tension between the conflicting goals of Infection Control and Human Resources. The context was a mini-outbreak of gastroenteritis; three nurses were off sick. The Infection Control Nurse got wind of this outbreak, and wanted to ensure the nurses stayed home for 48 hours after the last symptoms, as per hospital policy. She wanted names, which I refused because of confidentiality.  She then wanted me to call the nurses. I refused again. I knew at least one of them was already in some difficulty with the attendance management program, and I was unsure about the rest.

“Well,” she said. “Let me call them.”

No, I said. I explained to her how Human Resources will punish the nurses for following hospital policy.

“Oh,” she said. “That’s a human resources issue, not an infection control issue.”

Actually, I thought, if you have an otherwise diligent, handwashing-fanatical nurse like me resisting infection control directives, human resource policy is an infection control issue.

In the end, hospitals must choose between trying (and mostly, I think, failing) to control sick time costs and making infection control truly a priority. It’s no good telling nurses to stay home if they are sick, only to turn around and punishing them for fulfilling what is really a professional obligation. Half-measures, like telling nurses to mask for their 12-hour shift, or to be “extra-diligent” in handwashing are impossible to enforce. Maybe some innovation is needed on how we look at sick time. One U.S. hospital I know of recognizes only 2-3% of employees abuse sick time, and assigns twelve days a year for “personal use,” no questions asked, after which HR begins to apply the screws. Nurses who leave part or all the personal days untouched get a payout of three of those days on a pro-rated basis. A change like that would indeed entail a massive culture shift. Present practice does not truly address infection control issues raised by health care professionals working sick, and sends conflicting messages to nurses. Either infection control is a priority for hospitals, or it isn’t. Which is it?

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*I’d be interested hearing from new grads whether this is still true.

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Those Crockpot Blues

Today I am not going to delve into any heavy-heavy nursing issues, or talk about cholera (though you may see an update later). There is only so much this nurse can give, and my brain is tired. Instead, I am going to rant about a crockpot. The one we bought a couple of weeks ago.

It’s a Hamilton Beach Model # 33723C. Why, o why, you might ask, did buy a crockpot, the curse of church suppers and mid-week dinners? Well, because, frying eggs taxes Mister Man’s culinary skills, I loathe having to cook after getting home from a busy day of playing charge-nursey, and yes, I am cursed by the occasional church supper.

We didn’t intend to buy it. We were at Zellers. For my American readers Zellers is a low-rent department store that really wants to be the Canadian version of Target but usually ends up looking like a slightly tacky Walmart. Anyway, we had to get something at Zellers — some fancy lightbulb evidently something exclusively available at Zellers — and when we went through the check-out the girl there said “You have enough Club Z points for sixty dollar gift certificate!” (It took us twenty years of shopping to accumulate enough points, incidentally.) Oddly, just that morning I had said to the husband, “We should by a crockpot.” Some things are meant to be.

Anyway, it’s not goumet cooking, but I am reasonably satisfied with it. Stew and soup and such are credible. It makes a tolerable bœuf à la bourguignonne, believe it not. Pot roast not so much, or maybe I’m not doing it right: it’s strangely flavourless. Midweek stew and church potlucks, that about sums it up.

None of which is the real reason for this post. The point is that after two weeks of using the crockpot maybe five times, the little writing on the temperature control dial, which tells me “High”, “Low”, “Warm”, and “Off” have worn off completely. It’s not like I’m using some weird concoction of bleach, ammonia and oven cleaner to wipe the thing down. Yet the happy sticker on the side, which tells me I have bought a lovely Hamilton Beach Crockpot with Travel Case in the event I forget, remains stubbornly stuck on despite repeated assaults. It’s not that I need to know where “High” is. It’s the principal of the thing. Why should something which I paid fifty bucks for develop a defect after two weeks?  So yesterday, I emailed the company:

The defective crockpot. Note the sticker on the side.

About two weeks ago I bought a crockpot at Zellers, the fancy one with the travel case. I am very pleased with it, except, the markings on the temperature dial have already worn of. Ironically, I cannot get the promotional sticker on the side of the pot off. Can you please send me another dial, and instructions how to replace it? Also, how do I remove the sticker?

Thanks
[redacted]

I have not received a reply, perhaps because of my faintly sarcastic tone. (I am constitutional unable to write to anyone in authority without being faintly or obviously sarcastic.) But then I remembered something about the concept of “quality control.” Most people believe “quality control” means making something the best way possible. It actually means making something to the cheapest, most minimal quality standard possible that will sell to an ignorant and apathetic public. Hamilton Beach obviously strongly believes in quality control. The company also knows it can save ten cents a unit on dial labelling because few people will complain about such a triviality, and if they do bitch, they can be safely ignored, because we won’t do anything about it. (Customer service essentially has the same definition as quality control. Bell Canada has elevated customer service to an art, for example.)

So I feel cheap and used. By a corporation. I know, take a number, and stand in line.

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Being a Naive Nurse Will Get You Thrown to the Wolves

In matters related to practice, errors, or sentinel events, are nurses far too naïve when it comes to dealing with their employers, regulatory bodies, or police? Nurses falsely assume that all of these authorities will act in, or at least be mindful of, their best interests. The thought that any of them might act solely in their own self-interest (at best) or in bad faith (at worst), is probably beyond most of us. The fact is none of them have a nurse’s interest as their top priority, if in fact they consider it all. Aside from a duty to ensure patient safety, hospitals have a legal, fiduciary obligation to protect themselves from liability issues and legal action. Regulatory bodies act in the public interest. Police decide if behaviour is criminal and lay charges. We should not be shocked (but often are) when any of these lie, manipulate or misrepresent themselves to gain a nurse’s trust and coöperation in order to pursue their own agenda. Woe to the nurse who trusts authority to do right by them!

I’ve written about the Winkler nurses, where this seems the case, and about Brian Sinclair’s death in a Winnipeg emergency department waiting room; here I fear the police will use information obtained from the triage nurses in the original investigation against those same nurses, information incidentally given in good faith that no charges were pending. Or think about what happened to Gita Proudman, who was unjustly charged with killing a dying infant in 1998. The charges were withdrawn over a year later.

Or consider this case, in which  an employer and police  have accused two nurses of deliberately cutting umbilical catheters, a type of intravenous used on newborns:

Two Sunrise Children’s Hospital nurses whose licenses were suspended because of disrupted catheters — which left one newborn in critical condition — are targets of a Las Vegas police investigation into “intentional patient harm,” State Board of Nursing records reveal.

Another infant had to undergo an emergency procedure as a result of a catheter disruption, the hospital reported.

Registered nurses Jessica May Rice and Sharon Ochoa-Reyes were suspended by nursing board President Doreen Begley “in the interest of public health, safety and/or welfare” after the regulatory agency received notice on June 10 from law enforcement officials that each nurse was a “person of interest” in an “ongoing criminal investigation,” according to documents obtained Tuesday under the Nevada public records law.

[snip]

Katherine Ramsland, a criminologist at DeSales University in Pennsylvania who has long studied health care workers who run afoul of the law, said Sunrise officials now must study incidents and deaths in the neonatal unit “over many months and perhaps years.”

Sunrise officials would not say how many infants had what medical officials term “unexpected outcomes” when Rice or Ochoa-Reyes was on duty in the neonatal unit.

Ramsland said nurses who do harm to patients are very good at covering up what they do. “Often they’re not caught for years,” she said.

Nurses who harm patients are known as “Angels of Death” because after they are caught they say they were putting patients out of their misery.

Angels of death?* Seems straight-forward, doesn’t it? But some salient points in this case: the nurses had complained to the hospital in good faith about problems with the umbilical catheters; the hospital ignored their complaints until infants began to suffer complications from the catheters, when they fired the nurses and called the police to investigate; the hospital in fact knew about problems with the catheters, but was dilatory in addressing the issue; the hospital refused to consider testing the catheters for product failure, but chose instead to have a “forensic analysis” attempt to prove the lines were intentionally cut to build a case against the nurses; the hospital contacted the manufacturers about potential problems, yet refused to disclose the email communications with the manufacturer; problems with the lines ended when the hospital changed manufacturers; and the Food and Drug Administration had issued advisories about the problem previously. Significantly, after initially pulling the nurse’s licences, the Nevada State Board of Nursing reinstated them in September, citing a complete lack of evidence of negligence or wrong doing. The police investigation, unfortunately, is continuing.

Read carefully what the nurses have to say about this nightmare:

Both nurses now say they realize they were naïve in dealing with authorities. Both agreed to police interviews and polygraphs because they said they had nothing to hide.

But in separate interviews with police, each said a detective ended up yelling that she enjoyed killing babies.

“I couldn’t believe what I was hearing,” Ochoa-Reyes said. “I told them over and over I would never do such a thing.”

Rice said she listened to a police detective rant and rave about her being a baby killer for four hours.

Finally, she said, the detective told her to leave when she kept repeating that she would never hurt a child. [Emphasis mine.]

Let me return to Gina Proudman for a moment, who wrote about her experience for the Registered Nurses Association of Ontario:

[I] am the nurse who had that charge against her withdrawn on November 9,1999. I had held a dying baby, who had no one there to hold him, and he died in my arms. I was naïve. When the police wanted me to answer a few questions, I said of course, I had nothing to hide. For that same reason, I did not take a lawyer with me.

Needless to say, that was a serious error in judgement. That particular piece of naiveté resulted in a charge of second degree murder, complete with a nine-day period of time spent in a segregated cell.

*****     *****     *****

What did I do wrong? My first, and biggest, mistake, was not getting a lawyer immediately. When the situation was presented to me by management, I knew it was serious, but I felt that since I was not guilty of anything, I did not need a lawyer. I felt that obtaining one would make me appear guilty (a view that was reinforced by the police when I made mention of possibly bringing an attorney). Wrong. If anyone needs a lawyer, it is an innocent person. You need someone to discuss with you whether or not you will give a statement to police, and if you will, what the content of that statement will be.

Do not give a statement without having discussed it with a lawyer first. The innocent can be easily manipulated because of a desire to clear their name. There is a strong belief that the police and people in authority really are seeking the truth. As I discovered, this is not always the case, and one has to protect oneself immediately. [Emphasis mine.]

You see the common theme. We trust too much. The lawyer of Sharon Ochoa-Reyes is fairly clear the hospital is trying to scapegoat the nurses for avoiding, and then covering up a known problem with a medical device, in order to escape their own liability. Did the hospital act in bad faith towards its nurses? From my particular perch, it looks like it. Here lies a lesson for all nurses: ultimately, your employer will only ever act in its own interest. And ditto for regulatory bodies and the police.

Nurses are sometimes deceived by the perception of commonality, that employers and the rest always have our best interests — our professional lives or even the care and safety of our patients — at heart. It isn’t true, and all nurses need to develop a high degree of skepticism and critical evaluation to navigate a minefield of competing and conflicting goals and agendas. It’s important to remember why nurses are frequently thrown to the wolves: we’re relatively small fish in the hospital food chain, we tend act passively, even when accused of negligence and malfeasance, and we are too deferent to authority. When bitten we tend not to bite back. We scarcely even bark. This must change, and I think it is changing as nurses clearly and forcefully advocate for their profession and for themselves.

However, to some degree we can also take practical measures to protect ourselves. Clear, accurate and timely documentation and charting is essential (and obvious) for nurses to protect themselves, and is something none of ever give priority to. But we never think to take notes, even immediately afterwards, when meeting with a manager or some other administrator, or documenting for our own records concerns about practice or equipment. Membership in a professional organization is essential, especially if like the RNAO they offer a degree of legal advice. Don’t hesitate to enlist your union to back you, or if the police or a regulatory body comes to investigate, a lawyer. In short, nurses must always aggressively defend themselves, because in the end, no one else will.

[Many thanks to the ever diligent Vernon Dutton (TwitterFlickr) for pointing out the Nevada cases to me. His take can be found here.]

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*Nurse stereotyping at its best. The expert here also has an abiding interest in ghosts.

[UPDATE: some minor wording changes for clarity.]

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Framing the Discussion Around What’s Best for the Patient

There’s been some discussion around here and in other places about what nurses ought to do when they disagree with the physician. The general consensus among nurses, is that we are professional obligated to advocate — even aggressively — for the best possible care and treatment for our patients. Theresa Brown’s recent article in the New York Times about her own conflicts with physicians articulates this point of view well. But what to do when that discussion fails, as it often does? The traditional answer, as all good nurses were taught in school, is to advocate up the food chain, either on the nursing side or the medical side. But sometimes this is not an effective approach nor is it realistic. Nurses are constrained by power structures and institutional culture which devalue the opinion of the front-line — a chief of medicine once told me three nurses witnessing a physician error was insufficient for him to do anything about it, because the physician herself denied the error — or perhaps managerial indifference; there are constraints of time (the problem must be dealt with immediately) or timing (going up the food chain in the middle of the night is difficult). The system, in general, can make it difficult for nurses’ voices to be heard.

So when all attempts fail at persuasion, we resort to other tactics and stratagems . Some nurses, like Maha at Call Bells Make Me Nervous, exceed their scope of practice and put their licences at risk trying to do right by the patient. Another example: we have all heard of nurses who will give a “generous” 5 mg dose of morphine (or whatever) if the patient has insufficient pain control, rather than fight the physician to up the amount. Or you can be like me, the crusty old charge nurse who gets tired of confronting physicians, and does end-runs to get desired results. Trust me, it’s tiresome and demoralizing for us to act this, and in the end, it’s bad for nurses and nursing.

Nurses, being nurses, tend to put the blame squarely on the physicians for not listening or for failing to engage in more collaborative practice. I am not sure this is completely fair. To be sure, some physicians will insist that theirs is the absolute final word when it comes to patient care, which is patently false theoretically, and impossible in practice; I’ve had more than one physician insist I was practising nursing “under his licence” and should therefore shut up. However, it is equally true these physicians are a small minority. And I will say, I have worked with many physicians, even in the emergency department setting, who represent the ideal in collaborative practice, who will discuss treatment plans in a manner in which nursing input and perspective is essential for good patient outcomes.

Obviously, the key here is good communication, and if we’re going to be honest — and I’m as guilty of this as anyone — nurses don’t communicate their concerns as well as we might. We can be adversarial, blaming, or judgemental, or worse, passive aggressive. We tend to forget that we possess a unique body of knowledge related to nursing and to our patients. This should empower us greatly, to advocate effectively, but often it doesn’t.

I want to back up a bit to the point where the nurse disagrees with the physician about the treatment plan, and bring in a recent interview in the New York Times with Dr. Peter Pronovost, the medical director of the Quality and Safety Research Group at Johns Hopkins Hospital in Baltimore. He speaks about flattening hierarchy and egos to maintain good patient care, about creating an institutional culture where patient safety is paramount and where management empowers and (more importantly) tangibly supports nurses to speak up. “In every hospital,” he says, “patients die because of hierarchy. The way doctors are trained, the experiential domain is seen as threatening and unimportant.”

He spoke about a situation where he knew a patient was going into anaphylaxis  from a latex allergy, and having to confront the surgeon (even physicians have this problem!) to get him to remove his latex gloves:

“I said to the surgeon, “I think this is a latex allergy, please go change your gloves.” “It’s not!” he insisted, refusing. So I said, “Help me understand how you’re seeing this. If I’m wrong, all I am is wrong. But if you’re wrong, you’ll kill the patient.”

This, I think, is exactly the way to approach it. Show me how I’m wrong, because if I’m wrong, than all I am is wrong,and I hope so, because being right about this may harm the patient. Suddenly it isn’t about externalities. It isn’t about nursing judgement, or physician qualifications or ego. All of that is off the table. It’s about patient safety and about providing the best possible care.  The next time I disagree with a physician, I promise to ask this: when disagreeing with physicians, nurses must be prepared to be wrong in order to best advocate for their patients. But then, so must physicians.

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Being a Nurse Sometimes Means Disagreeing with the Physician. Loudly.

I don’t often devote a single blog post to pointing out another blog post at another blog, but here’s an exception: an enormously thought provoking article by Theresa Brown RN on the New York Times Well blog. Money quote:

Obviously, doctors and nurses have different roles in the hospital. Our training is different, and so are our responsibilities. It’s also true that patients choose their doctor and only end up with a particular nurse through the luck of the draw. But when a doctor and a nurse disagree over patient care, should the doctor always prevail?

Many of the nurses I know could share their own, dramatic stories of rescuing patients or catching frightening errors by other health care workers, including doctors. In fact, the same day the doctor cornered me at the nursing station, I had caught a potentially risky medication prescribing error by a doctor in training. I took my care question to a clinical pharmacist and the attending physician to insure that my patient was given the right treatment. Nurses don’t have the power to make certain types of care decisions, but they do have the power -– and the responsibility — to go up the ladder until they are satisfied that good decisions are being made.

[snip]

So is the doctor-patient relationship really more sacrosanct than the nurse-patient relationship? I don’t think so. Physicians have the ultimate responsibility for treatment decisions, but because nurses spend so much more time with hospital patients than doctors do, we have a unique view of how the patient is really doing. And at times, patients present very different faces to nurses and to doctors — complaining to a nurse in a way they never would to a doctor.

Thank you, and amen. In a way, this represents the core — and ideal — of intentional, thoughtful nursing practice. And as always, the comments following the post are enlightening and revealing; the condescension, misinformation and hostility contained therein are remarkable.

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Some Thoughts on “Independent” Nursing Practice

Over at Nurse Story, Terri Schmitt poses a question:

Being the rabblerousing heretical feminist that I am, I have always sought to think of nursing as part of the medical ‘team’ where all professionals provide input to build the best care of the patient. I am beginning to wonder if my pie-in-the sky view and push to have nurses see themselves as independent professionals with a unique body of knowledge is accurate?

In one of the health systems that I interface with nurses can no longer document that they held a patient’s medications based on ‘nursing judgment’. Such an instance might be when a patient had hypotension from pain medication and thus the morning anti-hypertensive is held. Instead, they need an order from a physician to hold such medication. Further, something like ‘Tylenol’ on a patient’s medication record ordered for fever could not be administered by the nurse for a headache if the patient requested it because that would be ‘practicing medicine without a license’.  A nurse cannot order a social services consult, flush a urinary catheter should it become clogged, refer a patient for diabetes education, etc., etc., without an order from the supervising physician. Although we have been trained to recognize these things, we carry an independent license, sit for an examination to obtain that license, and have had years of education. Perhaps nurses really cannot do any of these things without a supervising physician to tell them?

Physicians, are critical components of the health care team there is no doubt, but why send a nurse to school and give him/her an independent license, scope of practice, and make them answerable to a board of nursing but then limit their usefulness? [emphasis mine]

It’s a good question and one I have pondered a lot, usually in the context of finding a work-around for physician obtuseness, or contemplating some idiocy from hospital administration.

First thought: sometimes pie-in-the-sky lets us think about possibilities, rather than limitations.

Next thought: the quick and easy answer is that nursing usefulness depends on where and how you practice. Institutional culture counts for much, especially when hospital administrators view nurses as a human resource problem to be “managed” and not professionals capable of independent judgement. (I suspect the institution mentioned by Terri has a particularly authoritarian workplace culture.) In most hospitals in Ontario, there are medical directives in place: formal documents which let nurses, using nursing judgement, to perform acts traditionally reserved to physicians. So in the Emergency Department, I can order x-rays and blood tests, give medications, defibrillate and so on, all without a physician order. Jurisdiction is important. In Ontario, for example, a nurse would be disciplined by the College of Nurses of Ontario, our professional regulatory body, for not holding that anti-hypertensive — and I don’t think I have ever asked for physician approval to flush a catheter, or to refer a patient to social work, diabetes education or home care. We can pronounce death, write DNR orders, and in certain circumstances, even start IVs without a physician order.

So well and good. The long and complicated answer: there is a dichotomy between the expectations of nursing as professionals and actual practice; it comes down to whether nurses are professionals in the same sense that physicians (among many others) are. I’m sceptical. In this case the word  “professional” conjures words like “independent judgement” and “autonomy”. It is somewhat difficult to imagine, except in some limited and particular circumstances, where nurses actually engage in independent judgement, decision-making and autonomy in the same way as physicians. We defer not only to physician orders, directives and judgement (which often see fit to determine and define practices clearly within the expertise of nurses), but also hospital policies and procedures and government regulation of our competencies. And as I have often argued, nurses do it to themselves. The culture of nursing hinders. We are resistant to change; we acquiesce all to readily to “superior judgement”; we don’t question why physicians and (increasingly) other health care professionals can write “orders”, and nurses can’t; we often refuse to learn new skill sets that would enhance our practice; we don’t push the envelope. All in all, it’s a picture where nurses are theoretically are professionals in the fullest sense, but practically we fall somewhat below the mark.

Last thought. I will speak the ultimate heresy: is it possible that the push for nurse practitioners as “advanced practitioners” was in the end damaging for the nursing profession as a whole? It consumed the energies of nurses’ associations for decades, lobbying governments and bureaucrats — and continues to do so —  so instead of arguing for advancing competencies and standards for all nurses, we focused on the independent practice and judgement of the few. The rest of us were left behind, even as other allied health professionals with comparable levels of education were granted authority to perform acts traditionally reserved for physicians. Was it worth it? Some days I am not sure. Terri mentions the difficulty and constraints in establishing nurse-led diabetic foot clinics — an area well within nursing scope of practice. Lobbying for nurses to do this sort of service independently — and there are plenty of other examples — and without direct physician supervision (which really represents a sort of unnecessary duplication) might have been more useful for both the profession and our patients.

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