Florence Nightingale is reported to have said, "Being obedient is a great quality for horses and dogs, not nurses." Although it is not known what circumstances prompted this statement, it is not hard to imagine what might have happened. Some physician or administrator placed demands on her (or the nurses) that she felt she could not handle while remaining an advocate for the patient.
Advocacy is a very important role for nurses. Patients are vulnerable at many points during their care. Simply not understanding fully what is happening or going to happen to them creates an inability to control the outcome. Using a simple analogy, if you saw someone bag your groceries and put the eggs and bread at the bottom of the bag, you would stop that person because you know the outcome. On the contrary, if you saw a repairman wiring your new appliance incorrectly but did not know it was wrong, what could you do? You would likely have to wait until some malfunction occurred in order to appreciate what had happened.
Consider this scenario: A nurse was hired by a physician to work in his office. She had little to no knowledge of the kind of work she would be doing, because she had never worked in an office-based operating room. On being hired, she told the surgeon that she did not know about operating-room nursing, and he agreed to train her. So he did train her to "do things his way"-and his way included cutting corners by reusing supplies and not buying protective equipment. When the nurse asked him about these procedures and the way he was teaching her, she was told that because it was an office, the usual things done in a hospital operating room were not necessary because the risk of infection was much less. Patients started talking about how odd the care by these two clinicians seemed; then serious complications started to occur.
Several questions emerge from this story. Can a nurse do the wrong things under the guise of acting under the instruction of the physician? Does the physician's knowledge supersede the nurse's? Should a nurse speak up about "cutting corners" when patients may suffer? What if the physician considers these areas "variations in his practice" and will not change, claiming that if the practice cannot make a profit, it will close? What if the nurse might lose her job by complaining? Who serves as a regulator of private practices? Should every nurse seek independent education in her area of practice so that there is some third party guiding care?
It is my opinion and, I hope, yours too that nurses are licensed as independent professionals by each state. That license requires that each nurse act in the best interest of the patient by serving as the patient advocate. Knowing how to advocate means that each nurse must be trained adequately in basic procedures for the setting, keep up to date with changes in practice, and feel personally responsible for each patient under her or his care. That may mean finding education to practice safely, attending conferences, obtaining advanced education, and reading on your own. Undoubtedly, being loyal to colleagues in a practice is important to maintain a positive work environment. But loyalty and obedience cannot be blind when patients trust you with their lives and limbs; you must act professionally as their advocate.
Joyce M. Black, PhD, RN, CPSN, CWCN
Editor