I began working as an emergency room receptionist in the medical field in 1990, nine years before graduating from nursing school in 1999. My job duties even then were far more than clerical and included much patient care.
In the year and a half I worked in that department, I learned more about medicine, human rights, patients’ responses to loss, and the ambivalent relationships of medical personnel than throughout my entire medical work history and career as a nurse.
Although I later moved on to direct care positions in multiple departments (OB and surgery, Mother/Baby/PP, Med-Surg, Trauma), the emergency room experience was my formal introduction to many foundational aspects of the medical environment, especially regarding the unaddressed conflict in the relationships between the differing roles of providers in medicine.
The main concerning dynamic I observed was that nurses were generally dismissed and disregarded by many physicians, as both professionals and as necessary components in the practise of medicine.
In my experience as a professional, this aspect has still not changed over time and spans throughout all specialties in medicine.
When I became a nurse in the year 2000, I was no longer just the observer of adverse or lack of communication toward nurses from physicians or the frequent poor treatment of physicians toward nurses. I became the receiver of both.
Nursing Expertise Is Still Mostly Misunderstood
Many physicians do not see the nursing staff as an imperative extension of their own care and knowledge. Many are unaware of what most nurses do and how much they know. They do, in fact, just expect their orders to be carried out and quite often neglect to understand the gap that nurses must close from orders of care to implementation of care and then to continued follow-up of care. The latter two skills are what create and sustain patient health and wellness.
Nursing responsibilities, experience and skills remain a neglected and misunderstood facet of healthcare. Most lay people see nurses as the medical personnel carrying out their doctor’s orders, making the necessary calls to patients and hopefully, effectively understanding the medical reasoning and intricacies behind the care and information they are delivering.
However, true nursing goes beyond this.
Learning to regurgitate orders and instructions is not what gets a good nurse through school or what keeps his/her patients alive. Critical thinking, research, and observation while responding appropriately in and to emergent, acute, and chronic situations, listening when no one thinks we are listening, and knowing when the wrong medicine or treatment has been ordered or recommended are.
The doctor will not go to jail if the nurse gives an inaccurately ordered medication, resulting in an adverse event or fatality; it is the nurse.
We are, first and foremost, the buffer between a physician and his patient.
And both patients and physicians need this.
What Effective Nursing Offers To Physicians’ Care of Their Patients
Good nurses listen to their patients and have a knack, not just the training for, for excellent triage. Body language tells more than a patient’s report. Patients’ verbal reports must be delicately and discreetly screened for hidden information that is critical in many cases, to appropriate safe care and orders. Nurses hone in on things not said, or that are mis/underrepresented, which often results in a totally different approach to treatment than at first written.
Nurses’ bedside experience yields a wealth of information and patient history that frequently change the initially documented needs and treatment of the patient’s condition. The following are some common examples: (Note that global and national MyChart EMR records now give access to patient medical information and have greatly improved providers’ knowledge of documented patient information.)
- A patient comes into the emergency room or the clinic reporting a “terrible headache” and is nauseated and dizzy but denies a history of hypertension. Vital signs reveal a dangerously high pressure, but the patient defines themselves as non-hypertensive because they are normally prescribed hypertensive medications, so they consider themselves “cured.” This is a much more common thought process than is understood, especially for elders.
Further nursing triage reveals that the patient is “between” PCPs (very often this is code for the patient’s dislike for their previous one and so they just quit going to visits) and the patient has been out of their medication for two months (due to an inability to cover changing Medicare/other insurance costs). This knowledge prevents the ordering of further hypertensive medications (for perceived acute/undiagnosed episodes) by the ER physician or urgent care clinic doctor which could cause a dangerous drug interaction and/or overdose because the patient is very likely to refill the original medication as well at a later date. This is another common problem among elderly patients, especially. Gaining a full picture of the patient’s circumstances in this situation will also predicate running lab tests which may have not been ordered otherwise or ordered differently. This would offer additional insight to the patient’s current cardiac and renal status/risk in association with current signs and symptoms.
Nursing also contacts the inhouse social worker to assist the patient in funding available to cover the cost of medications and to elicit a list of PCP’s in the immediate area that take patient’s insurance (this is providing SW is as thorough as expected.) Nursing also provides a follow up call a few days after the visit to ensure that patient has had their needs addressed.
2. Patient presents with guarded abdominal pain. Their eyes are dark, their pupils pinpoint, and they are jittery and talking fast. The nurse notices skin irritations and sores and a “slack jaw” appearance in the patient. Many physicians immediately write this patient off as an addict, document “drug-seeking behaviour” as cause for visit and stop there. This has been both my personal and professional experience. Given the patient’s appearance which concurs with heroin/meth addiction, this may be a correct standing diagnosis. However, there is always more to know and investigate. This patient is a human being in need of care and thorough assessment. The pain the patient complains they have often has another root source besides withdrawal. The nurse notices after the doctor leaves the exam room that the patient winces when standing and limps on the right side. An astute nurse will pull the physician back in and subsequent due diligence medically reveals appendicitis. A life is saved.
*A more frequent finding with patients in addiction is bodily injury due to violence perpetrated against them from the population they associate with. Since shame is a huge factor in this group, the patient will often not divulge a criminal act against them and associated injury is easily missed in assessment.
3. Patient complains of generalized dizziness and imbalance. She mentions that she notices one side of her body seems to be “lagging.’ The neurological “tug” test is performed along with the routine balance test. No present abnormalities are observed, yet the patient insists she is experiencing increasing episodes. Although labs are ordered to check for abnormalities in hydration, glucose, and possible tell-tale results of a recent stroke or myocardial infarction (cardiac enzymes and CRP), they come back normal. As the physician is writing discharge orders for PCP follow-up recommendations, the nurse checks in with the patient.
The patient is sitting with her head down. Her off-handed mumbled comment catches the nurse’s attention. “I feel like I’m literally living in darkness and am scared most of the time.” This comment strongly hints at mental health issues. Adverse mental health conditions that are left untreated will absolutely affect the body (altered stature, weight balance, gait, eye movement, posture, cognitive word halt/jumble.) Upon further assessment, the patient also reveals long-term anxiety-related insomnia, one hallmark (though not entirely definitive) of compromised mental health.
A discussion with the doctor now adds a psych evaluation, a mental health consult to her PCP follow up and community referrals. The patient’s time is not wasted reaching out to the medical community because a nurse made the decision to follow the cornerstone of his/her medical training to observe/listen to the patient. Nurses are taught to observe both the presence and absence of information and body language and many other factors. The picture presented when first meeting a patient is most often just the tip of the iceberg.
The Benefits Of Honoring and Respecting One Another as Providers
When physician and nursing roles support and complement each other’s expertise and knowledge, and each respects the other’s insight and practice, great results occur for patients:
- a much more in-depth picture of the patient’s overall physical and mental health is revealed.
- potential risks and needs that often go unidentified are exposed.
- the patient receives a much more comprehensive, relative treatment plan.
- patient trust in the medical community increases
Better patient health is achieved, and a much-needed deeper level of patient trust in their care team begins to be restored.
Unified medical forces create reliability and safety for all involved.
Patient compliance is directly related to patient trust for their provider.
When physicians respect the nurses they work with and understand that good nursing staff are an immeasurable source of support and diverse medical knowledge, the target of healthcare, patients, benefit the most.
They are why there are doctors and nurses in the first place.
