What Does it Really Take to be a Good Nurse?
I’ve often heard the complaint that nurses aren’t handmaidens and shouldn’t be treated as such. Head Nurse does a great job of addressing this in her post Handmaidens, Helpmeets and the Problems of Nursing. As much as I want to believe this, though, I have never been able to convince myself that this isn’t true.
To illustrate my point, I’ll give you a day in the life of working in the recovery room:
The charge nurse hands me a paper with a very minimal patient report. It usually includes the name of the procedure the patient had, any outcomes of the procedure, current vital signs, sedation and any other meds the patient might have received.
The patient is rolled in to the recovery room. I hook them up to the monitor and do a very minimal assessment (Are they awake? Are they in any pain? Are their vital signs within normal limits? Is the incision/puncture/drain site dry, clean, and intact? And most importantly, do they have a ride home?)
When I’m finished, I call the waiting room and let the family member(s) know they can come in.
I record vital signs and check on the patient’s site every 15 minutes for an hour. Sometimes this is extended to every 30 minutes for the next hour, sometimes it isn’t. If the patient is hungry or thirsty I’ll give them a beverage, perhaps some crackers, maybe even a turkey sandwich. Sometimes I will help them on to the bed pan. If the patient is nauseous, I call the doc and ask for some phenergan. If the patient has pain issues, I call the doc and ask for some Tylox.
If the patient’s vital signs fall out of wack I page the appropriate MD. If they fall precipitously out of wack I will have someone go to the procedure room of the appropriate MD and grab him or her. If they have no vital signs I will imediately call for help and start ACLS (this has never happened.) Sometimes the patient will bleed, or develop a hematoma at the puncture site. If this occurs, I hold pressure until it stops and notify the MD.
If the patient is being admitted I call report to the floor nurse. I unhook the patient from our monitor. If the patient is going to a monitored floor, then I hook them up to a transport monitor and take them to their floor. If the patient is going to a non-monitored floor, then I arrange to have a patient escort take the patient.
If the patient is going home, I give them some pre-printed discharge instructions, verbally explain them to the patient, and answer any questions. Then I remove the patient’s IV(s) and send them on their way.
Is what I’m doing skilled and technical? Yes.
Am I using autonomy or intellect? No.
Am I using my skills of compassion and care? You bet I am. One of the only things that make the tedium of nursing bearable for me is when I get a patient who is anxious, or has questions, or wants to talk about their disease. They talk, I listen. I might even hold their hand. I answer questions. Sometimes I ask them questions because I know that they just need someone to talk to. They want someone with medical knowledge to help them process what is happening to them. I’m happy to be that person.
To further illustrate my point I’d like to say that some of the best, most effective, and knowledgeable nurses I’ve seen are either diploma nurses or associate degree nurses. It doesn’t take a bachelor’s degree to do what they do.
So why is there this big movement to “intellectualize” the profession of nursing? At the university level they like to teach about the politics of the profession, and what nurses can do to gain more power. If that’s the agenda they want to push forward, fine. Maybe some day they will gain power and change our healthcare system for the better. But I think it does future nurses a disservice when they find themselves in their first hospital job, expecting to have all these autonomous, intellectual tasks but instead find themselves doing all the skilled, technical, and menial stuff. Sometimes I think that what the nursing shortage really comes down to is that there are these tasks surrounding patient care that need to be completed around the clock, and there aren’t enough nurses willing to do this kind of work.
But if the nurses aren’t going to do it, who will?
I'm a part time 
Well, I wouldn’t mind having you at the bedside if I was in the recovery room.
I often wondered why they made pharmacists have a mandatory PharmD degree. I have done just fine with B.S., although no matter what degree you still have to keep up over the years. I just wondered if the over clinical teachings really helped the guys that are in retail, for example, feel like they were then getting the short end of the stick.
PharmacistMike — August 26, 2008 @ 2:12 pm
Wow. This is exactly the issue I am facing right now in nursing school. I’m in an accelerated entry level master’s program in nursing. It seems that the faculty at my school are really hell bent on indoctrinating us into the importance of nursing research and theory, the difference between a profession and an occupation, and memorizing the ANA nursing Code of Ethics. Meanwhile, I’m being thrust into clinical situations where I’m being asked to perform technical tasks for the first time: foley catheters, IVs, NG tubes, wound dressings, etc — without much instruction! In my opinion, nursing education (at least where I’m at) has way too much emphasis on theory, and not enough of the day-to-day practical skill of nursing.
Wounded Healer — August 26, 2008 @ 3:00 pm
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Pages tagged "thirsty" — August 26, 2008 @ 5:17 pm
When I was a first semester student, we were basically techs in clinical, so any intellectual aspirations went out the window then. I think the reason why there is such a big push to “intellectualize” nursing is due to the shift of teaching nursing in universities.
To justify us having nursing departments in universities (versus all our training being done in diploma programs like the old timey days), they come up with all these fancy theories as to exactly WHY we choose to clean up poo and the most therapeutic and holistic means of approaching it. Universities are good at that, hence the gaping divide between the academic approach and practical experience of pretty much any job learned with college education.
Also, I think the intellectualization is a push to try to standardize the definition of a nurse. A lot of times people don’t know/appreciate what nurses do, even nurses don’t agree. What I think defines a nurse as a Gen-X person varies a lot from my supervisor who went to nursing school during the Pleistocene era and was working the day Moses coded himself (and hasn’t practiced on the floor since then). These differences reflect in the day to day staffing and politics of the unit.
Since there is so much knowledge to be crammed into a short period of time, the university based, theoretical knowledge wins over practical knowledge. Besides, you learn EVERYTHING you need to know that you didn’t learn in RN school in orientation, yes?
Anonymous — August 26, 2008 @ 6:05 pm
This post and some of the feedback have shined a light on the huge difference in registered nurses who enter the profession through an ADN program and those who enter directly through the 4-year university route. I started nursing in an ADN program attached to a hospital in New York City, Phillips Beth Israel School of Nursing. Given the school’s ties to Beth Israel Medical Center, the majority of our clinical rotations were completed there. And said rotations started approximately three weeks into the very first semester.
Couple that with NYU nursing students we’d occasionally run into on our units. They’d spent two or sometimes three years in university before ever getting to the bedside and when they got there, well, it would not be disingenuous to say that there was a certain air of superiority. The bed bath was beneath them. Injections all the time, and passing meds. Little did they know, passing meds would eventually become the most mundane of tasks.
Anyhow, I’m beginning to ramble. To wrap up, I graudated from the ADN program and worked a bit as a nurse, before completing my BScN (or BSN as they call it in the States). Myself and my classmates learned from the get go that being a nurse includes some very basic patient care at times. It isn’t all research and case management. I worry that those coming directly out of 4-year nursing degree are sometimes out of touch with what this job really requires.
I would proffer that those who find any idea of basic patient care distasteful aka baths, poop and feeding, perhaps consider a career as a physician’s assistant or doctor. There, you can be entirely hands off and let us nurses provide the direct care. The same nurses who, while feeding your loved one and wiping their bottoms, can also explain to you why their kidneys are failing in plain English and alert your loved one’s doctor to the fact he’s ordered a medication that is directly causing side effects he believes are the result of something else.
Just my two cents. There’s plenty of room in nursing for basic patient care and putting one’s mind to real use at the same time. It’s all saving lives.
Canuck Nurse — August 26, 2008 @ 7:13 pm
Hhhmm tough topic, but a very real in our world of nursing these days.
I think the BSN push may be a result of technology’s influence on nursing. It’s not a simple answer, nor a simple topic. LOL
I will agree with you, your degree means nothing to me nor does it have any correlation to the quality of your performance as a nurse.
The proof is in the puddin’, and the last time I checked a BSN, and a MSN, and a DN (yep… phD in nuring) still means your a registered nurse.
Strong One — August 26, 2008 @ 10:08 pm
When I talked to my nursing school advisor at UW, he told me my greatest downfall was going to be the fact that I have a lot of dialysis tech experience. He said that I had learned to be too hands on and I thought to myself, isn’t that what a nurse does? Hands on stuff…it kind of baffles me that a nursing school wouldn’t encourage hands on nursing! I am going to be a first year BSN student, he also added that half of us will fail which made me feel so much more confident.
Kim — August 26, 2008 @ 10:13 pm
One of the reasons why changed careers in the hopes of becoming an RN is that I was tired of working a job steeped in theory. Application of that theory was difficult and sometimes impossible. I was chained to a desk. I was good at that job. I had merit raises and praise on every evaluation. I had long, intellectual conversations about the profession (electronic records management) and its future. I was also bored.
I want to be part of a profession where I directly help people - even if that means wiping poo. I want to interact; I want to teach; I want to be active and busy! I want to care about people, even if it hurts sometimes. Hopefully, if I’m ever too tired or burned out to do that anymore, nursing will provide me with opportunities to help with other ways, possibly through theory and research. Theory and research aren’t my reasons for wanting to be a nurse, though.
Keep up the great posts! This is definitely stuff to keep in mind when researching nursing programs.
Alicia — August 27, 2008 @ 12:51 am
I went the long route to my MSN (Diploma - BSN - MSN) but feel that I gained the necessary clinical foundation to get the most out of those latter degrees.
The nice thing about nursing is that you can find places to work where you can use your intellect and make autonomous decisions if that’s what you like.
I like having that flexibility, and I feel like I have a more collegial relationship with the physicians I work with, as compared to places where I was granted little autonomy. If I couldn’t do anything but call every time I felt something wasn’t right, I’d feel like a trained monkey, not a nursing professional. The nice part is, I can call if I need to.
I have a copy of the Cardiovascular Nursing Scope and Standards of Practice and carry it with me for those occasions when someone wonders where their boundaries are.
Ken — August 27, 2008 @ 9:37 am
What Does it Really Take to be a Good Nurse?…
I’ve often heard the complaint that nurses aren’t handmaidens and shouldn’t be treated as such. Head Nurse does a great job of addressing this in her post Handmaidens, Helpmeets and the Problems of Nursing. As much as I want to believe this, though,…
Healthcare Today — August 27, 2008 @ 9:41 am
Oh man…what to say…
You know what? I’ll write it in a post! LOL!
Thanks for the inspiration! : D
Kim — August 27, 2008 @ 12:03 pm
If you want autonomy, go to anesthesia school. The Nurse Anesthetist is the pinnacle of our profession. I live in a gray space between nursing and medicine and I love it. I give 100% of my mind and skill to one patient at a time. I interview the pt., formulate an anesthetic plan, implement that plan, i.e. i establish lines and monitoring devices, perform a regional block, put in a spinal, or intubate the pt., assess vital signs and fluid status during the case and treat any disturbances. I communicate and collaborate with the surgeon and anesthesiologist (if there is one around. we can practice with just a surgeon, dentist, podiatrist, etc.). I basically assist the patient in maintaining homeostasis. If the pressure needs to be augmented, i treat it. If the pt. needs fluid or blood, i give it. If the O2 sat drops, I figure out the cause (accidental extubation, R mainstem int., atelectasis, embolism, just to name a few…) and I fix it. I take away a persons ability to breath, think, hurt, remember, etc. and I give it back at the end of the procedure. During the case, I become a physiological detective. I monitor all the data from my measuring devices and use my senses and experience to identify problems and prevent them from becoming life threatening/altering issues.
One of the biggest problems I face when working with students is helping them realize that they aren’t just Nurses anymore. They must be strong, independent, competent, clinicians who show initiative and can take a large amount of complex data, under stress and crunch it to see the “big picture”. I am a third generation nurse and am proud to be a nurse, so please don’t think I’m knocking the LPNs or ADNs out there. However, I know that BSN RNs receive a better science education and that is what we really need. Our product is care of the human body and soul.
Hypnos4hire — August 31, 2008 @ 10:28 am
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blogosphere buzz #2: “the intellectual nurses” » about a nurse — August 31, 2008 @ 11:17 am
yep, my comment is way too long, so i posted it on my blog. i hope you don’t mind :0
may — August 31, 2008 @ 11:41 am
my feeling is that the theory of nursing and the scholarly aspects of the profession were born of the old handmaiden days. It was a way for nursing to make its place as an intelligent profession and try to gain some respect from medicine and the public. The problem with this just for the profession itself is that some of our own look down at plain old bedside nursing. And we need bedside nursing more than ever.
Having just completed an MSN program, I have to say that true automony comes with advanced practice. However, there are times as a nurse that I make autonomous decisions. The rest are tasks and the art of caring for laboring women.
Labor Nurse — September 1, 2008 @ 9:01 am
I think you have put your finger on the pulse of the needs of higher education in conflict with the needs of the profession of nursing.
The professions of nursing, dentistry and similar professions have a need for a wide range of skills, from rank and file who practice the routine skills all the way through to sophisticated researchers who need both basic and advanced skill sets as well as exceptional literacy, data manipulation and analysis skills, and much more. To continue to have the latter group exist, we need to have Schools of Nursing (etc) in institutions of higher education training people with advanced degrees to do the advanced work.
In institutions of higher learning, especially in economically lean times, each school is asked by top administration to justify the continued existence of the school on ACADEMIC merit, not compassionate merit or need for the workforce. The result of the continued existence of the school being dependent on academic products (i.e. top level researchers and managers who will influence the future shape of the profession) pushes the schools to create exactly the sort of environment you describe.
The alternative is to shift the education for the profession to community colleges and similar schools. But if this happens, you won’t find the other role represented (researcher, leader, manager, influential decisionmaker), and the future and shape of the profession will depend on persons outside the profession.
The choices are small and local (or individual), the ramifications are huge.
PF Anderson — September 1, 2008 @ 7:33 pm
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