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:-) Interesting discussion Nerissa. not going to address most of it at all - you have already encouraged far more dialogue than i usually muster. I am surprised a bit that anyone would leave any field because of documentation to enter nursing since the demand for nurse's documentation is the worst I have ever seen in any profession. But that does raise a couple of points. I am not at all sure that nurses are being paid to document. yes, the demands for documentation grow exponentially - but i really don't think there is a general consciousness that the documentation is reimbursed - rather, i think, there is a poorly documented assumption that nurses are delivering care and the documentation is a little tweak. not to say that there is nobody that recognizes that 50 - 60% of most nurse's time is spent documenting rather than caring - just that little is done about it. I used to teach a legal issues in nursing class - and one of the things i kept trying to stress is that the way nursing has embraced documentation is actually working against a nurse's ability to defend him/herself in court. Documenting the same act in 99 scattered places in a patient's record (we'll get to medical professionals anon) serves no good purpose legally if the 100th place is left unaddressed. Given the propensity for clerical errors, the more instances of documentation we require the more likely that one or more instances will be omitted, and the mere omission may win the day in court. The obvious solution would, of course, be to dispense with documentation totally, thereby effectively thwarting the least appropriate but most successful malpractice strategies of litigants. This seems so obvious and yet, as you note, most people clamor for more. Each new administrator comes with some specialty focus, a desire to improve the environment, and little or no commitment to reduce paperwork and duplicative documentation - often adding a new form containing mostly redundant information, but not eliminating the forms introduced by his/her predecessors. There is a very troubling downside to all this - since 50 - 60% of nurses' time is spent in non-clinical activities, and since we are coming to some very dire budgetary issues as the economies around the world tank, when the correction is embraced, we run an exceptionally high risk that there will be an absolute glut of registered nurses, with declining salaries, declining status, and declining job security. Yet, the powers that be in nursing education seem wholly unmindful that the expansion of nursing programs at every level is simply as unsustainable as the business practices of the big three domestic automakers, Lehmann Bothers, ENRON, or AIG. So, what is desparately needed is a cohort of nurses brave enough to challenge the utility of documentation practices before the correction is imposed on nursing, by the same forces that introduced the delightful practices of mismanaged care, capitation, and DRGs. Now, just a minor issue about medicine and medical that i may have misunderstood. I don't practice medicine - not licensed for it, not interested in it, and there are already plenty of people who do it as badly as I possibly could hope to do. I do practice nursing, the field i chose to enter, trained for, and work at from time to time. And there are good reasons for doing so - patients, as you note, often elect not to follow medical advice - but i think they are far less reluctant to follow good nursing advice - we just have to be very careful and make sure we are providing good nursing advice and not merely echoing the medical advice they have already chosen not to heed. nursing advice, in this context, involves listening to the patient, understanding why they are not going to do what the medical folks want them to do, and supporting them in how they are going to proceed. yes, there is often a conflict here - nurses get paid by medical institutions and deal with a lot of medical practitioners - but the worst conflict is that so many nurses 'think' they are medical rather than nursing practitioners... bear --- On Wed, 11/19/08, Nerissa Belcher <[log in to unmask]> wrote: From: Nerissa Belcher <[log in to unmask]> Subject: Fw: Re: dignity -- say what? To: [log in to unmask] Date: Wednesday, November 19, 2008, 4:31 AM Once again I assumed the default setting for this group was "reply to all" so I accidentally sent my reply to an individual. That message is being forwarded to the group. Nerissa --- On Wed, 11/19/08, Nerissa Belcher <[log in to unmask]> wrote: > From: Nerissa Belcher <[log in to unmask]> > Subject: Re: dignity -- say what? > To: "Chris Hanks" <[log in to unmask]> > 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 > > --- On Wed, 11/19/08, Chris Hanks > <[log in to unmask]> wrote: > > > From: Chris Hanks <[log in to unmask]> > > Subject: Re: dignity -- say what? > > To: [log in to unmask] > > Date: Wednesday, November 19, 2008, 3:26 AM > > Dear all > > Thank you Olga for the reference, I will read this. > > I have to say that I fully agree with Stephen's > > eloquent outburst. And there is no reason not to be > > passionate in decrying a situation which is commonly > > encountered (though there are delightful exceptions). > > As I read Stephen's contribution I did feel for > > Nerissa, as I think that I recognise the anxiety of > the new > > nurse placed in a stressful environment, however, I > feel it > > crucial that the points Stephen makes are carried into > > practice. I have been having discussions with senior > > undergraduate student nurses regarding these ethical > issues > > for many years; the students express positive patient > > centred ideals. When I visit practice areas or teach > some > > post qualifying classes, it saddens me that often the > ideals > > appear lost. In particular it worries me how often > nurses > > think that they know best, sometimes blessed with only > > scanty second hand knowledge, and no inclination to > > question. > > > > Thanks Stephen > > > > From Chris Hanks > > Senior Lecturer > > University of Plymouth > > England > > > > ________________________________________ > > From: A list to promote discussion of philosophical > issues > > in nursing [[log in to unmask]] On Behalf > Of > > Olga Jarrin [[log in to unmask]] > > Sent: 19 November 2008 01:31 > > To: [log in to unmask] > > Subject: Re: dignity -- say what? > > > > Medical facisim, lol... and after days of dialogue on > how > > we ought to disagree and present our arguments! > Stephen, > > Nerissa is an ex-podiatrist and new nursing grad (oh > the > > wonders of google). I'm going to take a different > tack > > and reference the latest issue of ANS 31(4), 283-295. > > Gweneth Hartrick Doane & Colleen Varcoe's > article > > Knowledge Translation in Everyday Nursing: From > > evidence-based to inquiry-based practice addresses > their > > "deeply felt concern with the profound disparity > that > > often exists between what nurses know and what nurses > > do." They go on to give an example of a nurse who > > provided care to one of the authors in a way > inconsistent > > with her education. The authors wonder briefly if > workplace > > stress or culture might explain the incongruence > between the > > nurse's perception of her nursing practice and the > > author's perception of her nursing care. > > > > Here is another side of Nerissa, something she wrote > just a > > year ago: > > > > I'm in nursing school with one semester to go. > Student > > nurses are taught to be supportive of all their > patients. > > This includes Christians, atheists, minorities, gays, > etc. > > > > I agree strongly with this approach. Nurses should > provide > > the best care they can and not attempt to impose their > > opinions on the people they care for. > > > > Nerissa Belcher > > September 23, 2007 > > > > > > > > --- On Tue, 11/18/08, Stephen Padgett > > <[log in to unmask]> wrote: > > > > > From: Stephen Padgett > > <[log in to unmask]> > > > Subject: Re: dignity -- say what? > > > To: [log in to unmask] > > > Date: Tuesday, November 18, 2008, 7:20 PM > > > I don't know where to begin to say how much > this > > message > > > disturbs > > > me. The astonishing arrogance and self-regard of > it is > > > matched only by the > > > wild self-pity. Oh, poor us! Forced to do more > > > documentation, to protect > > > ourselves from vengeful patients who had the > temerity > > - the > > > cheek!-- to > > > refuse our always-excellent advice! But now they > > regret it, > > > don't they? > > > they wish they'd listened to us, they'll > try > > to > > > "re-invent themselves" > > > (whatever that means) to blame us for their > lapses, > > but we > > > know better, > > > don't we? don't we always?! > > > > > > and that this should arrive in my inbox > under > > the subject > > > heading > > > "dignity"!! > > > > > > No, Nerissa, this isn't dignity or > respect > > or even > > > nursing in my > > > book. This is medical fascism. First off, it > > conveniently > > > ignores all > > > the mistakes *we* make, all the ways our > > "advice" > > > changes with the > > > latest research, the shifting fashions and > priorities, > > the > > > season. It > > > ignores all the nonsense we say to people... > > > > > > Have you been a patient recently, Nerissa? > Or a > > family > > > member of > > > one? I don't wish you any ill health, but it > is an > > > excellent way to shake > > > off professional arrogance. To be the recipient, > as > > opposed > > > to the > > > dispenser, of so much well-intentioned and > utterly > > useless > > > (if not > > > downright offensive) advice that nurses, doctors, > and > > > others dish out > > > everyday is a profoundly humbling experience. And > have > > you > > > looked > > > recently at the data on patient lawsuits & > > malpractice > > > claims? Most > > > clinicians wildly over-estimate their actual risk > of > > being > > > sued. > > > > > > And that's not even the main issue. The > main > > issue is > > > simply that > > > people do not give up their rights to make > choices > > when > > > they come into the > > > healthcare system. It's astonishing to me > that we > > > continue to have > > > to debate this in health care. And no, Nerissa, > > you're > > > not the only one > > > who thinks like this -- this attitude is all too > > common > > > among the > > > providers I meet. Not everyone, not by a long > shot, > > but far > > > too many. It's > > > the seamy side of professionalism - the "we > know > > > better" side. > > > > > > Whether you agree with a patient's > choices - > > whether > > > you think > > > they make the most sense from a medical > standpoint, > > whether > > > they are > > > congruent with YOUR careplan -- is not the point. > The > > point > > > is, it's > > > their call. This ethical orientation is > fundamental to > > our > > > system of > > > professional relationships -- it helps to counter > that > > > "we know better" > > > pull - and it is very disheartening to hear you > wave > > that > > > away because > > > people making the *wrong* choices might become > > > "problems" later on - > > > problems for us, of course. (Poor us!) > > > > > > "Warning" people is fine, > documenting > > is always > > > a good idea, but I > > > think you need to do more than just "consult > with > > the > > > ethics people." I > > > think you need to have a long talk with them > about > > what > > > you're in charge > > > of and what you're not. > > > > > > Stephen Padgett > > > > > > > > > On Tue, 18 Nov 2008, Nerissa Belcher wrote: > > > > > > > Hi Ms. Davis, > > > > > > > > IMO, if a patient deliberately chooses to > > increase > > > their risk despite > > > > nurses advising them of the danger then they > are > > > problems waiting to > > > > happen. We all know the drill. The > > > nurse/doctor/therapist, etc. didn't > > > > warn them firmly enough, or document well > enough, > > or > > > consult the ethics > > > > people. I support free choice but we need to > be > > very > > > aware that people > > > > reinvent their pasts to claim ignorance of > things > > > later. Sadly, still > > > > more documentation for nurses needs to be > > completed in > > > anticipation of > > > > problems. > > > > > > > > Nerissa > > > > > > > > > > > > --- On Tue, 11/18/08, Davis, Betty > > > <[log in to unmask]> wrote: > > > > > > > >> From: Davis, Betty > > <[log in to unmask]> > > > >> Subject: RE: dignity > > > >> To: "Nerissa Belcher" > > > <[log in to unmask]> > > > >> Date: Tuesday, November 18, 2008, 3:10 > PM > > > >> You stated, "Show them respect > unless > > doing > > > so harms > > > >> their medical > > > >> care." Does that imply that > > noncompliance or > > > >> disagreement with the plan > > > >> of care warrants disrespect? That > statement > > seems > > > to > > > >> disallow free > > > >> choice.... And, please, be gentle.... > > > >> > > > >> Betty W. Davis, PhD, RN, CNE > > > >> Assistant Dean, Nursing > > > >> Program Head, Associate Degree Nursing > > > >> Meridian Community College > > > >> 910 Hwy. 19 North > > > >> Meridian, MS 39307 > > > >