A Good Nurse

Good nurses practice in accordance with the Nurse Practice Act of the state in which they are licensed and working, and in so doing carry out all of the components of the "nursing process," and they do this well. That's all there is to it.

Yet among the thousands and thousands of patients who receive nurses' services every day, and the thousands of organizations that employ nurses, precious few folks seem to know what a "good nurse" truly is or how to spot one.

A nurse can be kind, compassionate, considerate, friendly, thoughtful, smart, funny, and able to change a bandage or administer an injection without causing pain, yet still not be a "good nurse." A nurse can be a conscientious employee who is well-liked, responsible, and loyal, yet not be a "good nurse." And most of all, a nurse can be "nice" (Lord help me if one more person tells me how "nice" a nurse is!), while being a professional disaster at the same time.

The problem is that state laws and professional standards of practice just aren't typical recreational reading for most people, and the essence of good nursing practice often is concealed in mundane activities. So it's all too easy for the public, and for business people who own and/or administer healthcare organizations, to assume that handing out pills and applying cool cloths to fevered brows is professional nursing, and that people who hold RN licenses and do those things well are "good nurses." 'Tain't necessarily so.

Some years ago a recruitment ad running in professional journals showed a nurse standing at the bedside of a patient who was sitting up in bed with a meal tray on the table in front of him. They were smiling at each other and obviously enjoying a pleasant exchange. The caption read something like, "He thinks they're talking about green jello. Actually she's halfway through 146 assessments." That would be true, if she were a good nurse, and the point of the ad, directed to good nurses whom the sponsor hoped to recruit, was that this is the sort of nurse sought and valued by that hospital.

A nurse indeed could merely banter about food with a patient and then head off to hang the next IV, having noticed and learned little. But more probably the nurse at that bedside noticed whether, what, and how much nutrition the patient was taking. She knew if he was enjoying his meal or if eating was a struggle or a chore. She recognized if he seemed to be in pain or to be having difficulty eating, from trouble swallowing to challenges manipulating utensils to inability to see clearly the things that were on his tray. She noticed his color, his breathing, and his speech. She could estimate his level of literacy, and had a sense of his willingness to engage with her and other providers. She had a sense of his communication style and whether he tended to be blunt, evasive, or something in between. She noticed his position and if he favored or guarded any body part, or if he just seemed more comfortable being "crooked" in the bed. She could tell if he was likely to engage, ask questions, and want to be an active participant in his care, or if he preferred a passive "wake me when it's over and I'm all better" approach. The nurse noticed any hearing deficit, if the patient seemed light-headed or dizzy, or if he was confused, forgetful, hallucinating, or demonstrated impaired cognition. She recognized effects, intended or otherwise, of the medications the patient had taken, and whether he might need something more, less, or different. She had a sense of how eating was affecting his stomach and entire GI tract. She noted sensory impairments he might have, such as not realizing that coffee was hot or that a glass was placed too close to the edge of the table. She saw if he had trouble grasping objects or tended to drop them, and if this involved one hand or both. She noticed if he did not move normally, and if he was tired, or tired quickly. She saw how he coped with whatever health problems he had, and knew the approaches to which he likely would be most receptive. She knew if his IV was running properly, if his bandages were intact, and the significance of displays on the monitor over his bed. And more.

The nurse also knew what to do with all of this information. She used it to formulate diagnoses, plan treatment, evaluate the effectiveness of treatment, prepare to teach the patient, include supportive others and exclude others, plan his discharge, and give other team members heads-ups about the patient's status, needs, and actual and potential problems. She knew what to disregard for the moment, and what warranted prompt action. She knew what questions she still had, and had a plan for pursuing their answers.

But when the phone rang and she excused herself from the bedside as the patient answered it, chances are she overheard him saying, "Hi, Honey. I'm having lunch and just was talking with Jane about the jello. It's green! Yeah, Jane's very nice; she's a good nurse."

More sobering are the administrators and executives of healthcare organizations who don't know what good nursing is, or even what nurses are required to do to be in compliance with the law. Recently I spoke with a Clinical Manager of a home healthcare agency who lamented the unnecessary and time-consuming documentation that many nurses new to home healthcare wrote. "All they need to write is what regulators and payors require," she said, "The rest is superfluous and unnecessary."

Wrong.

Those new-to-homecare nurses indeed may have been including unnecessary information in their notes, but they are required by law and by the standards of their profession, to which they would be held accountable in any court of law, to perform and document the entire nursing process, not just the parts that satisfy the specific requirements of regulators and payors. One would hope that Clinical Manager would help new employees ferret out irrelevant information while fleshing out a complete clinical picture of each patient and of the nursing process as it is carried out in each case. I fear that was not the case in this instance.

Employers can be so focused on their business needs that they fail to be mindful of the larger responsibility of professional healthcare providers. If executives hold business degrees rather than professional licenses they may not even know the standards and requirements for which a nurse, or other licensed professional, is accountable. They may even, unwittingly, I hope!, encourage employees to flout the law: "Just document the patient's homebound status, the skilled services provided, and compliance with the treatment plan that the physician signed and be done with it." But business needs cannot be allowed to trump professional standards or the law.

Because an employer gives a directive does not absolve a nurse from the duty to practice in accordance with the law and with professional standards. If a manager told a nurse, "It's ok, you don't have to file a tax return this year," you can bet the IRS still would go after that nurse and would have no sympathy for what the boss had said. If a director told a nurse to reach a destination as quickly as possible, without regard for speed limits, it's a sure thing that flashing lights in the rearview mirror and a speeding ticket would be in that nurse's future, boss's directive or not. Similarly, when a manager or executive tells nurses how to practice and what to document, it is incumbent on those nurses to be sure that their practice and their documentation both satisfy the needs of the employer and those of the law and of the profession.

It's a wonder more nurses don't seem a little schizophrenic from time to time, given that so many of our patients don't realize even a small portion of what our practice with them truly entails and that so many of our employers are focused on the bottom line to the exclusion of good practices and of compliance with the law. But the next time you encounter a nurse and a dish of green jello, please don't be quick to confuse personality with professionalism. Because before you can down the jello that nurse will have completed 146 assessments, formulated diagnoses and a treatment plan, evaluated what has been done and how you have responded so far, and determined with whom she or he next needs to confer to help you take the next right step towards better health. . . if he or she is

A Good Nurse.