Transforming Care: A Christian Vision of Nursing Practice (30 page)

Acute care nurses are highly educated professionals, and their practice in
the acute care setting involves extensive amounts of responsibility and
leadership. Registered nurses have legal and professional responsibility for
providing care and evaluating the client's status. On a given hospital unit
the decision-making authority with respect to nursing care rests with the
RN. Licensed practical nurses (LPN), unit assistants such as secretaries and
supply managers (UA), and nursing assistants (NA) are under the direct supervision of the nurse and report all care information to the RN. As Patricia Yoder-Wise notes, "Today, virtually every professional nurse leads
and manages regardless of title or position" (Yoder-Wise 2003, x). Effective
leaders have the capability of assisting and empowering other staff members. Nurses in a leader/manager role work to advocate for excellence not
only in client care but also for fellow staff members. The nurse leader holds
a unit in trust, and the decisions he or she makes may affect the health and
well-being of many people. Improved client care as well as improved staff
morale and well-being can be truly rewarding. Nurse managers derive a
great deal of satisfaction in planning for resources and nursing care delivery systems that enable nurses to work more closely with their clients and
to provide the highest possible quality of care. All nurses, whether administrators or not, have positions with heavy responsibilities. While administrative nurses have responsibility for the operation of the unit and hospital
departments, the ultimate responsibility for care of the client is with the
staff RN assigned to that client.

An RN is indispensable within a hospital and is often expected to fill
many roles. Legally an RN must be present to supervise, deliver, and/or
give care. Evaluation of nursing care is also a part of the staff nurse's responsibility. He or she must determine whether the projected outcomes of
care have been met. Nurses are a central part of hospital care because the
hospital cannot function without them. Other staff members may be cut
for budgetary reasons, but nurses cannot be cut since the care they provide
is the reason for the hospital's existence. One result of this is that staffing
cuts tend to result in extra work for the nursing staff. If the unit does not
have a secretary scheduled for the shift, a nurse will fill that role and provide the clerical support needed - noting physicians' orders, answering
the telephone, filing routine reports and documents - all in addition to
the nursing care that he or she is assigned. Under these conditions nurses
are required to complete tasks that do not require nursing judgment or expertise.

The expectation that some administrations have that nurses are appropriately used in this way indicates the confusion people sometimes
have about the nurse's education and proper role. This confusion is not
limited to the administration. Many clients do not know the difference between aides and nurses, or between the different types of nurses that are
involved in their care. Based on outmoded models of hospital organization, many see any woman in a uniform as a nurse - and as a subordinate. Blurring of the nurse's role can be a common problem. Clients are not the
only ones who have trouble with a clear understanding of the nurse's role.
Physicians do as well, and when others do not understand what the nurse's
role is, it creates difficult issues for the nurse.

Cassandra Novak is the nurse in charge of caring for a young man
named Rick who has a serious head injury. She is on the telephone, attempting to contact a respiratory therapist who is urgently needed for another client, when Dr. Johnson, a physician known for his lack of interpersonal skills, approaches. Ignoring the fact that Ms. Novak is on the phone,
he begins quizzing her about Rick's status, asking for information that has
been documented in detail on Rick's chart and is readily available.

Ms. Novak covers the mouthpiece of the phone with her hand and
says, "Dr. Johnson, I have a serious situation here with another client. That
information is documented, in detail. Couldn't you take a look at the
chart?"

"How do you expect me to find what I need in that computerized
mess?" Dr. Johnson asks.

"I'm expected to read your progress notes," Ms. Novak responds with
an edge to her voice. "Couldn't you take the time to read mine?"

Dr. Johnson is now very angry. "Nurse, I can ask you any questions I
want and you are obligated to answer! Do you want me to report you for
insubordination?"

"That would be impossible," Ms. Novak shoots back, in a voice devoid
of any respect, and with a slight smirk on her face.

"And why would that be?"

"I'm not subordinate to you, so how can I be insubordinate?"

Dr. Johnson's face is red, and his voice is not steady. "Oh yes, you are
subordinate to me!"

Ms. Novak's voice has gone up a notch as well, but she holds her
ground. "No, I work for the hospital, not for you!"

Dr. Johnson ends the interaction by stalking from the unit. He did not
get the information he needed about Rick, and so he did not enter the
needed care directives in the chart. Nurse Novak's response to him was
true and her irritation at his behavior understandable, but the tangled
lines of interpersonal communication result in diminished client care.

As Dr. Johnson and Nurse Novak interact with one another, we recognize the fragile emotional state they may be in. The acute care context is
highly stressful, and health care workers deal with devastating difficult is sues on a daily basis. We've already noted how this can affect the individual
professional, but it also has important consequences for relationships between professionals. Both of these individuals come to this interaction
with a narrative, stories that make sense of their work and their lives. Physicians often have a great deal of personal identity invested in the respect
that their job generally brings. Challenges to their professional status are
felt to be attacks on their worth as a person. Nurses, likewise, are highly educated professionals who hold positions of power and authority in the
health care system.

To make the situation more complicated, the relationship between
nurses and physicians has been redefined over the past few decades, and
though most physicians have adjusted to this redefinition, there are a few
who see these changing roles as threats to their own prestige. By claiming
that the nurse was subordinate to him, Dr. Johnson attempted to assert his
own authority and control over his nurse colleague and fellow professional. Ms. Novak's response did nothing to defuse the situation, in part
because her own sense of prestige and identity were at stake. We can understand how both parties to this dispute felt badly used and disrespected;
we can also recognize that the breakdown in professional relationships
posed more of a risk for the client than for either of the two caregivers.

For the sake of the client's well-being and for the sake of their own
ability to do their jobs well, both Nurse Novak and Dr. Johnson need to
work on developing a working relationship that includes a clear sense of
personal boundaries and appropriate professional interaction. Mutual recognition of the skills and abilities that each of them brings to client care
would help this process. Physicians bring an extensive educational background and current medical research to the client. The nurse has a similar
yet different body of knowledge from her or his training in the nursing
profession. The nurse brings knowledge of different cultural practices with
regard to health and strong interpersonal skills in providing support and
comfort to those who are suffering (Sledz 1997). Nurses and physicians
may learn a great deal from each other if they are willing to demonstrate
an interest and to listen. In the stressful, acute care environment, tempers
may flare quickly in interpersonal relationships, particularly when the client is doing poorly and not responding to treatment.

Again, the Christian nurse has resources for thinking about the challenges of interprofessional relationships. No matter how flawed other professionals maybe, they, like clients, are bearers of the image of God and de serve to be treated with courtesy and respect. Because others are made in
the image of God, however, it is also appropriate to hold them responsible
for the ways in which they use their power and authority. Nurses may at
times be required to adopt a prophetic stance in dealing with those in
power in the acute care setting, responding to abuses of power with a word
of rebuke or warning. When physicians run roughshod over the nursing
staff it is detrimental to all aspects of hospital functioning, and such physicians can properly be held to account for their choices.

Gender issues have colored nurse-physician relationships since the beginning of modern health care. Some of the traditional stereotypes of masculine, authoritative physicians and feminine, subordinate nurses still linger in people's minds. Of course, it's no longer true that all doctors are
male and all nurses are female. But apart from that obvious fact, the reality
is that nursing is not a subordinate profession in medicine, and nurses are
skilled professionals who play a leadership role on the health care team.
Most care-givers, physicians and nurses both, would not have it any other
way, but some feel threatened by relationships that are more a matter of
equal partners than that of dominant and subordinate.

In cases such as these, our earlier discussion of care and justice may
provide helpful tools for thinking about how to respond to difficult interpersonal conflicts. The importance of care reminds us that we need to focus on the most needy and vulnerable in a situation. In the case of Ms.
Novak and Dr. Johnson, it is the client, Rick, who may end up paying the
price for the breakdown in communications. If we are striving to become
caring people, we will recognize that sometimes our justified annoyance at
another's obnoxious behavior needs to be set aside so that those who are
dependent on us are not harmed or put at risk. If Ms. Novak was not at the
end of a shift, tired and frazzled, she might even find it possible to feel
some compassion for the physician whose sense of self is so easily threatened. However, if Ms. Novak worries only about care, she might make not
take the steps that are needed to bring about change in nurse/physician relationships in her hospital. If Dr. Johnson is treating her this way, there is a
good chance he treats nursing students, aides, and perhaps even clients just
as badly if not worse. Those who use power abusively often do so in many
different situations. Ms. Novak may need to consult with her supervisor, or
discuss the situation with the hospital administration, to make sure that
Dr. Johnson's behavior does not cause worse problems in other cases. Justice reminds us that ignoring the misuse of power is just as wrong as failing to care for the vulnerable and dependent. In fact, failing to do justice may
make it difficult to provide care.

Interprofessional relationships can be sources of frustration and difficulty even when both professionals are nurses. Take the example of Kathy,
a nurse who had worked over several days with a family to accept the fact
that their brain-injured son would not recover from his automobile accident. The parents trusted Kathy and responded affirmatively when she
brought up the possibility of notifying the organ donation team to see if
their son's organs were viable for donation. They experienced some comfort in the fact that their tragedy might at least provide hope for someone
else, but they wanted to spend time in the room to say good-bye prior to
the termination of life support. In the middle of this event, the charge
nurse approached Kathy and told her that she must leave and go to another unit immediately to take a new admission. Kathy explained about
the relationship she had developed with the parents and what was taking
place, and she asked if another nurse could go to receive the admission.
Saying "That boy is dead, we need to get on with things," the charge nurse
told Kathy that if she did not go now, she would be terminated. Kathy was
a single mother and dared not risk her job, at least until she could find another. She went to take the new admission. And she did find a new job,
eventually, but not in nursing.

The charge nurse could have used her authority and power in this situation to enhance the quality of care and support that Kathy wished to
provide to the family. She used it, instead, to force compliance with her orders. When we are put in a position of authority, it can be very tempting to
use that authority for our own benefit, rather than for the benefit of others. Presumably the charge nurse's life was made easier by not having to
find another nurse to take care of the new admission, even though her use
of authority caused suffering to the family whose son was dying. Misuse of
power in professional relationships can increase the suffering of those who
are vulnerable. In the context of acute care, the vulnerable are extremely
vulnerable, and so misuses of power can have devastating effects.

But Kathy's response can be challenged as well. She chose not to confront her supervisor, and later she chose to leave nursing without fighting
for change. Sometimes this is appropriate, of course, but other times the
Christian nurse should recognize that she or he may have a responsibility to
speak the truth to power. When a supervisor is using power in ways that are
harmful to the functioning of the health care team as a whole, concern for clients and for the other members of the team gives us reason to think
about whether the supervisor needs to be challenged. The challenge should
not take the form of personal attacks or anonymous letters, obviously. As
Christians we are called to be creatures of the light. Part of our responsibility as members of the kingdom of God is to be willing to speak the truth
openly. At the same time, we need not do so in ways that are guaranteed to
be ineffective. An obstreperous supervisor will not be restrained by one
person's complaint. But when the whole unit reports to the administration
that a charge nurse is abusing her authority, the administration is more
likely to take the charges seriously and to respond productively.