Tuesday, September 22, 2009

Being a nurse

After doing the registry shift the other day I have been thinking about what it is to be a nurse versus a midwife. I know and have known for a long time that I would never be satisfied as 'just a nurse'. It wasn't enough for me. I have been pondering why that is.

I think that working as a nurse turned out to be not at all what I thought it would be. It isn't what I tried to teach nursing students when I was still doing that. Well wait, it can be sometimes. But more often than not, nursing is about completing tasks.

There. I said it. Yes, being a nurse is about getting tasks done. With a little patient education thrown in. It seems that most nurses I work with are about getting their jobs done so they can sit at the nurse's station. I look at their interactions with doctors and midwives (myself included). Rarely is it a team approach to patient care/diagnosis/treatment. It's a doctor (or midwife) giving orders, the nurse running off to complete the orders. Rarely does a nurse make a suggestion to me. I have even asked at times, 'what do you think?'. And the response is usually "I don't know" (not always). I want to include the nurses in the POC...I try to tell them what my thoughts are and why we might be approaching a situation a certain way. Some of interested in learning but most are just like 'whatever, let me do my job so I can go home'. And god forbid I want to do something that means more work (??) for the nurse, such as intermittent auscultation, etc.

When I was in nursing school, I thought nursing would be about that team approach to healthcare. Multiple disciplines working together to achieve the best outcome for a patient. I thought everyone would be equally respected. Yes, I was d*mn naive. After all, I had no healthcare exposure prior to nursing ( Iwas a bartender!). But lets face it, nurses don't get any respect, especially not from doctors.

When I began to teach I tried to instill in nursing students this picture of what I thought nursing was supposed to be like. But really, once you get out in the 'real world', you quickly get beaten down into your place.

I always though that certain specialty areas offered more autonomy, such as L & D or the ER. And they do, but still I see the same behaviors. I don't see nurses that are willing to fight and advocate for their patients. And that's what nurses are supposed to be - patient advocates. But instead many become steamrolled by the juggernaut called healthcare. It's hard to always 'fight the power'. It wears you down quickly. Maybe that's what I am seeing where I work.

As a midwife, I have a great deal of autonomy. I can spend a lot of time with patients. I get to give the orders instead of being told what assinine things I need to go do to a patient. Maybe that's an issue for me - I am a type A personality and I like control. I am learning to give more and more of that control to patients though :)

I would love to hear thoughts from nurses and from lay people who have had nursing care that made a difference (negatively or positively) in their lives.

*Sorry about the rambling!*


mitchsmom said...

One of my OB MD friends (and now I work on the unit where she works) said that's why she became an MD instead of a nurse, etc... the control issue.

She also is the person who delivered my last baby... since she "knew" me she stayed close by, and she let me do things the way I wanted to (things she would not ordinarily let other pts do)... but even still, it was my NURSE who I remember the most.
I had even chosen to go back to that particular hospital because I'd had her with my second baby and I hoped to have her again... and happily, I did. Since I was getting the 'special' treatment from the MD/friend, she didn't have to advocate for me with her, but she did defend my choices when some other nurses made snide remarks about my choice for unmedicated labor (my husband overheard the discussion at the nurses station).

On my unit, I think we have a good amount of teamwork. We do not have 24 hr MD coverage, and they tend to listen to RN suggestions once a nurse has proved herself to be competent (calling them at home on weekends or at 4am, or relaying a message while they are in a case in the O.R., whatever).

Many times, I think that patients believe that their nurse cares more, and is more trustworthy than their MD... I think many providers have instilled a sense of distrust with the paternalistic (whether male or female provider) attitude: lack of truly informed consent/ one-sided or incomplete information (that people wise up about at some later date and become resentful about), and feeling of being commanded instead of being presented information with which to make choices.

Granted, I'm saying this in light of speaking with new mothers at a meeting last night, where one of the comments was "I will deliver in the street before I go back to a hospital".
Many of them have changed to midwives (both hospital & home delivery based), which has generally worked out well for them & I support (I would like to become a CNM myself). However some of them I feel have put themselves at risk (while generally great, we do have a couple of midwives who I feel do not risk out patients to MD providers when they should) and it's a shame that it's really been the MD's that pushed them to that point - that these women don't even want to see them or go to a hospital with high risk situations.

I've kind of strayed from your topic, but I just think it's a big deal that all the providers need to moderate and meet toward the middle in order to provide better care for women, and not be so polarized (and for many MD's, paternalistic).

Anonymous said...

I work med/surg, and I know what you mean. The thing is, it gets tiring being the squeaky wheel. Our unit sees a lot of the postpartum infections, and the hospitalist group at our hospital has a hard time with breastfeeding moms and meds. I have fought for those patients A LOT to get them "permission" to bf while in the hospital. I have been told flat out "Do not call me about this again, and DO NOT LET HER BREASTFEED!" (a mom that was on all L2 meds grrr)

I think that in order for there to be a real team approach, the docs have to be on board. Too many docs don't want to be "challenged" by the nurses.

The nurses you work with may have just been shot down too many times by other practitioners and are now afraid to state an opinion. Hopefully, you can change that!


Paula said...

OK. I have been frustrated by my own profession (Doula and LC) because parents listento docs and nurses with a different ear. My input is so that they will make informed choices, the doc or nurse is prescriptive. Often folks are not offered a choice and they do not know that they have one.

I am taking prerequisites to apply to nursing school. I respect RN's. I know they work like crazy and as a population I see that they do not always make the best choices (forgive me, but the word girth comes to mind) I get it that docs dismiss nurses and I am hearing more and more that there can be a lot of competition among nurses too. It seems to be kind of a camp of tough cookies. Tough it out and don't whine.

So now though I am taking prerequisites at age 38 with a degree in sociology, I'm not sure I want to be a part of a culture that is so unhelpful to one another.

I'm going to work hard at being the best gal at the bottom of the rung. If you nurses think docs don't listen to you, try being a doula or a non RN Lactation COnsultant. I do not exist. But I press on... sending those docs information about thrush and vasocontriction and whatnot.

Sorry I rambled!

Just wanted to say that I have lots of respect for nurses. I think they wield enormous power in L&D. Good ones are fantastic and bad ones are heartbreaking. Nurses hmake a huge difference.

Joy said...

I have to agree. As a patient I felt like I was cumbersome if I had to call the nurse to come into my room (post delivery) for something. I also felt like my nurses didn't really see me but saw me as a list of tasks and paperwork to complete.

So sad!

Anonymous said...

I am "just a nurse," and I make suggestions, provide labor support, help mom and family make educated decisions, and occasionally catch a baby. I am not Just a nurse. My job is to be there for mom, baby and family and to help make this a wonderful memory for the family. It is her labor not mine. We have great midwives and MD's who depend on us to let them know what is going on with mom. We check our own pts. Rarely does the midwife or the MD come in for a labor check. They know we are trained well and trust our judgement. The phrase just a nurse is demeaning to the nurses that take pt care seriously. There have been times that I have had pts tell me I am the only reason they were able to handle labor. Not the midwife or MD. Yes, I follow MD orders but I have also refused to follow them when not in the best interest of my pt. That is my right as an RN and advocate for my pt. I am there with them. I see what is going on. I assess them and notice any changes there are. Our L&D is great. The doctors do show us respect. We are given a lot of autonomy. Most of the time I tell a the provider what I think the pt needs. A lot of the time I get the orders. Mostly at our hospital we are relied upon to take care of the pt with little intervention from the MD unless it is needed. We are included in the POC. It may be due to the fact that we are a high risk unit with 400+ births per month and a level 3NICU that makes it this way where I am. There are a few nurses there who just wanna do the min and get paid and go home, but for the most part we have a Wonderful team.