The nurse's role

One of the most interesting things about my program is learning that nurses understand themselves and their role, and position themselves professionally in a way very different than, I think, most non-nurses, or at least non-medical professionals, understand. There's a whole lot more to it than "patient care." Or maybe I mean that "patient care" is a phrase that should be understood very broadly. I'd had no idea. I'd had vague notions that nursing was more about process and prevention, and possibly education, than medicine. But there's a lot more to it.

The absolute hierarchy we'd had given to us as NACs involved us being at the bottom of the totem pole (of course), and the stipulation that under no circumstances were we to ever take direction from a physician. We are nursing assistants, after all. But there is more to it than that. Especially in a hospital, nurses just don't work for doctors. Nurses work for the hospital, and doctors are independently contracted, which is why hospital visits that include doctors always involve at least two sets of bills: facility and equipment and possibly procedures (depending on who did them), and the doctor's charges. Nurses don't really take orders from doctors. They are _not_ assistants to doctors. They work with physicians in different settings and are often below them in a hierarchy in particular situations, but this is not on-going. They also carry out physician-prescribed patient care, but there's often a lot of leeway in how and when it happens.

One of the most important ways in which nurses and physicians interact, and which I didn't really get at all before school, is around medications. Nurses are the patient's last line of defense against medication errors. One of our instructors, Evelyn, told us never to "administer a drug if you don't understand the reason for its use." Nurses are responsible for knowing what any medication they are administering to a patient does and how, knowing why it's being administered to _this_ patient, who it shouldn't be given to and for what reasons, knowing whether and how it might interact with the other drugs the patient is taking, knowing correct dosages, dosage schedules, and all the various methods of administering drugs, and knowing what side effects are possible and monitoring for them and dealing with them when/if they appear. Evelyn has said, "if you don't defend your license, no one else will."

One of our [many] textbooks says that "nurses play a major role in promoting and maintainng client health by encouraging clients who need medications to be proactive consumers" (_Fundamentals of Nursing_, Craven & Hirnle, p. 495). We teach patients about how the meds they are taking might affect their lives, tell them what side effects to watch for, In fact, a lot of what nurses [should] do is patient education (which often includes educating their families) and advocacy (which often involves educating clients and helping them make decisions around the benefits and risks of different treatment options). We also engage in assessment and management.

So this brings me to a weird thing I have encountered, and did not expect to find, in nursing: the Nursing Diagnosis. Notes I've taken from my various textbooks lead me to explain a nursing diagnosis thus: a clinical judgment about individual, family or community responses to actual or potential health problems or life processes, which provides a basis for selection of nursing interventions to achieve outcomes for which nurse is accountable. Ideally the cause of the ND is something that can be treated by a nurse. This is weird, subtle animal, and clearly I'm not yet "thinking like a nurse"*, because I don't come up with the same diagnoses when given the same set of objective and subjective assessment data as others do.

*(This is a phrase often bandied about, occasionally, and frustratingly, in lieu of an actual explanation as to why a given test answer is not as good as the "right" answer.)

Among the unexpected aspects of nursing diagnoses is that they cannot share language with medical diagnoses, even though they are occasionally discussing exactly the same issue. For example, a nurse cannot diagnose a patient with dehydration, but can diagnose that patient with "fluid volume deficit." This is odd to me. There are lots of diagnoses that are "at risk" diagnoses: "at risk for falls" is a big one. I'm wondering how, when, and where nurses in hospitals, say, have time to come up with diagnoses and apply them--are they paid for that? is it part of their job description? The professionalization of nursing requires standardization, so there is a governing body, NANDA (formerly the North American Nursing Diagnosis Association), which "defines the knowledge of nursing" by publishing journals and references with standardized diagnoses, their typical signs, symptoms, and concomitant care plans and outcomes. I have a NANDA guide, and currently find the language somewhat mystifying, and occasionally impenetrable. There is definitely a nursespeak, and I'm frequently reminded of how far from fluent I am.

Finally, another cool thing about nurses is that, at least with all the instructors I've encountered so far, there's a lot of respect afforded, and credit given to, people just starting nursing school. Our instructors, while individually teaching a group of us, will say "we" in reference to nurses. We are encouraged to identify with being nurses already, even though we're far from done with our training. This is motivating, and actually has some parallels to letting beginning language-learners attempt to communicate with more adept speakers and each other: mistakes are okay, it's assumed you'll get there eventually, and you can only get there if you're working hard and trying stuff way outside your skill level. But you're not motivated to put in the time if the "experts" don't welcome you to join them and learn from them.

Throughout my time in academia, I never felt included by my instructors. It was always made clear to me that I was below them on some hierarchy that mattered to them, and that obviously they thought should matter to me, as well. I like this a whole lot better.