patient advocacy - not as easy as you'd think

I received my first, rather horrible, critique of my nursing practice the other day from a comment on this blog. As a person who is used to praise and commendation, I was first dismissive and cold when this person presumed to judge my nursing skills, my patient devotion, and overall ability to be a fabulous nurse. When I first read this comment, I was pissed. My unedited mind said: "Fuck you. You wish you could have a nurse like me. You don't know me. How dare you put me in this little box, focusing on out of context words, and trying to chop me at the knees. Get some fucking counseling and kiss my ass." This IS a rather extreme reaction, and I held myself from responding that evening, and instead, drank some wine and slept on it. Many days later, I take a deep breath and brood on patient advocacy. Could I have done more? Should I have done more? What prevents me from acting more, on what I believe are my patient's best interests?

There are many factors involved in being completely present for your patient, and I am not perfect people! I try to be the best patient advocate that I can be, but there are a few issues in my practice that fluster these intentions. First, I am the NURSE - I take orders, not give them. Second, people say "no" all the time - this doesn't mean that they "mean" it. Third, I am fucking busy, and do not have the resources it takes to research deep issues and have many heart-to-heart discussions. These three concepts will be further explored in this essay. Angry commenter, please accept this as a rebuttal and understand that I am not an evil sadist, but a person just like you - trying to get by, and do the best that I can with my time on this Earth. Peace.

I am a nurse. Not a doctor, soothsayer, or magician. I get orders and pretty much follow them unless they are totally stupid, totally wrong, or cause more pain than they are worth. The third reason is fairly subjective and frequently, if I suggest that this might be the wrong choice during rounds, I automatically seem to sprout two heads and am stared at without comment, and the interns return to their patient plan quickly so as not to embarrass me further. Nurses during rounds are really only worth anything when the Attendings are trying to look PC, or when all other ideas have failed. So yeah, I do say what is on my mind - "This person is sick and probably going to die, have we had a family meeting recently?", "Has Palliative Care been consulted?", "Is this invasive procedure necessary, and is it going to change our plan of care?". I say this stuff, and I hope for a meaningful response - but really am only effective if I take issues up with a resident in private, and they then present the idea as their own. They proceed to get a pat on the back, and then wink at me meaningfully when they are done rounding on my patient. nice.

People shout out "No!" many times during my day. They come into the unit with a GI bleed and are tachycardic and hypotensive. I explain what I am going to do beforehand, but they are of course upset and kicking away as I push a tube into their nose to go to the stomach in order to lavage the blood out. They say "No!" when I start IVs, restrain them from pulling out tubes, or putting in a foley because they are pissing all over themselves. These same confused/sick people tend to clear up within a couple days, and are sent off waving goodbye as they leave with a thank you, and I hope to never see you again. Coming into the ICU sucks, it is not a trip to the spa. It is hell to get better sometimes, and I walk the fine line of trying to figure out if the discomfort is worth it. Sometimes no means "I hate this, I hate you, but I don't want to die like this". During these times, my patient advocacy means putting the patient's long-term interest before what they may want at that particular time.

My third reason for not being a super patient champion is because I am stretched to the max sometimes. With two patients who should actually be one-to-one, I am running my ass off all day, and can't even sit down to review their chart. Maybe this is my fault for working in a hospital that doesn't provide adequate staffing. Maybe it would be different somewhere else where I wouldn't have days where I feel like a kicked dog when I leave. Is it different anywhere else though? I don't know. My work has great benefits, awesome staff, usually a good working relationship with the doctors, and I have good potential for the future. The patients are great; very colorful, rich histories, amazing families, and usually I feel very satisfied at the end of the day. Sometimes though, I know that if I had an ICU physical therapist, respiratory therapists who actually cared about vent weaning, or even a competent nursing aide, I would be much more effective at my job.

This is a depressing post.

As a nurse in a small hospital without much nursing support, I do the best that I can with the time I can afford. There needs to be a fundamental change in the way we view patient care at the ICU level, with a holistic focus and commitment to improving patient outcomes, and accepting when we are beyond our means of making some of them better. Probably, my best way to be a better leader in patient care is to move into administration and really push for greater resources and training. But, then I would be away from where I really shine - at the bedside, with the patients whom I really do appreciate, and try to either get them better, or help them leave this world peacefully with dignity, surrounded by someone who really does care.