How do you get it through nurses heads that we MUST be patient advocates?

URO-RN · Jan 15, 2005

I am not in management. I am a nurse of over 22 years. I just see newer nurses almost afraid of "standing up" to doctors for example. I do not mean being disrespectful. I mean speaking up when they know they are right. Do people see us as being a "*****" ? I try to be assertive rather than aggresive.
I 100% agree about teaching through example!

I agree. There is a big difference between being assertive in a respectful way, and being a witch or a jerk to get your point across. Some nurses and doctors believe that being assertive means being aggressive or abrasive. Talking to someone in a respectful manner does not make a person "weak", it conveys a message that "I am willing to work with you to make sure we meet in the middle and that the patient best interests are # 1 "...

pghfoxfan · Jan 15, 2005

I am on the "Patient Safety Committee"...we go around and ask nurses if they are comfortable reminding doctors to wash their hands inbetween patients, or telling them to remove their wedding rings before they scrub, etc. You would be surprised how many say don't say anything to them. sigh

Town & Country · Jan 15, 2005

You would be surprised how many say don't say anything to them. sigh

I have never seen or heard of a nurse who "reminded" a doctor to wash his/her hands or the like.

I shudder to think what would happen to them!

I imagine they would be out of job.......

If nurses don't say anything to doctors it's because they're afraid (quite realistically, I'm sure), of the backlash.

I agree that nurses MUST be patient advocates - however, they must ALSO be willing to pay "the price"...whatever that may be - but you can be sure, it will be SOMETHING.

Nurses who have questioned doctor's orders have had their licenses suspended by BONs - when all they were doing was advocating for the patient, which is their duty.

Too bad the BON doesn't support them when they do their jobs.

Town & Country · Jan 15, 2005

I was just sitting here, thinking that maybe the reason I HADN'T seen this is because I usually work third shift.

Then I remembered.........

.......I once watched a doctor remove an infected port - from an HIV-patient.......without gloves on! :eek:

He was in teaching mode at the time and had students with him. :uhoh21:

Tweety, BSN, RN · Jan 15, 2005

Being assertive and standing up to doctors and others is a skill that is acquired after one graduates and hits the work environment, imo. I remember how nervous I was in my first MD/nurse interaction where I needed to be assertive. With time and experience I became better at speaking up.

I think newer folks tend to keep quiet, and then look to other nurse-mentors, managers, charge nurses to help support them.

There are some of course, that right out of nursing school and need no assertiveness training whatsoever. Perhaps 22 years ago your generation was different, I don't know I haven't been in nursing that long, just 15 years.

Then again, some nurses when they are asserting themselves are very *****y about it. That turns me off immediately.

Again, I try to lead from example and coach new people along. For instance when I hear a new nurse call a doctor and say "I'm sorry for bothering you.............". I'll gently tell them "don't apologize, you're the patient's advocate, you call 24/7 to get what you need without apology. The patient always comes first."

Long Term Care Columnist / Guide · Jan 15, 2005

Well put, Tweety. It takes a while to become confident enough with one's nursing knowledge and skills to challenge a physician; even for someone like me who's had a lot of life experience before becoming an RN, it can be several years until you stop quaking in your shoes at the thought of questioning an order or disagreeing with the MD's course of treatment.

In fact, it wasn't until I'd developed a good working relationship with my own doctor, who was the medical director of the LTC facility where I was a care manager, that I finally realized that doctors are human beings just like the rest of us: they have a house payment they're worrying about, they've got a spouse and screaming kids, they put on their pants one leg at a time and go to the bathroom the same way everyone else does. Once I got that through my head---and noticed that doctors, like police officers and politicians, have gotten younger and younger recently---I've never again been intimidated by a physician.

It also helps to know your stuff and be organized when discussing your concerns with the MD......they're on a tight schedule just like everybody else, and they HATE it when they can't find the chart or the nurse doesn't have the labs and current vital signs available to report. You can be the most caring nurse, the best patient advocate on the floor, but if you don't know what you're doing or why you're doing it, the docs are quick to pick it up and they'll likely blow you off.

Just a few thoughts, when my brain is still fried from yesterday and it's past my bedtime....... :lol2:

URO-RN · Jan 15, 2005

Then again, some nurses when they are asserting themselves are very *****y about it. That turns me off immediately.

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That turns off everyone.

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Again, I try to lead from example and coach new people along. For instance when I hear a new nurse call a doctor and say "I'm sorry for bothering you.............". I'll gently tell them "don't apologize, you're the patient's advocate, you call 24/7 to get what you need without apology. The patient always comes first." ------------------------------------------------

Exactly, the "sorry to bother you...." should not come out of any nurses' mouth.

Good post.:)

chris_at_lucas_RN, RN · Jan 15, 2005

Build patient advocacy into the nursing curriculum.

Oh, do I have a sad story for you.

In my second clinical rotation, my assigned patient's roommate was a wee hours transfer from a nursing home. Apparently someone determined that the DNR for the LTC wasn't in effect in the hospital. The woman was curled up in her bed and moaning. It was clear even to us students that she was on her way out. She had tylenol (no codeine, just plain old tylenol) for pain. Every breath was a loud moan.

My heart broke for her. I went immediately to my instructor. I described the situation, I asked her if this wasn't an advocacy issue. She came to the room, saw the woman, heard her groans. She agreed that this was "not right."

She said she would speak with the assigned nurse about getting a pain med order for the lady and contacting the next of kin for some sort of "keep comfortable" plan. An hour or so later, I saw my instructor and asked her what was happening. The patient was still groaning, but instead of 20-25 times a minute, it was only about 12 times a minute.

Her response was classic. "This is not your patient, and it is not your business." The patient finally passed around 11:30 a.m. I had been listening to her and praying helplessly for her since 7.

This kind of irresponsible behavior is one of many reasons I was so glad to get away from my brick and mortar school and into my nontrad program.

Yes, it needs to be built into the nursing curriculum. But first, instructors need to understand this very, very basic part of caring.

Thunderwolf, MSN, RN · Jan 15, 2005

Well put, Tweety. It takes a while to become confident enough with one's nursing knowledge and skills to challenge a physician; even for someone like me who's had a lot of life experience before becoming an RN, it can be several years until you stop quaking in your shoes at the thought of questioning an order or disagreeing with the MD's course of treatment.
In fact, it wasn't until I'd developed a good working relationship with my own doctor, who was the medical director of the LTC facility where I was a care manager, that I finally realized that doctors are human beings just like the rest of us: they have a house payment they're worrying about, they've got a spouse and screaming kids, they put on their pants one leg at a time and go to the bathroom the same way everyone else does. Once I got that through my head---and noticed that doctors, like police officers and politicians, have gotten younger and younger recently---I've never again been intimidated by a physician.
It also helps to know your stuff and be organized when discussing your concerns with the MD......they're on a tight schedule just like everybody else, and they HATE it when they can't find the chart or the nurse doesn't have the labs and current vital signs available to report. You can be the most caring nurse, the best patient advocate on the floor, but if you don't know what you're doing or why you're doing it, the docs are quick to pick it up and they'll likely blow you off.

I totally agree. What also is helpful is to develop a good working relationship with the docs. Confronting a doc or questioning the rationale with a doc doesn't mean being adversarial, but coming across as another colleague...mutually interested in the best care for the patient. Some times, reminding the doc that I'm on his/her side to help provide the best care for his/her patient goes a long way. Using humor with the doc to bridge the distance is also helpful. Sometimes, being a patient advocate also means keeping the lines of communication open with the doc...the doc being receptive to listen. I also agree that the nurse needs to be organized with the patient data in order to present the concern and to be knowledgeable in what is being presented. Whe advocating for a patient, the worst thing you can do to your credibility in front of a doc is to present yourself as being disorganized and ignorant. If you want to be a successful advocate, you have to be credible.

Malt123 · Jan 15, 2005

Well, I don't know where some folks went to school, but the program I graduated from drilled it into our heads literally from the first day of classes that we were to be the patient's advocate in everything. It didn't necessarily mean giving them every little thing they wanted, like bringing them a beer when they were in the hospital for detox......but it DID mean fighting for the patient's best interests, even at the expense of the doctor's good will or going against the family's wishes.
As a preceptor, I tell nursing students that our job is NOT to make the doctor happy, to kiss up to the family, or to make sure nobody is offended; our job is to see to the patient's needs and desires, and to be willing to go against the grain if that's what's in his/her best interests. I've had many a disagreement with physicians over pain relief, and I'm sure I've upset relatives and friends when I've asked them to leave a patient who clearly needed to rest. I am nothing if not diplomatic; however, some folks' egos are quite fragile, and to tell them something they don't want to hear is to open oneself to the possibility of complaints, write-ups, and other negative consequences. It doesn't matter. We are there to protect the PATIENT, first, last, and always.
'Nuff said. :stone

I agree totally with this yet we are told by management otherwise. I guess it is one of those times when the real world conflicts with nursing

VickyRN, MSN, DNP, RN · Jan 15, 2005

Build patient advocacy into the nursing curriculum.

Patient advocacy is very basic to nursing. It should be an inherent part of all nursing curricula and present in clinical practice settings. The ANA Code of Ethics for Nurses affirms the nurse's primary commitment to the patient (whether individual, family, group, or community). The Code states that patient advocacy is central to the role of the professional nurse: "The nurse promotes, advocates for, and strives to protect the health, safety and rights of the patients."

True patient advocacy involves a synthesis and application of the basic ethical principles of autonomy, veracity, nonmalfeasance, beneficence, justice, and confidentiality. In order to build patient advocacy into nursing curriculum, nursing instructors should role-model collegiality on the clinical floor in consulting physicians about the best care for the patient. The professional nurse should be portrayed as a capable, valued, and equal member of the interdisciplinary health care team, and the one who possesses an uncompromising voice on behalf of patient's needs and desires.

Students need to be taught that nurses are here to serve the patient and the community, and to do it safely and to do it well. We teach our students that the nurse is even responsible for knowing when the physician is wrong. Ignorance is no defense in a malpractice suit. Therefore, the nurse must be willing to go against the grain for the patient's best interests.

The advocacy role is a critical, perhaps unique dimension of professional nursing that is changing rapidly and may be diverging from the usual role. The IOM has stated, "The concept of advocacy in nursing should be expanded to include advocacy on behalf of groups and communities, in addition to advocacy on behalf of individual patients and their families."

Nursing education is challenged to adequately prepare students for this integral and ever expanding role. Patient advocacy has three essential attributes: valuing, apprising and interceding. Advocacy is possible only when all three attributes are present. How can nursing faculty adequately prepare students in the role of advocacy?

The Journal of Nursing Scholarship article provides this advice for nursing faculty:

1. Describe the critical thinking process used in patient advocacy.

2. Demonstrate advocacy in clinical practice throughout the nursing education process (role-modeling is a critical component in developing advocacy).

3. Identify situations in which nursing students engage in advocating practices and discuss such encounters.

"These are beginning steps toward enabling recognition of advocating practices and instilling a sense of self-confidence and self-esteem while nursing students are in the formal learning process" (Kee, 2002).

Another promising method of incorporating patient advocacy into nursing curricula is providing case studies for student discussion. The Nursing Standard article provides one such study:

Box 2. Advocacy: a model case

A 55-year-old woman with a diagnosis of inoperable pancreatic cancer was offered the opportunity of participating in a randomised controlled trial (RCT) involving cytotoxic chemotherapy. The patient confided to the nurse involved in her care that she was having difficulty deciding whether or not to participate in the trial. The GP and the patient's family were supportive of the trial. Participating in an RCT meant that she had no control over whether she would have to remain in the hospital: one of the treatments involved being an inpatient. The patient asked the nurse to help her find out more information about the specific drug.

The nurse, with the support of the patient's family, contacted a national organisation's helpline and obtained written information about the nature of the cancer and the drug to be trialed. She also contacted the oncologist who provided additional information about the drug. Stating that the patient had a poor prognosis, the oncologist hoped that the trial might be able to offer some `quality of life', although what this involved could not be specified. The patient, in possession of the information the nurse had provided, decided not to enter the trial.

Reference

American Nurses Association. (2001). Code of ethics for nurses with interpretative statements. Washington, DC: American Nurses Publishing. Retrieved January 14, 2005, from http://www.nursingworld.org/ethics/code/ethicscode150.htm#2.1

Baldwin, M.A. (2003). Patient advocacy: A concept analysis. Nursing Standard, 17(21), 33-39.

Bastable, S.B. (2003). Nurse as educator: Principles of teaching and learning for nursing practice. Sudbury, MA: Jones and Bartlett Publishers.

Institute of Medicine (IOM). (1995). Nursing, health, and the environment. Washington, DC: National Academy Press. Retrieved January 15, 2005, from http://www.nap.edu/execsumm/030905298X.html

Kee, C.C. (2002). How nurses learn advocacy. (Profession and Society). Journal of Nursing Scholarship. Retrieved January 15, 2005, from http://www.highbeam.com/library/doc3.asp?DOCID=1G1:88100448&num=4&ctrlInfo=Round9c%3AProd%3ASR%3AResult&ao=

Tiki_Torch · Jan 15, 2005

i agree that once we are out of school and in the workplace, the best way to encourage others to be patient advocates is to lead by example.

in school our clinical labs instructor told us something that has stayed with me all these years and helped me in countless situations. she said:

when you need to make a decision about what to do in any situation big or small, remember that if you do what is in the best interest of the patient, no one can ever fault you.

also, over the years, i have developed my own philosophy of nursing. i had a thought one day that people who decide to spend their lives working with other people in order to help them through critical and vulnerable times in their lives (like medical professionals, religious leaders, justice system, etc.) need to do their absolute best because i believe (and this is my own personal belief) that we will most likely be held accountable to a higher degree in the afterlife for how seriously and compassionately we took our responisbility in our work. even if a person doesn't believe in an afterlife, the simple notion of consicence should encourage us to be advocates for the people we take on the responsibility of caring for.

my two cents...

tiki