Nerissa --

Good to hear from you again! I certainly did not want to shut down a conversation – always a risk when responding too fiercely in this sort of forum, which is why I usually try not to (mostly...).

Anyway, thanks for coming back & clarifying.  I concur with your desires for quality patient care & respecting patient wishes, and your impression that they are sometimes entangled & messy.   I hear a couple of issues, then:

1) Frustration with what seems like excessive documentation required of practitioners
2) Attributing that excessive documentation to a need for protection from liability & patient lawsuits
3) Validity of medical/ nursing claims to expert knowledge
4) Relationship of that ‘expert knowledge’ to patient preferences (requests, wishes, etc.)
5) How nurses should negotiate those relationships with their patients, other providers, systems, etc. (or, what do we DO about this big ol’ mess?)

There are probably others, but that seems like plenty to start with.

#1 and #2 are interesting and important, but a bit off to the side for a philosophy list. I would just say briefly that no-one here is going to argue with the claim that there’s too much documentation, though it may not be quite so easy a problem to fix as you might think. What you are describing sounds like what we used to call “defensive charting” – always a bad idea.

I think it would be great if more nurses (and others) went to their risk-management departments and said, look, you’ve got to figure out another way to deal with your anxieties and fears – medication,  perhaps?  It would also help if hospitals & healthcare providers were a bit more candid and straightforward when we do make mistakes.  Meanwhile, I would still argue that you over-estimate the extent to which you are “putting your job at risk” when patients reject your advice.

In terms of  #3, 4 , and 5 – those might be good topics for a nursing philosophy list, eh?

You wrote, “I disagree with Stephen Padgett who seems to think that since medical standards change over time we should assume patients are as likely to be accurate in their medical assessments as nurses and other trained medical professionals. Fact is the patients are likely to know less about what works than we do.”

I think there are LOTS of reasons to be a bit skeptical about medical assessments, diagnostics, prognoses, and announcements about “what works.” The fact that those assessments have changed over time is only one reason. I’m not saying wholesale rejection of all medical claims, anyway – I’m just saying, a bit of skepticism. We could be wrong. This might be our best understanding right now, but it’s only that. A bit of humility in the face of life’s mysteries?

And even if we’re not “wrong”, we may not be completely “right.” Our truths are only a part of the story, and it might not be the part of the story that our patients are most interested in.  We don’t need to debate medical facts with our patients; they don’t have to know the same things we do. They just might know more about “what works” FOR THEM than we do. And mainly – here’s where epistemology bumps into ethics, I think –- they get to make choices that are not the choices we might make, or that we might want them to make.

So yes, absolutely we should “keep up” with the research to find out the latest & best thinking. But if we really “don’t have a clue”, as you put it, then how is “the patient not following our advice” really a problem?  I don’t know if you mean to imply that we should present all our advice with cheery confidence, regardless of how we feel about its validity... surely not? As if for some kind of “placebo effect”? surely not? But I know that many others do proceed in just that way.

And the nurse’s role in negotiating all this? For whom are we working, and WITH whom, and how? Lots of questions, I think, but I’ll stop there.

Here’s to respectful dialogue!

Stephen Padgett


On Wed, 19 Nov 2008, Nerissa Belcher wrote:
>> Date: Wednesday, November 19, 2008, 4:10 AM
>> Hi everyone,
>>
>> It appears my position has been mis-interpreted. What
>> I'm trying to say is we need to provide quality medical
>> care while respecting our patients. As for protecting
>> ourselves with documentation if only it were not necessary.
>> In the USA, however, nursing is much more about
>> documentation than patient care. I'm a new nurse but was
>> a podiatrist for twenty years. The same rules applied to me
>> as a foot doctor. Documentation requirements in the USA (UK
>> too?) are out of control. But, like it or not if we wish to
>> retain our employment we do what we're paid to do. Which
>> is to document. A major reason I got out of podiatry is I
>> wasn't paid to document. Each and every ridiculous new
>> documentation requirement to come down the pike did not come
>> with any funding for it. As advantage of nursing is as
>> ridiculous as the requirements are if someone wants to pay
>> me good money to write for the 10,000th time my nursing
>> focus about pain control and preventing falls (hint to the
>>  administrators - I got the ideas well before writing them
>> down for the 100th time) then so be it. I can cash my checks
>> in good faith.
>>
>> Getting back to patient care the ethical issue is when
>> quality care conflicts with patient desires. I disagree with
>> Stephen Padgett who seems to think that since medical
>> standards change over time we should assume patients are as
>> likely to be accurate in their medical assessments as nurses
>> and other trained medical professionals. Fact is the
>> patients are likely to know less about what works than we
>> do. If they decide not to follow our advice then we should
>> support them in doing so but not put our jobs at risk by
>> failing to document the discussion.
>>
>> Additionally I wish to point out that patients will more
>> likely follow our advice if we show confidence in ourselves.
>> I.E. if we really believe we don't have a clue, since
>> things are always changing, patients will be prone to not
>> following our advice. IMO part of being a professional is in
>> keeping up with our studies so our advice is as current as
>> research allows.
>>
>> Nerissa
>>