Posts Tagged Patient

Fat Nurses Need Not Apply

A Texas hospital has declared war on the scourge of obese nurses:

A Victoria [Texas]  hospital already embroiled in a discrimination lawsuit filed by doctors of Indian descent has instituted a highly unusual hiring policy: It bans job applicants from employment for being too overweight. 

The Citizens Medical Center policy, instituted a little more than a year ago, requires potential employees to have a body mass index of less than 35 — which is 210 pounds for someone who is 5-foot-5, and 245 pounds for someone who is 5-foot-10. It states that an employee’s physique “should fit with a representational image or specific mental projection of the job of a healthcare professional,” including an appearance “free from distraction” for hospital patients.

“The majority of our patients are over 65, and they have expectations that cannot be ignored in terms of personal appearance,” hospital chief executive David Brown said in an interview. “We have the ability as an employer to characterize our process and to have a policy that says what’s best for our business and for our patients.”

It all sounds so, well, high-schoolish, and I don’t think the CEO is seventeen, though he’s acting like it. I mean, can you get any more shallow? Since when does physical appearance have anything to do with competence or worth or dignity of any health care professional?

Or maybe David Brown doesn’t really believe nurses actually have skills — we just stand around as decoration, lookin’ pretty.

And fitting the  “representational image” of hospital employees to meet patient “expectations?” What the hell does that mean, anyway? If  patients expect this (and this is a pretty common “representation”)

A representational image of a nurse

then hiring practices should make sure all nurses are boobalicious? What if the patients want all-white nurses? Or all females? Or no Muslims?

The man is a bit of a dink, obviously. I can only imagine how valued overweight nurses employed by this hospital must feel.

The article goes on to note that this David Brown, CEO of Citizens Medical Center, has some issues. In 2007  he wrote memo about some foreign-born physicians in which he  stated: “I feel a sense of disgust but am more concerned with what this means to the future of the hospital as more of our Middle-Eastern-born physicians demand leadership roles and demand influence.”  He continued, “It will change the entire complexion of the hospital and create a level of fear among our employees.”

Needless to say, there is a discrimination lawsuit over that.

So let’s summarize what the leadership at Citizens Medical Center believes: scary scary fat nurses scaring patients. Scary scary dark-skinned physicians scaring employees and patients.

Clearly a place where I would want to work. Or be treated.

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10 Questions for Banner Health

Lo, a Tweet from Banner Health on the Amanda Trujillo incident, and possibly the most content-free in the history of Twitter:

Uh, huh. “Listening” and “hearing” rather imply, in this context, some sort of follow-up action (though I think Banner Health SM guru is advising the appearance of action, rather than any actual action, to fool the rubes, i.e. us.)

Given that for reasons of confidentiality employee matters won’t be discussed, there are still plenty of things Banner Health might talk about.

To wit, ten questions for Banner Health:

1. Does Banner Health have a written zero tolerance policy against abusive behaviour? If so, who deals with complaints? Does the policy apply to physicians and managers? If so, how are they disciplined?

2. What steps is Banner Health taking to ensure patients are fully informed of their treatment options at all times?

3. What steps is Banner Health taking to clarify the process for ordering team consults?

4. Does Banner Health have a stepped or graduated disciplinary process? 

5. Under what circumstances may an employee be fired pre-emptively? For example, for med errors? For abusive behaviour? For theft?

6. In what ways specifically does Banner Health support nurses to act as patient advocates?

7. What is Banner Health’s understanding of collaborative practice?

8. Under what circumstances may a physician override the concerns of a nurse? Of a patient?

9. How much training do managers receive annually on nursing ethics and practice?

10. Is it written policy to refer nurses to the state board of nursing for any violations of hospital policy? Under what circumstances is that decision made? 

Awaiting a response.

 

 

 

 

 

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Bedside Nursing as Menial and Demeaning

Ian Miller, blogging over at ImpactedNurse.com, notes a disturbing trend in Australia, one, I’m afraid, is becoming more common in North America. “These days,” he writes, “being a nurse is tough. Really tough.”

I look around and see many struggling at the bedside. I see the increasing perception that this is menial or bottom-of-the-professional-foodchain work.

I see more and more of this sort of feeling online.

[SNIP]

What our brightest and best nurses should be doing instead of creating a culture of escaping the bedside or doing time at the bedside is acknowledging that it is the nurse providing direct care to the patient or client that is the absolute most important domain of our increasingly diversifying profession.

Nurses do not really want to be business entrepreneurs, unless they have no other choice. They want to be nurses.

I would even argue that if you are not regularly within arms reach of your patient/client you are not nursing. And if you have not done this for a long time you are not really a nurse. You are something else. Strong stuff1 I know.

The bedside nurse should be re-valuing themselves not re-inventing themselves.

Miller’s solution is “8 in 8,” i.e. having non-bedside nurses work an 8 hour shift every 8 weeks at the bedside as a condition of their registration. This is an idea I like the more I think about it. However, it would be complicated to implement, not the least because of resistance from said non-bedside nurses — and can you see all those functionaries from nursing regulatory agencies or upper management pulling on scrubs and Crocs and tending to stool incontinence and urinary drainage bags?

Hmmm. Maybe not.

But Miller’s premise, that bedside nursing itself is demeaned and devalued to the point where many of us — including myself — are plotting our escape to greener pastures is sadly true. But why? The reasons for this are pretty simple. Despite years of education and rhetoric, nurses aren’t really permitted to practice to the full scope of our knowledge. We all have heard managers speak of their time at the bedside like it was a prison sentence. Television shows like Grey’s Anatomy tell us bedside nurses are stupid. We know that hospitals view nursing not as a valued added service, but as an expensive cost centre, and that Human Resources thinks of nurses as a “problem” to be managed, like the kitchen guys who make the salads, not as practising professionals.

To be clear, we menialize ourselves as well, when we view nursing as a job rather than a profession, or when we see nursing as a series of tasks to be completed before shift change, rather than a process requiring frequent periods of critical thinking.

It’s all pretty overwhelming, and though I will publicly stand up for the value of bedside nursing, and argue strenuously to its central importance in health care, there are times when even I have a little shadow of doubt.

So really I’m not very surprised if nurses of all ranks and positions view the bedside as menial and demeaning. If people around you all day tell you you’re worthless and menial, and if you view what you do as being more or less thankless and trivial, pretty soon you’re going to believe you are worthless and menial — and so is your professional practice.

I would like to tell you my own motives for escaping the bedside are pure, but when I seriously reflected about it, I realized some of my reasons for wanting to leave had much to do with decent hours and status. And something else:  the ability to act autonomously and effect change in a real way.

In other words, it’s all about power, and this explains why bedside nurses are so demeaned and devalued and want to escape.

Because we have none. Or think we do.

(I would argue front line nurses have far more power to shape their practice and workplace culture than they realize, but we all have been indoctrinated since the first day of nursing school never to question their place in the food chain and to always ask permission. And I’m not speaking about “making a difference in patient’s lives” — a phrase which has always struck me as infantile and meaningless. But this is a subject of a whole other post.)

 

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On Allegations of Patient Abuse at St. Joseph’s

This story concerning alleged abuse of a senior at St. Joseph’s Health Care Centre (and yes, I know “alleged” is a weasel word) has been making the rounds in the Toronto media, including some blaring front pages in the Toronto Sun:

Ron Meredith claims two burly security guards at a west-end hospital manhandled him, dragged him to an empty room and shackled him to a bed like an animal.
The frail 79-year-old alleges he lay there unattended at St. Joseph’s — forced to wear a diaper — for seven hours until he was discovered by cleaning staff.
His only crime, he claims, is that he was sitting in a chair waiting patiently to be discharged.
“What they did to me was unbelievable,” Meredith said Monday, still in shock and covered in bruises two days after his ordeal.

Woken up by a noisy patient in the next bed, Meredith got dressed, went for coffee, and believing his discharge was imiment, sat down by the nurses station to wait. Unfortunately, the situation escalated.

He claims two security guards, “big guys,” approached shortly before 7 a.m.
“They accused me of trying to escape and told me to go back to my room,” Meredith recalled.
The senior explained he was waiting to be discharged but the guards again ordered him back to his room.
“I told them I was already dressed and I didn’t feel it was necessary to go back.”
After a third warning, he says the situation turned ugly.
“All of a sudden they pounced on me,” Meredith claims.
Both guards allegedly pulled him out of the chair, pinned his arms behind his back in a painful position and dragged him down the hall to an empty room.
“They threw me on the bed and I hurt my back on one of the rails,” Meredith said, adding the guards then cuffed his wrists and ankles to the bed.
“They really did a job on me,” he said. “And when that diaper was put on me I knew I was in for a long haul.”

Ugh. Nasty story. The thing is, as an old RN, I can immediately see suggestions there is much more to this story than meets the eye. The bruises, for example, on this poor patient’s arms are clearly old and related to IV starts or blood draws; they are particularly common in patients taking anticoagulants, which I strongly suspect this patient is on. They weren’t caused, in any case, by undue restraint. Further, one wonders if this patient refused a reasonable request to return to his room and wait for discharge; the patient then became increasingly angry and frustrated, and matters escalated from there.

On the other hand, as an old RN, I can clearly (and distressingly) understand how this story is completely plausible. Poor (or no) communication from the nurses on the inpatient unit to the patient and family on the care plan. Overreaction and assumptions made on the part of the nursing  staff. Stereotyping of the elderly as always confused and/or demented. Overuse of restraints. Underlying view of nurses that patients must be under control at all times. (Hospitals aren’t prisons!) Et cetera.

The point  is that there isn’t enough information to make an informed judgement one way or another, accusations made by the media notwithstanding. The problem is when health care horror stories — a favourite Canadian meme — appear in the press, it’s always a one-sided conversation. When hospital spokespeople say they cannot discuss the issue because of patient confidentiality, they aren’t being obfuscatory. Hospital administrators aren’t perpetuating a cover-up  By law, hospitals absolutely cannot make public patient information. This is to protect patients themselves. I mean, do you want information about you bum boil perianal abscess publicized?

The interesting thing for me is that the story, and how it is being played out in the media, suggests the public has a fundamental lack of trust in hospitals/health care and their ability to address complaints, and especially serious complaints like this one. This is precisely because there is a legislatively mandated lack of transparency. It’s not like hospitals want to treat patients shabbily, or think unethically (and possibly illegally) restraining patients is best practice, or don’t approach patient complaints with the necessary due weight. From experience, I can verify hospitals take all sentinel events extremely seriously, because we are, after all, in the business of making people better. I have no doubt that multiple various administrators at St. Joe’s are addressing the issue as I write. In short, time is needed for the appropriate investigations to be made.

I have to think, whatever the outcome, that this whole business was fundamentally a nursing issue. It could have been avoided. Basic Nursing 101: Avoid power struggles.  The nurses should have just let Mr. Meredith sit in his chair. Maybe that’s the ultimate takeaway.

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Observations and Assessments

Notions to small for a blog post, all in one place.

You need to take your pain medication. Once upon a time, TorontoEmerg had some fairly significant surgery on a major joint. It was (theoretically) exceeding painful, but fortunately TorontoEmerg’s orthopod was very generous in supplying TorontoEmerg with Percocets and Tylenol 3s, and thusly TorontoEmerge experienced very little pain. Even when going to (really) painful physio, TorontoEmerg was kept more-or-less comfortable and at the end had a full recovery —- all because of adequate pain control.

TorontoEmerg was an RN, and knew how to take pain medication effectively.

So when five patients show up at Triage in one with poor pain control post operatively, even with adequate analgesia prescribed, TorontoEmerg begins to think some surgical nurses know squat about pain control and/or failing to teach adequately about analgesia when discharging patients. It isn’t about throwing a script for some opioid at patients and telling them to take the med “when the pain is really bad.” Is there is some deficit in our training which makes us reluctant to counsel patients on pain control?

You need to take your stool softener. Same topic. Different angle. I had several patients come to Triage yesterday for constipation related to opiate use post-operatively. None of them had any instructions about preventing or addressing what to do about the (inevitable) constipation. Again, why are we screwing up our discharge instructions?

Myth of the Queen Bee. Some research probably pertinent to nurses aspiring to leadership positions.

Drop Me a Postcard. This is kind of cool: internet postcards you can drag and drop to email, Facebook/Twitter messages, which pose some pertinent, challenging, difficult questions. From droppingknowledge.org.

How to deal with difficult colleagues. It seems too simple.

“Please do not let them breed.” Yep.

Size does matter. I thought this story was interesting because it exemplifies the anti-science, anti-intellectual climate we seem to be labouring under. Shorter version: right-wing web sites excoriate supposedly taxpayer-funded study of penis size and gay men’s health as trivial and frivolous, except, as it turns out, the study was not directly funded by the U.S. government and there is in fact an important correlation between sexual health and penis size, which in turn has implications for reducing HIV transmission.

Speaking of bad foodDeep fried butter. Really. Move over cheeseburger-on-a-glazed-doughnut. As Sean says, I’m speechless.

Dumb road signs

 

 

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How Mr. Jones Died

Mr. Jones was 83-years-old when he died. He came to us by ambulance from with shortness of breath beginning a little after lunch. He was from a nursing home; he had the alphabet soup of morbidities: CHF, CVA, NIDDM, CAD, COPD  — topped off by dementia related Parkinson’s.

He had pancreatic cancer, and plainly, he was dying. His advanced directives, outlining the plan for end-of-life care stated no heroic measures, but if he became seriously ill, he was to be transported to the emergency department for evaluation.

The nursing home where he lived did just that. He went through the usual emergency department process — seen, treatment started and referred to the internist for admission — all the while obtunded and gasping for air, despite the high flow oxygen. He  was a tall man, broad-shouldered; he lay restless in the narrow emergency department stretcher, his gnarled feet hanging over the end.

A flood of patients had deluged the hospital. There were no beds upstairs. I talked with Bed Flow and we made Mr. Jones a priority for a bed. But somehow his criteria never met bed availability, and when I came back two days later, he was still in the Observation room — and still no room on the floors. I had Housekeeping look for a regular hospital bed for him. There were already three being used in the department, and the overflow of  admitted patients meant there were none to spare. The Obs room nurses provided comfort measures, did mouth care, applied barrier cream over bony prominences, repositioned every two hours. They did what they could, but in truth, they were not palliative care nurses, a unique speciality unto itself. He never opened his eyes and he died by inches. Mr. Jones finally went three days after admission. His feet were still hanging over the end as we packed him away in the body bag and sent him to the morgue.

For the nurses, who knew what care Mr. Jones deserved, the experience was distressing. For the family, it was devastating, a layer of suffering over grief. For the patient himself, we can only hope he knew little and felt less.

There is absolutely no space in the system for patients like Mr. Jones — elderly, debilitated and often requiring complex amounts of care — to die with dignity. Nursing homes, despite their demographics, are very poorly equipped and frankly don’t have the resources to deal with dying patients. They dislike having dying patients; they will send them to the emergency department even when the advanced directives explicitly state the patient is not to be transported. Emergency departments are similarly not geared for end-of-life care, even though death is something we deal with frequently. We have neither equipment nor expertise; we don’t even have ready access to expertise.

And yet the case of Mr. Jones is not exceptional. How can we ensure people can die comfortably and with dignity? It’s a problem, I think, without at quick fix, but is by no means intractable or even complicated. It means explicitly recognizing that for the majority of cases, the best place to die is not in hospital, but at home or under nursing care in the community, and providing the resources to make it possible. And if such patients must come to ED, giving us the tools to do our jobs properly, so we can provide safe, competent and ethical care. That would be a good start, and a necessary one.

Because all I can think, that might be me one day. Or you.

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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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Want To Be Called a “Dependent Clinger”? This Medical Journal Thinks It’s Okay

I’ve written before how labelling patients — humorously or not — demeans and devalues those look after, and sometimes has consequences harmful to patient and practitioner alike.  Now we have an article in the medical literature which seems to legitimize the practice. Via FiercePracticeManagement:

The debut issue of Neurology: Clinical Practice, launched Nov. 2, takes a deep look at the complexities of difficult interactions between neurologists. Although the neuropsychiatric problems often seen in this specialty may make for more intense situations than might be seen in your practice, the four main types of patient “maladaptive coping styles” identified by the article may ring all too familiar.

Consider whether any of your needy or demanding patients fit into any of these categories and how the following insights might help you respond more effectively:

1. Dependent clingers. Early in the medical relationship, these are the patients who pour on the praise. .

2. The entitled demander. This type of patient likes to tell you what types of tests to order and medications to prescribe–and may threaten legal action if denied. . .

3. The manipulative help-rejecting complainer. This type of patient drags physicians through an endless cycles of help-seeking and help-rejecting. . .

4. The self-destructive denier. This is the patient that knowingly continues behaviors that are dangerous to their health. . .

[The original article can be found here.]

I don’t think this represents an advance in providing patient-centred care. None of us in health care, in the end, treat “maladaptive coping styles” or even disease and certainly, we don’t treat labels: we treat patients, individuals with their own particular, complex histories and needs. Patients don’t need the condescension of being labelled — and being called an “entitled demander” is about as condescending as it gets.

And yes, labelling patients creates its own problems. It allows practitioners to ignore what might be legitimate concerns from patients about their care. Furthermore, I’m pretty sure documenting a patient as a “dependent clinger” or a “manipulative complainer” will not work to a clinician’s advantage if the treatment of the patient is ever called into question. More seriously, labelling causes both nurses and physicians to generalize to the extent of missing valuable pieces of information necessary to treat and provide care, sometimes with catastrophic results. So is it good practice? From my point of view, it’s a fail.

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When is Black Humour Unwise?

If you’re a health care professional, you know black humour. Inculcation starts early. When I was a student working through a med-surg rotation, I cared for a demented patient who was literally bleating like a sheep; my instructor, walking by her room, began to sing “Mary had a little lamb” before throwing a mock-shocked hand to her mouth, and giggling. Later on, younger and idealistic, I was appalled by what I now know is typical cynical emergency department humour. GOMERs* go to ground and GOMERs never die. Elderly patients with conspicuous luggage, dropped off by families unable to cope, have a “positive suitcase sign”. Certain patients get labels, humorous in intent, but not usually in execution. Repeat visitors are called “frequent fliers”, young women (“MIDs” — muffins in distress) and persons wanting narcotics (“DSIs” — drug seeking individuals). Codes and death are in particular subjects of black-toned laughter, as we rustle the body bags and remove the tubes. I’ve heard some remarkably dark humour after the death of children, none of which I can bear to repeat. As nurses and physicians, we’ve all been there. Something unbearably awful happens to a patient, and somebody cracks wise. It’s all wildly inappropriate, horrible, demeaning to us and to the patient. We laugh anyway. Is it unwise? Perhaps.

A few days ago Paul Jones documented his discomfort with black humour:

Recently I heard a physician make a comment that this patient is “a classic case of FTD”.

I as a naive medical student enquired what “FTD” meant?
The physician responded drly, “failure to die”.

This comment left me with a deep sense of discomfort and reminded me of the type of humor I had witnessed many times before in the ER, OR and ICU. Often in the health care profession we are placed under extraordinary amounts of pressure where human lives hang in the balance. Doctors and nurses say things which would horrify the lay public (or even sometimes ourselves in any other context).

I’ve heard the term “FTD” myself in my emergency department. It’s not a term I particularly like, though it has a certain currency with my younger colleagues. Having said that, I know exactly who this FTD patient is. She is the nonverbal, contractured, 80-something from the nursing home down the road, with Alzheimer’s dementia and multiple strokes, who’s come for the fifth time in three months in for aspiration pneumonia/urinary tract infection/blocked PEG tube. She’s the one being kept alive, almost pointlessly, because our professional ethics demand no less. I’ve written elsewhere about black humour. We can talk about how stress, and the peculiar institutional culture of health care agencies fosters gallows comedy in all of us. But I think now there is something more essential happening; the term “Failure to die” provides a real clue. Simply, black humour allows us to maintain a semblance of control, and perhaps more importantly, distance over the seemingly endless, ungovernable suffering of the human beings we treat. Having seen, assessed, and cared for such patients in the multiples of hundreds, I can understand the impulse intimately. And so it goes for all the other instances of black humour. Laughter is insurance against giving up completely.

Black humour can be unwise. Patients and families may overhear us, and misconstrue our words as indifference or callousness. Danger lies when black humour stereotypes and therefore devalues a patient or worse, dehumanizes or even demonizes. It can destroy empathy and distort objectivity. This is how nurses provide poor care, and physicians misdiagnose. The wisdom is having the insight to understand the sources of black humour in our own relative helplessness, and to recognize it, first, as an inevitable part of our practice, and secondly, as having a time and a place. Truthfully, we see ourselves in our patients. We are burdened with the knowledge of what will debilitate, and eventually kill us. We laugh against fear. To that end, perhaps, black humour allows us to remain fully human professionals and to carry on treating and caring for our patients with care and empathy.

__________

*GOMER = Get Out of My Emergency Room, i.e. typically elderly, demented patients with chronic, complex and usually incurable conditions.

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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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