Ripping the Heart Out of a Nurse

Death Valley - photo by JoAnn Sturman

Scott Sturman
fliesinyoureyes.com

“Common sense is not so common”
Voltaire - French philosopher and writer 1694-1778

A call comes from the recovery room nurse caring for an out patient who is ready to be discharged after a minor surgical procedure, “Doctor, Ms. X. is ready to go home and you ordered Vicodin one or two tablets as needed before leaving the hospital. How many pills do you want me to give her?”

I know the nurse is as frustrated as I am. When this same patient, who has no medical training is discharged from the hospital and picks up a prescription later that day from the pharmacy, the instructions will read: “Vicodin 1-2 tablets every 4-6 hours as needed.” The patient will be required to make three simple choices: should I take the medication, should I take 1 or 2 pills, and should I take it every 4 or every 6 hours? In the hospital setting a registered nurse with years of experience caring for surgical patients is not free to make these decisions independently.

Last year the hospital administration declared nurses could not start routine IV’s on patients prior to surgery even though preprinted orders were in place. For nurses to do so was construed to be performing a procedure without adequate authorization from a physician. Even though placement of a preoperative IV is historically a nursing responsibility, nurses were expected to call the physicians at any time during the day or night to clarify the order. It is difficult to imagine not wanting to have an IV started prior to an operation, but to some nursing administrators this simple concept morphed into a complicated scenario.

Every year in a national poll nursing is selected as one of the most respected professions in the country. Nurses are lauded for their compassion, dedication, competence, and communicative skills but not the manner in which they fill out paperwork. Ironically, nurses are being forced to spend less time with patients and more time charting and attending to other clerical responsibilities. The explosion of information required for the medical record has transformed it into a legal document rather than one which highlights only pertinent medical information.

An observation in regard to medical documentation: most of it is never read unless by an inspector during an internal audit or by a lawyer in the case of malpractice litigation. Information which is accessed frequently such as the patient history and physical examination, orders, vital signs, medication lists, fluid status and laboratory results is important and should receive priority. The rest is boiler plate, a waste of time, and undermines patient care.

Many years ago while in the Air Force I had the misfortune of serving under an incompetent commander, whose primary motivation was promotion to colonel rather than improving the operational capability of the unit. He was paranoid that the slightest mishap would jeopardize his career, so he discouraged all but the most routine air rescue missions and kept his pilots out of the cockpit and at their desks filling out form after form. He believed, “the safest flight is the one that never takes off.”

In many ways hospital administrators and government bureaucrats remind me of my former commander. They discourage independent thinking and emphasize documentation at the expense of patient care. We all know the reason: any mistake puts their careers at risk and exposes hospitals to litigation. Supervisors play it safe and initiate overly restricted rules which are made for the lowest achievers. Transforming nurses into clerks and not taking full advantage of their intellectual talents may be the best strategy for personal careers and dealing with lawyers, but it is not the best for patients.