An experienced charge nurse reviews staffing for the next shift. She notes that two out of the three nurses coming on have less than a year experience and she is concerned. In addition, the intoxicated patient in 54 is requiring hourly medications and frequent monitoring to avert DT’s (delirium tremors). The charge decides that in order to safely staff the floor she needs four nurses, but the staffing office says they are very sorry (sick call or staffing grid), and she can only have three.

A surgical nurse helps her patient to the bathroom and the patient is weak and unsteady on post op day three from a hip replacement. She foresees the likelihood of this patient falling at home and reports her observations to the physician, recommending that the patient stay another day to gain strength and more physical therap, but the physician discharges the patient home anyway. He’s being dinged for his length of stay and can’t afford to look like an outlier.

Another nurse notices on the fourth post op day that the patient has not had a bowel movement for four days; but she can’t give Maalox or even a suppository without calling the doctor first. The nurse knows the surgeon is in the operating room and doesn’t want to interrupt. She also knows that the same over the-counter laxative that the doctor would order is currently ten feet away in the medication room.

An undertow is more powerful than a wave. An un-articulated conflict is much more damaging to our esteem than an obvious one. I could just as easily list scenarios where the nurses’ high level critical thinking, skill, autonomy and experience improved patient care. But the reason for discussing these situations is to raise awareness of their presence so that the effect can be mitigated. What effect?

Ambiguity increases self-doubt which in turn decreases self esteem; reinforcing nurses’ feelings of powerlessness. Raising awareness of these internal role conflicts however, allows us to intervene and change course.  Many nurses take the above situations as ‘part of the job’, and fail to see how these daily conundrums insidiously chip away at their sense of self.  But if we can identify and talk about the undertow that pulls us down, we can chart a different course.   

While nurses are highly trained, skilled professionals, many day-to-day experiences place the nurse in a dependent rather than an autonomous position. Furthermore, the degree of autonomy we experience often changes depending on whose patient we are caring for, or the time of day – or both. Physicians have been overheard in the morning thanking nurses for ‘taking care of it’, or ‘not bothering me’ which encourages nurses to put their licenses in jeopardy and practice beyond their scope. One nurse said:

“He looked at me like I was an idiot, and then, I felt like one.  After thirty phone calls, I should know that he always changes the morphine to dilaudid….why didn’t I just do it?”  

Every time we tolerate an unacceptable situation, we drain our personal power reservoir a little more. Learning how to tackle these situations professionally for many of us is a new skill because the most common way to learn is by imitation; and the responses we have witnessed have been totally absent, or far from optimal.  

So what do you do?  

Situation 1:  You can’t get the staff you need to safely staff the shift.  Ask yourself, “If my mother or child was a patient on this unit next shift, what staffing level would be appropriate?”  You can:

• Page your manager and explain the situation
   
• Page the house supervisor and explain that you either need more staff - or that the acute patient must be transferred to another unit
   
• Fill out an incident report to the quality department on unsafe staffing

Situation 2: Patient unsafe to go home and physician is discharging anyway. Say, “Dr. X, may I speak to you in private?”  Find a place where you can speak privately and sit down. Advocate for every patient as if they were your own loved one. Briefly state problem and options: “This patient is unsafe to go home. We can order a home safety evaluation, set up a 24 hour caregiver, or keep her another day. What would you do if this patient were your mother?”

Never let anyone, or any situation, make you feel less than the highly skilled and competent nurse that you are.  Nursing is the most trusted profession. Staying in your power at all times will keep it that way. As Margaret Wheatley says, “The future is not something that happens arbitrarily. We create the future every day by the actions and beliefs we are practicing now. If we want a different future, we have to take responsibility for what we are doing in the present”.

References

Bartholomew, K. and Cohen, S. (2008) The image of nursing: perspectives on shaping, empowering and elevating the nursing profession. HCPro, Marblehead, MA

Juice Healthcare: http://www.juiceinc.com/about/healthcare/register.phpPull Conversations

Wilson, Brady. Juice: The Power of Conversation -- The Secret to Releasing Your People's Brilliance and Expanding Your Leadership Influence [Paperback]

About the author: Kathleen has been a national speaker for the nursing profession for the past nine years. Her strong background in Sociology laid the foundation for correctly identifying the norms particular to the healthcare culture. For her Master’s Thesis she authored “Speak Your Truth: Proven Strategies for Effective Nurse-Physician Communication” which is the only book to date on physician-nurse communication.

In December of 2005, Kathleen resigned her position as manager of a 57 bed surgical unit in order to research horizontal violence in nursing. The expression, “why nurses eat their young” has existed for many years in the nursing profession (and has troubled many). In her book, “Ending Nurse to Nurse Hostility” (2006), Kathleen offers the first comprehensive and compassionate look at the etiology, impact and solutions to horizontal violence. Visit www.kathleenbartholomew.com.

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