Saturday, 18 August 2007

Give a little respect to me... (Tuesday)

...sang 80s popsters Erasure and I was chatting with one of the senior sisters on the intensive care unit (ICU) about respect earlier on today. She was telling me that the reason that she much preferred ICU to ward nursing was that, in her opinion, nurses on ICU get much more respect for their job than they do on the ward. She felt that on the general ward, the doctors don’t respect the nurses for what they do and for the role they fulfil and that the hierarchy of doctors above nurses was still very much in existence.

This hasn’t been my experience at all, so I asked her what she meant by this and she went on to say something very interesting.

She said that she thought that when doctors start, they are very “respectful” and ask the nurses lots about how things work etc… but then, after a while, that goes out of the window and the doctors start just commanding the nurses to do X, Y and Z. I think there’s an element of truth to what she said, but I think that what she’s getting at isn’t a matter of respect, but more a matter of experience. She sees it happen on ICU but it happens more often with new doctors, fresh out of medical school.

Let me try and explain.

When you graduate from Med School, you’ll have studied for the best part of the decade, you’ll have been tested countless times and you will have learned a hell of a lot of stuff. However, most of that learning will have been done in seminars, lectures, libraries, your bedroom, and comparatively very little will have been done on actual real patients. Even on your ward placements, the doctors will tend to take you to away from the patients to the seminar rooms to give you a teaching session on ECGs or chest Xrays or whatever.

When you graduate, you’ll have proven yourself and will have earned the right to call yourself “doctor.” However, when you walk onto the ward for the first timeas a doctor, you realise that things are a lot different to being a student. Obviously, a lot more is expected of you and one of the things that you’ll find is that there will be quite a few simple, practical things that you’re either not very good at or just don’t know how to do. I thinking of things like siting a naso-gastric tube or actually putting the leads on for an ECG. These things aren’t difficult but if you’ve not done them very much, you’ll be a bit wary the first few times you do them and it actually matters that you do them right.

The nurses will know how to do these things and they help you and show you how to do them. Some of the nurses will have been working in your field for twenty or thirty years and they will have seen a lot of stuff in that time. Their experience is invaluable. They will have seen and treated hundreds of patients have heart attacks, strokes, pneumonia, appendicitis etc… etc… and will have seen which treatments work for these conditions. As a result of this experience, they’ll try and point you in the right direction when it comes to the patient’s conditions and often, they are correct.

The thing is, after a while, your years of medical training kick in. After the first few weeks, you are no longer fazed by things like placing cannulae, talking to big groups of relatives etc… etc… and you are much more confident about the way your ward works. About this time, you realise that the nurses aren’t right all the time about things. Ultimately, nurses haven’t been to medical school and while they may have more experience about some things, they often don’t have the knowledge about medical conditions that you do to go with it. Thus, you realise that if you’re going to make a decision about what to do with a patient, it has to be YOUR call because, if anything goes wrong, it’s YOUR responsibility.

So, whilst the nurses may say to you, “I think we should put a “Do Not Attempt Resuscitation” order on this patient” or “this man needs thrombolysis” or “we should move this woman to HDU” at the end of the day, their opinions are only opinions because for medical decisions, you have to convinced in your own mind that what you’re proposing to do is actually in the best interests of the patient.

You’ll inevitably disagree with the nurses (and other doctors) from time to time about the management of patients. For example, you might think the patient needs diuretic drugs and the nurse might think he needs fluids but, ultimately, for medical decisions, what you say goes. This is not a matter of lack of respect of nursing roles, it’s a matter of taking responsibility for the decisions you ought to be making because, if it’s the wrong decision, then the fallout is going to be on YOUR head, not the nurse’s.

Like I say, medicine is so complex that disagreements are inevitable. Disagreements about patient care happen all the time between doctors and nurses, between doctors and doctors, between nurses and physiotherapists etc… etc… Ultimately everyone has their own opinions and rightly so. The point is that it’s not the disagreements per sé that leave people feeling disrespected, but the manner in which the discussion is conducted.


Mousie said...

You're absolutely right, we haven't been to medical school (and many of us would do well to remember that!) BUT we still have a responsibility and duty of care to our patients and we are still accountable for our actions.

If you tell us to do something which is wrong and we then go and do it, we are equally and jointly responsible.

It isn't good enough for a registered nurse to stand up in front of the coroner / NMC / patient / family and say "I did it because the doctor told me to".

There have been many, many occasions when I have been asked to administer drugs, treatments or interventions which were completely inappropriate and, had I done so, there would have been serious implications for the patient and the fallout would have been on MY head too.

What is needed is a culture of mutual respect, based upon communication as a two-way process.

We all have so much to learn from each other and we're all on the same side after all.

The Junior Doctor said...

"What is needed is a culture of mutual respect, based upon communication as a two-way process."

Spot on, Mousie.

Cal said...

What a well written post.

You know what, I'm actually scared of being a 4th year, I can't imagine me actually being a doctor one day. I seriously can't.

One of the resons that I love being a medical student is the fact that we can easily 'bow out' when the going starts to get even vaguely rough.

Like, I was doing an on-take and I was trying to take a history from a Portuguese speaking guy with loads of mental health issues. We communicated in broken Spanish and English, and I got about as far as the history of presenting complaint, and then it just wasn't working.

I gave up and went to lunch, thanking him for his time.

After lunch, I saw the House Officer with him who was seeing him for the first time. She was desparately trying to ascertain whether he had any drug allergies or not, and it was then that I felt really grateful that I could hide behind the fact that I was 'just' a medical student, and I didn't have to sit there asking him if he'd ever been jaundiced or what his parents had died of.

I feel a bit ashamed of my relief, actually, but I'm hoping that I'll naturally grow into the role.

One day.

Anonymous said...

It isn't good enough for a registered nurse to stand up in front of the coroner / NMC / patient / family and say "I did it because the doctor told me to".

Of course it is. I prescribed this drug which resulted in their death because the doctor said to.
Twist it around the other way when a nurse shoves a drug chart under your nose as you rush around doing a million other things telling you to prescribe an anxiolytic/painkiller/whatever, and you get a different result. Doctors head is on the block, not the nurse.

claire said...

From a nurse point of view i get this.
AHP and nursing support staff may ask us to do something which we feel ins#t in the patient intrest and we decline as its a decsion I disagree with.
.as mosuise says we have a registrion a duty of care and practice in the best intrest of our patients to the ability of skills of each nurse

Eithne said...

Anonymous, in Ireland, the nurse's head is also professionally and legally on the chopping block for their actions, regardless if their actions were precipitated by a doctor's decision. I can't imagine it being that different in the UK. I'm afraid you are talking through your arse.