The recent New York Times article, 'How Tech Can Turn Doctors into Clerical Workers,’ presents a unique perspective of a pervasive problem plaguing our current healthcare system. The author writes, “In America today, the patient in the hospital bed is just the icon, a place holder for the real patient who is not in the bed but in the computer.” The clear image depicted in this statement is alarming, but, as I believe most would agree, unfortunately accurate.
As I reflect on this article, I begin to ponder, where is nursing on this issue?
Since its’ inception, nursing has been the leader of healthcare coordination and delivery. I love the description of nursing published by the American Nursing Association (ANA):
"21st Century nursing is the glue that holds a patient’s health care journey together. Across the entire patient experience, and wherever there is someone in need of care, nurses work tirelessly to identify and protect the needs of the individual...nurses are best placed to take an all-encompassing view of a patient’s wellbeing.” (For the full description, visit the ANA website, page 'What is Nursing?')
The answer to my question hits me like a ton of bricks — nursing has been caring for the wrong patient.
More and more, I witness nursing no longer being the advocate for the patient in the bed (“the icon”) but the advocate for the patient in the computer (the “real patient”). I’ll never forget the enlightening experience I had with the first surgical patient I cared for in the hospital as a nurse practitioner. I worked for a plastic surgeon, and my role in the hospital primarily consisted of first-assisting in surgery, and admitting/discharging and rounding on the patient, as indicated, following surgery. The morning after this patient’s surgery, I arrive at the hospital and begin chatting with the patient about her overnight experience while I examine her surgical site. As I ask about how helpful the nursing staff had been in helping her get out of bed and walking around, I was shocked to hear her answer that no nurse helped her out of bed or walked with her. I finished my exam, and went to find and reprimand the nurse for what I perceived as a gross lack of care for my patient. Once again, I am shocked at the response I was given. The puzzled nurse carefully pulls up my patient’s chart and begins to show me her perfect care of my “patient.” She then points out that no activity order had been entered, so, of course she had neither gotten my patient out of bed nor walked with her. I was speechless. The nurse and I were caring for two different patients — the nurse was caring for the “real patient,” and I, “the icon.”
This modern day, “real patient,” has monopolized our attention; testament to this can readily be observed in both the direct provision of care and in the communication within the interdisciplinary care team. A recent conversation with a frustrated surgical resident revealed the inordinate number of times he is paged by nursing to scrub out of surgery and enter orders in the computer.
Another example scenario is described in the New York Times article about a personal experience had by the author of being in the emergency room as a patient for a sudden asthma attack. He offers commentary on the nursing care he received:
"The nurse came in regularly, but not to visit me so much as the screen against the wall. Her back was to me as she asked, “On a scale of 1 to 10, with 10 being great difficulty breathing ...?” I saw her back three more times before I left.”
It is very easy to identify in all of the above examples which patient was the focus of nursing care.
Nursing vigorously advocates and defends the “real patient,” often citing protocol as an acceptable rationale for any ridiculous request. My first job as a nurse was in the operating room at a hospital as a circulator and scrub nurse. While in training (what was called a “nurse residency program”), I remember being in a case where a 9-0 suture was missing from the final count. The nurse I was training under insisted on an x-ray being ordered before the patient was closed. One of the surgeons became very upset at the nurse’s insistence, as he explained a suture that small cannot be detected on x-ray and there was potential for greater risk to the patient by leaving the patient open the additional 45+ minutes that it takes to get an x-ray completed. When I gave credence to the surgeon’s rationale, I was chastised along with the surgeon for trying to go against protocol, as the supervisory nurse further explained that "protocol" required her to document that an x-ray was completed. The nurse was protecting the “real patient” and the surgeon, “the icon.”
My intention is not to cast blame over nursing but to cue a call-to-action. The definition of “patient” needs to be shifted back to the people who trust us with their care.