Not Nurse Ratched

I recently wrote a post on what I call spidey sense—otherwise known as nursing intuition. However, I barely touched on the explosive issues that result when nursing intuition conflicts with physician orders, and it’s worth discussion. Two other nurse bloggers have written excellent posts on this lately: Theresa Brown on NYTimes.com, “When the Nurse Disagrees With the Doctor,” and Maha from Call Bells Make Me Nervous, “Going Beyond Scope of Practice.”

Health care would be an easier row to hoe if nurses and physicians all viewed one another as team members, but they simply don’t. Maha’s story is played out all too often, and it’s the patients who suffer. I understand many cases of physicians’ reluctance to give nurses too much autonomy, because we have to order stuff under their names, and when you get down to it that puts them in the position of signing off on something they didn’t want to order or bringing us up on licensure charges. What I don’t understand is when physicians absolutely refuse to order treatment or investigate a condition that is very clearly necessary for patient well-being. I would like to think that no doctor would take out personality conflicts on patients, but I’ve seen it happen. Blissfully, rarely, but I’ve seen it happen, and it made me want to spit nails.

I’ve been a nurse long enough to see major differences between doctors. Some see us nurses as the help, and the help doesn’t get to demonstrate any independent brain activity. That attitude, shockingly, doesn’t make me mad in a defensive kind of way; it makes me mad in a frustration kind of way. We are in a health care crisis, in case they haven’t noticed, and allowing nurses to use our brains and collaborate results in speedier, more efficient, and more appropriate patient care. Not allowing it or actively preventing it makes a bad situation worse. Other doctors seem extremely willing to consider that nurses might know a thing or two and listen to what we say. I’m very lucky at my job because our docs nearly always do, if we make a good case for it. The nurses in my department are usually treated with respect, although I’ve seen some incidents of physicians pretty obviously feeling they needed to put a nurse in her place. Not appropriately by taking him or her aside and discussing it like colleagues, but by some passive-aggressive means. Why, why, why. I lament.

Anyway, we treat the patient, not the disease, and so we have useful information to contribute. Furthermore, we take patient advocacy very seriously. Mess with a nurse’s patient and you’ll find you’ve poked a snake. Maha’s behavior cannot be justified by any Nurse Practice Act, but the same Act probably (they vary by state) does list as part of the profession to advocate for the well-being of the patient. Sometimes you just can’t do that without pushing the envelope. I’ve never gone ahead with an order forbidden by a physician, and I probably never will, but physicians can be written up too. They too have professional standards and codes of ethics. If collegial discussion is off the table, maybe we need to start writing them up. Our patients deserve treatment free of personality conflicts.