I had the unique opportunity to shadow a nurse this morning as part of my clinical skills class, where we are wrapping up the year with brief tastes of surgery, pediatrics, emergency medicine, and other specialties and settings to which we have not been previously exposed. She was part of the maternity unit, which was great to see, although it certainly reinforced my conviction that pediatrics is right for me since I was paying much more attention to the newborns than to the moms.
It was a valuable chance to gain some perspective on what roles nurses actually play in patient care (answer: many, and important ones) and see what her day was like. But beyond just getting a chance to observe, I benefited from her being frank and philosophical about her profession. I asked her what the hardest thing was about being a nurse, expecting her to say something like working with difficult patients, witnessing individual and family tragedies, or having to perform tasks like cleaning up after patients who lose control of their bowels. Instead, without a pause she introduced me to the phenomenon of “nurse guilt.” The hardest thing for her, she said, is that every time she is with one patient she cannot be with her other patients; if someone pages her and she doesn’t leave then she isn’t caring for that other patient, and if something urgent happens and she does leave then she is taking herself away from the first one. (Compare this constant juggling and balancing act to the physician or medical student’s “snapshot” model of checking in on each patient once or twice a day without having any idea what has been going on in the hours that I have been gone but the nurse has been caring for the patient.) Caring for the patients in every sense of the word is so deeply ingrained into her and such a big part of her identity as a nurse that she feels guilty when she can’t be there for everyone and tries so hard to take care of all of her patients, sometimes to her own detriment. I watched a perfect illustration unfold as the nurses gathered to shift patients to another nurse just starting her shift. All the nurses, including the one I was following, had been running around busily all morning keeping up with the myriad things each patient needed; the nurse I was following still hadn’t had time to sit down and eat her breakfast, and by now it was almost lunchtime. Yet each nurse struggled as she looked down her sheet to pick the patient she would hand off, saying about each “oh, she’s having such a bad time, I want to stay with her” or “she’s going to be a lot of work, I wouldn’t want to push her off on someone else” or “but she’s so lovely!” Even the most overloaded nurses had a hard time giving up any of their patients.
A corollary that my nurse alluded to that I think is the most important lesson I got out of the morning, related to the fact that nurses are the ones who execute the orders that doctors decide on, but that this can create problems given the aforementioned “nurse guilt” – their dedication to each patient. She gave the example of doctors who order that particularly sick patients have certain signs checked every two hours, but that in order to take care of all her patients she may not be able to do it until three hours have passed. She’s already going to feel guilty because she wants to provide the best care and knows that two hours would have been better for the patient. Furthermore, I can easily imagine being that doctor and pulling up the chart, seeing that three hours had gone by, then carelessly berating the nurse for not following the order and for providing substandard care. For someone who is so dedicated to her patients, that insinuation would be both insulting and crushing.
The most common advice for medical students on the wards that I’ve picked up from older students and residents is to get on the good side of the nurses you are working with: they can make your life on the unit heaven or hell. While I’d like to think that I would already be inclined to be respectful of the nurses (intentionally avoiding still-very-prevalent doctor chauvinism), getting greater insight into the nurses’ “psyche” helped me see how the structure of the hospital system could reinforce the rifts between physicians and nurses and how some empathy for their position can help me value their contributions to the patient’s care and to the team’s understanding of the case and avoid the pitfalls that the “snapshot” role brings.
