That Which Sets Nursing Apart

Nurses and nursing have been thrust into a worldwide spotlight this week after panelists on ABC's "The View" made snarky, uninformed comments about Registered Nurse Miss Colorado's "talent" segment of the Miss America competition, which was a creative monologue depicting the life-changing story of her work with a particularly memorable patient. The backlash was swift and severe, with hundreds of thousands of nurses and their supporters blowing up social media and blasting conventional media as well. Many sponsors pulled or paused their advertising on The View, and television hosts from Ellen to Dr. Oz have scrambled for a piece of the action. There have been many well informed and thoughtfully articulated tributes to nurses from those who know us best, that is, our physician colleagues and others who serve side by side with us every day, as well as our patients, some of whom were so inspired by the nursing care they received that they later became nurses themselves. It has been a week of many proud and humbling moments after an initial ugly slap in our professional faces.

But for all that has been said about nurses and nursing, there remains a critical omission, a missing nod to that which sets nursing apart.

The questions that most define nursing practice perhaps are something like, "What are the barriers to this patient's enjoying the very best possible health?" and "What are this patient's strengths and the things that are working well, upon which we can help him/her build so as to be and do even better?"

The reason this approach and these questions are so important is that they transcend the purview of any individual healthcare discipline. Nobody other than a nurse builds his or her practice around assessment questions broader than his or her own scope of practice.

This does not mean nurses practice beyond their legal and proper scope; rather it means they know the resources to tap to meet their patients' needs, and how to coordinate those resources for efficient care with optimal outcomes. Only a nurse does this.

Physicians diagnose and treat pathology, and often it indeed is one or more disease processes that are significant barriers to optimal health. In those instances physicians order diagnostic tests and appropriate treatments, and often rely on nurses both to implement these orders and to assess and evaluate their effectiveness, alerting the appropriate doctor if problems arise. While this aspect of nursing practice requires great skill and keen clinical acumen, it is but a small part of what nurses do. Indeed, sometimes patients' healthcare needs do not require a physician's input at all, as there is no pathology present that requires medical diagnosis and treatment.

Consider "Shirley." Shirley is a determined, high-energy, almost-ninety year old woman who was headed to an appointment this week when she had an unfortunate encounter with a hose that careless workers had left stretched across a sidewalk. Down she went, evidently with unusually great force, and she couldn't get up. Passersby summoned help, and EMS soon arrived to take Shirley to a nearby hospital. There she was scanned and xrayed, poked and prodded, bled and monitored, and ultimately told she was badly bruised but nothing seemed to be broken, that she should wear an immobilizer on the knee that took the biggest hit when she fell, and that she should follow up with an orthopod as a precaution and see her primary care doctor as previously planned. She then was dispatched home. Later that night she fell again trying to walk to the kitchen for something to eat.

The next morning she called me.

The doctors had reassured her that all was well medically, but had not addressed the things that were wrong otherwise.

I had seen Shirley just one time, several months before. Then she had just been discharged after a hospital stay for a gut infection, and I determined that she was doing well overall but would benefit from some Physical Therapy to help her regain strength properly and safely. The Physical Therapist took over the case, and I signed off. But Shirley remembered the one visit I made, and she kept my phone number. And so the morning after that trip to the ER, when the sun barely had topped the horizon, my phone rang. "This is 'Shirley Holloway,'" a feeble voice said. "I don't know if you remember me, but I live at 1234 Anystreet and you helped me get Physical Therapy once before. [exhausted pause] I need services again. Different services. I would appreciate if you would call me." I did, and then called Shirley's doctor, because Medicare still requires a "doctor's order" before I darken a patient's doorway if Medicare is to pay the bill. The doctor agreed that I should evaluate Shirley, and then call with my findings.

When I arrived the doorman sent me right up, and said Shirley's door was unlocked and that I should just walk in. I did, and found Shirley settled into a recliner almost completely unable to move about. The leg that had taken the brunt of her fall was deep purple from the thigh to the ankle, and quite swollen as well. There were bruises on one arm and one hip, scraped and torn skin on both hands, and a lump on her head. Every time she tried to walk she felt so weak and dizzy that she thought she would fall. She wasn't hungry and had eaten minimally in the past 48 hours. Her blood pressure was low, and fluid was starting to accumulate in her lungs (two points I ascertained by using my stethoscope, a device the ladies of "The View" had dubbed a "doctor's" tool). And she was hurting, alone, and worried.

Shirley already had been worked up by doctors in the Emergency Room, and had been determined to have no pathology in need of medical treatment. So the doctoring was done. But clearly this patient had significant unmet health needs.

I explained why her leg was purple and how to manage the swelling and optimize circulation as well as recognize changes that would signify a problem requiring medical attention, such as blood clots or nerve compression. With Shirley's permission I snapped a photo of the leg and sent it to a Physical Therapist colleague; within minutes we had arranged for him to be there that day to work with her on safe mobility and additional management of the pain and swelling. I explained the hazards of being sedentary in that recliner for days, including the fluid in the bases of her lungs, and the mobility and breathing exercises needed to improve this. We discussed other common complications of decreased mobility, including the potential for everything from skin breakdown to constipation, and the need for attention to hygiene and nutrition. Shirley admitted avoiding drinking in order to minimize trips to the bathroom, fearing the she would fall going or coming. I explained the need for adequate hydration and the relationship between this and her blood pressure; Shirley quickly reached for a glass of water. I referred her to an organization that provides caregiver services, as she had realized she needed someone with her. I showed her how to clean and dress the torn tissue on her hands, and instructed her to "graze" on nutritious snacks throughout the day until her appetite for normal meals returned. We talked about what those snacks might be. I removed loose throw rugs from her hallway and explained the fall risk associated with them, and made sure she was wearing safe footwear with good support.

On reaching my office later I called the physician with an update, and received an, "Oh, ok" in response. There was no medical need, no need for doctoring at that point, nothing for the physician to do.

The next day I returned. Shirley asked if I minded if she iced her leg while we were talking, as the Physical Therapist had given her very specific instructions, and she walked (!) steadily (!) with her cane to and from the kitchen to retrieve the ice. Her bruising was better, she had washed at the sink by herself and changed the bandages on her hands, she was eating and drinking adequately, her blood pressure was normal, and her lungs were clearing. She had called for information about caregiver services, had prices, and was going to follow up. She was on the road to recovery.

Once the Emergency Room doctors had determined that there was no fracture or pathology present, no doctoring or hospitals were needed. But nursing was. And it was the nurse who recognized the need for Physical Therapy and for a caregiver and who made those referrals. It is the nurse who continues to coordinate that care and help Shirley move forward.

Physicians request consultations of other physicians, e.g., the internist requests the opinion of the endocrinologist, the surgeon asks the cardiologist to evaluate a patient before an operation, the hospitalist calls in the nephrologist when a patient's kidney function declines in the course of treatment. But it is the nurse who coordinates all the pieces and knows to add any that have been omitted. It is the nurse's perspective that is broader than pathology and treatment, mobility and function, speech and cognition, mental health and coping, nutrition, wound and skin care, community resource needs, and the functioning of any given body system. It is the nurse whose perspective encompasses all of these, and whose expertise includes knowing whom to consult and how to coordinate the players and assure the patient is progressing. And it is the nurse who is most likely to have occasion to know the patient well as a person and so determine the individual strengths and obstacles likely to be significant to his or her progress, or lack of same.

Physicians look for pathology to diagnose and treat. Physical Therapists look for problems with mobility, strength, and endurance. Occupational Therapists look for needs in functional status and cognition. Speech Language Pathologists look for deficits in communication, swallowing, and mentation. Social workers evaluate social systems and resource needs and provide counseling and referrals. Mental health workers evaluate thought processes and intervene accordingly. Dietitians assess nutrition, recommend meal plans, and teach therapeutic diets and healthy eating. Many specialists are experts in one body system, e.g. Respiratory Therapists in the respiratory system.

But it is the nurse, and only the nurse, who does it all. Not so as to supersede any other healthcare professionals' role or judgment, but rather in order to refer to them and to ensure that not only nursing needs, but also the patient's overall healthcare needs are met.

Nobody else has a perspective so broad and yet so narrowly focused on the particular needs of each unique patient. Consequently while there are many patients who don't need a doctor or don't need a therapist or don't need a counselor or don't need a specialist, there are precious few who, at least briefly, don't need a nurse. And while many of the tasks we do and many of the functions and responsibilities we carry out overlap those of our colleagues in other disciplines, that broad perspective and narrow focus is

That Which Sets Nursing Apart.