Thursday, February 21, 2008

the influence and power of being a nurse

I have always felt the weight of the influence I can exert as a nurse in my sphere of the world - acquaintances sidle up to me and ask for advice on this or that ailment as we mingle at social gatherings; my emphasis on the importance of this or that medication contributes to patient compliance on discharge; a failure to stress the importance of chest physio or leg exercises or sitting out may make the difference between a complication free recuperation or not.

Conversely, what I say may make no difference at all. Which nurse hasn't experienced the mortification of educating a patient only to have them ask the doctor the self same questions? Of course when the doctor advises them of the exact same information we provided, they sit up and listen as if it is news they have never heard before and we, silly nurses, are left looking incompetent and uninformed.

What fascinates me is the subtlety with which a person can be swayed. A couple of weeks ago I was looking after a patient who needed significant rehabilitation, but he had no insight into this. In fact, because he was improving physically he was convinced he was ready to discharge straight away. He repeatedly asked why he could not leave today and I repeatedly advised him of the need to wait for a place in the rehab unit in order to ensure he was fully ready for discharge. He wrestled with the constraints of the delay, but with constant redirection he could be reminded of how useful waiting would be. His wife backed me up in reinforcing the situation.

The next morning another nurse sailed into the room, listened to the patient's pleas for discharge and, before providing any care in terms of assistance with daily living or observation of mental capability, decided he could see no reason why the patient could not be discharged. The next thing I knew the patient was surrounded by his four young children advising me he was going home to be with his five children. The children stared rather strangely at him, because in truth there were only four of them, but they still smiled with shy joy, for dad was finally coming home. Suddenly occupational therapists, physios, doctors and the charge nurse were all milling around trying to ensure the patient would be well supported at home despite his decision to discharge himself against medical advice. The patient was discharged into his wife's care with a full range of community support in place.

I can't help wondering what role the patient's allocated nurse played that day. When I cared for the patient the day before there had been no talk from the wife or the patient of going home immediately. We continually steered the conversation back into the safe waters of rehabilitation. What did that nurse say that day to convince the patient he might succeed in his quest to go leave hospital?

I was so curious about this I actually challenged the nurse about his actions and comments to the patient and his wife. He looked wounded as he defended himself, assuring me he had said nothing that might be construed as encouraging the patient to discharge himself. But I am not convinced - nurses have influence, patients listen to what we say. They observe our actions, they notice our attitudes and they make decisions with this in mind. That nurse only needed to imply agreement with the patient's readiness to discharge and it could have been enough to convince him to pursue the option.

Two weeks on, I wonder how he's going, the too-soon-discharged man. Is his wife coping with the demands of someone who in all truth needed rehabilitation? What impact is his early departure from hospital having on those four young children?

Maybe I will never know, but one thing I am sure of is this - what I say makes a difference to my patients. Whether I like it or not, a great deal of power is vested in my status as a nurse, and with that power comes the responsibility to work through the implications of my influence for a patient's good or bad. It would be beneficial if I used my power wisely and carefully in order to achieve the best outcomes possible for those entrusted to my care.

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