By LAURIE GOTTLIEB, Special to The Gazette
MONTREAL - A recent report by the British National Confidential Enquiry Into Patient Outcomes and Death contained a disturbing finding: that more than 38 per cent of cardiac arrests in British hospitals could have been avoided if junior doctors had accurately assessed the situation and communicated with senior doctors earlier. In reading the report I was struck by its exclusive focus on the junior physician/senior physician relationship and its lack of mention of the role of nurses. Let me explain.
Nurses are the unsung teachers of young doctors. In their book Clinical Wisdom and Interventions in Acute and Critical Care, authors Patricia Benner, Patricia Hooper Kyriakidis and Daphne Stannard, all nurses and researchers, describe cases of nurses pointing out to medical interns and residents the warning signs of a patient's deterioration, correcting their misinterpretations of signs and symptoms, suggesting diagnoses, and anticipating when and how to intervene. Many physicians, years later, will recall with gratitude those expert nurses who protected them as young doctors - and, more importantly, protected the patient. These nurses "saved" them when there was no time to call a senior physician. They depended on these nurses who knew the patients and were attuned to subtle changes in their condition. Yet nurses have never been recognized for their role in doctors' education.
Who are these nurses who serve as the first and last line of defence for both patients and doctors?
They are professionals who possess a depth of theoretical knowledge acquired in the classroom and practical knowledge honed in real-world settings. Theoretical knowledge gives nurses the flexibility to understand and interpret observations; practical knowledge enables them to "situate" that theoretical knowledge and use it in ways that are responsive to the individual patient. There is a body of research that attests to the complexity of nursing care and the years of practice it takes to amass the knowledge and skills to achieve a high level of expertise. Knowledgeable nurses protect the system in countless ways, not least by ensuring that physicians have the most up-to-date and salient information about their patients so they can make medical judgments and take appropriate action.
They are people who have committed themselves to nursing as a career and have selected workplaces that value nursing. Experience working in one place or with one group of patients is required to develop expertise and intuitive know-how - a key to reading the signs correctly and predicting which patients are in trouble.
Two decades of research have exposed the deleterious effects of devaluing and undermining nurses and nursing. The cost has been high in terms of nurse burnout and patient morbidity and mortality.
Research has also revealed the conditions needed to retain professional nurses. When nurses are recognized and respected for their expertise and given status, resources and opportunities to function autonomously within their scope of practice, they stay in the profession. The most intriguing finding in this research is that the most consistent predictor of nurse satisfaction and good personal health (i.e. a low burnout rate) is positive professional relationships with doctors. When doctors partner with nurses and there is clear communication between them, patients' needs are met.
Within the McGill university and hospital network these lessons have been heeded. For example, there has been ongoing dialogue within McGill's Faculty of Medicine and School of Nursing about how to improve inter-professional education. (This discussion extends to physical and occupational therapists and speech therapists.) At the Jewish General Hospital, nurse-physician partnership is the organization's managerial structure in all matters of patient care.
These are important beginning steps for restoring the health-care system and a healthy nursing workforce. We are still recovering from the effects of the recent past, when Quebec's nursing operations were dismantled and the nursing workforce was left not adequately prepared for today's health-care challenges.
In the next decade we need to continue to build a workforce of front-line nurses who are well educated, knowledgeable, skilled, compassionate and committed to nursing as a career. Quebec nurses took this step themselves when they voted at this year's meeting of the Ordre des infirmières et infirmiers du Québec to make university education a basic requirement for entry into the profession.
Employers need to continue to create workplaces where nurses are given support to practise to the full extent of their training, and where physician-nurse partnership is the governance structure. Physicians need to treat nurses as respected and valued partners, not as subordinates. Nurses need to embrace these new opportunities and become accountable for their practice. And governments need to dedicate resources to support innovative nursing roles that complement those of doctors and other health professionals to meet the complex needs of patients and their families.
When this happens, the health-care system will be transformed and quality, safe patient-and family-focused care will follow.
Laurie Gottlieb is a professor of nursing at McGill University and is Nurse-Scholar in Residence at the Jewish General Hospital.