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Question: Nursing, nurturing, or negotiating?

Updated: Mar 21, 2018

Sandwiched between Nurse’s Day (this past Tuesday, May 6th) and Mother’s Day (this coming Sunday, May 11th) resides my writer’s block… oh, and my mother.

You see, my mother (macromom) has been a nurse since before I was conceived and a mother as long as I’ve known her (ha!). For me the two roles are meshed. Never a moment when nurse wasn’t mother and mother wasn’t nurse. In fact, she transitioned from a rigorous career as a psych nurse for 25+ years into school nursing almost entirely to spend more time with yours truly when I was growing up. In contrast, she kissed every wound (like any mom would) only after disinfecting it properly, applying essential oils and monitoring it for signs of pus and erythema regularly (like only a nurse mom would… a holistic nurse mom, at that).

To bring the nurturing close to home, yet again, I’ll briefly discuss my grandmother. Talk about nurse. Talk about inspiration. That woman carried the whole family on her back… and never fell down. She was strong and passionate; after all, she was Latina. She grew up in Puerto Rico and moved to the United States when still young. At some point in her life she decided to make caring a career and being set on becoming a doctor, but within the confines of societal views of Puerto Rican women in medicine; she “settled” for becoming a nurse. If you ever met her you’d be willing to bet she knocked a few doctors on their butts in her time. She knew her stuff and from the stories Igather from my parents, she was always their light at the end of the hospital hallway — guiding them around when they didn’t know better.

She become a clinical coordinator and remained such throughout her career. She never missed a beat in keeping up the caring at home with every single member of our family until the day she passed. My last conversation with her was a day before her passing when I looked at her, with my dad beside her bed he said, “you know mom, she’s starting medical school next week”. The look she gave me was the epitome of pride in her eyes. Any struggles I had in medical school since, I was nursed through by that memory – and the nurturing presence of her angelic spirit.

So with that, when my mom suggested this week I write a blog about the nurses, I froze with writers block. How could I possibly put into words a lifetime of nursing & nurturing as I struggled to even briefly describe above?

So, I sat down at the computer and the result was far from a post. I drafted an email to my medical student colleagues asking them for their words on nurses emphasizing unbiased, positive or negative thoughts, especially focused on any opinions pre and post medical school. The compilation of responses yielded three important questions about nurses, in my mind:

1) How might medical students view nurses?

“Nurses: they are the teachers of doctors. The unsung heroes of the wards. Their care and interaction with patients is where the healing really happens. They are the bridge between conventional medicine and the mind body and spirit. I dream of a day when there are no divisions between docs and nurses. We would all benefit from nursing being a requirement to become a doc.”

“Yeah, my experiences have been varied. It is very similar to attendings, you meet the good, the bad, and the inspiring. There are some that not only know the patient better than you, but the pathophysiology, the treatment, the outcome, etc. Then there are others that tell the patient wrong information, muddle the picture, upset the family members, etc. It all varies based on the unit, experience, and personality. Just watch out for the triage nurse, they will cut your nuts off.”

…and one response, interestingly, similar to my own. Must be something special about the mom-nurse/nurse-mom:

“My mom’s a scrub nurse and when I was little she used to bring me to some of their get-togethers outside of work, so I grew up seeing nurses as really caring and nurturing. I was sick a lot as a kid too, and I remember feeling like the nurses went out of their way to try and make my day when I was in the hospital for long stretches of time– playing board games with me and things like that. In that way, I always saw their role as sort of a mothering one. Yes, they have to get blood draws and give you medicine at regular intervals, but I think the most important thing they do is invest their time and care in getting to know the patient and making them comfortable when possible. They spend the most time with patients and, just like a good mother, they have a good intuition when something isn’t right with the patient and can tip off the doctors to take a closer look.”

I think the line that struck me most was, “…similar to attendings, you meet the good, the bad, and the inspiring.” As medical students, we spend the entirety of our clinical years aiming to please our attending physicians. We spend the first week of the rotation figuring out what will please them. Maybe it’s shorter presentations, maybe longer, maybe they are the “type” of attending that likes numbers, but maybe they’re the type that only wants to hear abnormal values… list goes on. So, by week 2, when we realize we are already -at best- 1/4 into the rotation, we think up all the ways we can make up for the mistakes of first impression week 1. Maybe bringing articles, maybe seeing patients without being asked, maybe staying later, maybe simply not bothering the attending at all. Yes, we work with residents, but often it’s still all in a big picture effort to please the attendings to get the good grade, the better course evaluation or the eventual residency application letter of recommendation. We must do this regardless of the attending; good or bad at patient care, bedside manor or clinical medicine, in general. BUT every now and then you get the attending that inspires you. The one that sits you down day 1 and says, “this is how you can succeed”. The one that kneels down next to the seated patient on walking rounds to complete the physical exam and points out all findings to you after. The one that the patients have to say goodbye to before discharge. Medical school clerkships are a game of negotiation. I may have to negotiate my way through 80% of the experiences to determine what will simply get me to “do well”, but the other 20% of the time… you get nurtured. I’ll take the struggles to get the inspirational ones.

It’s no different with nurses. You get the good (nurse mom types) and the inspiring (see response above regarding the, “unsung heroes of the wards”). As students we spend 80% of our time gauging the nurses personalities, shifts, patient interest level because each bit of information we know about them, allows us to better work with them in acquiring information on our patients. Negotiating if they wouldn’t mind paging us when our patient’s blood pressure changes, sharing information on the events of the past night, or drawing our patients blood just a few minutes earlier so results will be ready in time for rounds. BUT 20% of the time you get the inspiration. Probably only 1% of the time you’re lucky enough to get my mom or grandmother.

I recall finally committing to medical school training when in college and sharing my biggest fear with my mother. What would I do the day I’d face my first code? (A code is when a patient’s heart stops and a “code” is called for the medical emergency team to try and revive them). “Don’t worry,” my mom comforted, “The nurses run it anyway. They’ll tell you what to do.” This couldn’t have been more true of my first code experience. It happened when I was on call with the intern, just a few months into her training. The senior resident was off for the night. The code was called and the crash team was running before we even realized it was our patient’s room. When we got there – stunned and hopeless – the nurses tugged on us and firmly instructed how to help. The head nurse called out orders and yelled out important questions she needed answers to in order to instruct the team. The intern followed in suit. There was no question where her place was – it was to listen to the nurses.

Still within that 80%, between good and inspirational, comes the struggle of negotiation:

2) How might nurses view us?

“I started my post-college career as a patient care technician, which basically means I was the lowest person in the healthcare hierarchy and it was my job to assist nurses in whatever way possible. I absolutely loved those two years, and thought at the end of it that I could’ve been perfectly happy as a nurse instead of a doctor. I loved all of the nurses I worked with and formed a really strong bond. I saw the way some the doctors treated them (and myself), and I thought, I need to become a doctor to make sure the stereotype of doctors treating nurses like lesser human beings does not continue. What I was hurt to find as a medical student that has continued as a resident is that I have been treated way worse by some of the nurses I have interacted with than I ever experienced back when I was a tech. After years of being treated badly by doctors, I think many nurses see med students and residents as easy targets to project some of the built up anger that has developed from the way certain doctors act toward them, and I found that I was always having to prove myself worthy enough of their respect, which meant constantly trying to “kill ‘em with kindness.” In most instances, I am able to build that trust with them and they eventually stop treating me so poorly, but there are still some to this day that never treat me with the respect that every human being deserves. As a former nurse tech, I have the utmost respect for all parts of the nursing staff and know how hard they tirelessly work for the good of their patients without often getting any form of recognition, so in a way I understand why they do what they do. I guess it just hurts more knowing that I used to be a loved and respected part of that community.”

This is only one account, but it captures some important aspects of the good, bad and negotiating.

A nurse’s account of her career and interactions varies as well:

“My first experience working for and with doctors was at a doctor’s office…it was the first of it’s kind in the 70′s…a “walk-in” clinic/emergency treatment and general physician’s office all in one. They did labs, X-rays, and minor emergency medicine. I worked there as a “student nurse” in my first years in college. The doctors were into educating the nurses as we assisted them. They did not treat us as subordinates but as assistants and co-workers. So, it was a rude awakening to me when during nursing school (I had received my LPN license so that I could work and help pay for my college costs) when I obtained a job at a hospital, to have a physician yell at me and throw instruments across the room! I learned later that this particular doctor was a neurosurgeon and that this behavior was part of his job description! Fast forward to my years in psychiatry. From the very beginning I found the psychiatrists to be into education of other disciplines. They enjoyed explaining diagnoses and interviewing patients in front of the team. It inspired me to continue my education in psychiatric nursing and received my master’s. At that time I worked at San Francisco General Hospital. This was my introduction to a full array of med students, residents and doctors both in psychiatry and medicine. Overall the experience was positive and I continued to experience a true exchange between our two disciplines. There were occasions where a resident would be filled with his or her greatness and would refuse the nurse’s help and wind up getting themselves in trouble…however that was very occasional and for the most part we worked together. The last experience that I had in the hospital setting was the best. My years at Westchester County Medical Center were totally positive and inspiring. Doctors and nurses both in psychiatry and medicine worked collaboratively. I worked psych/liaison and covered psych and medicine. We (myself and the other clinical nurse specialists) had a wonderful relationship with the residents! They were in fact often the ones who called we nurses for our services and we exchanged updates on patients regularly. Many of the clinical specialists at WCMC (in medicine, oncology, ER, etc) had dual appointments with the New York School of Medicine to teach medical students and residents. I also had a dual appointment and I taught medical students and residents group psychotherapy. It was such a joy to work hand in hand with future doctors, residents and fellows. Though I have moved toward more of a model of preventive medicine and health, I have loved my 30 years or so in hospitals and working side by side with doctors.”

The take home message for me is – med students, residents, physicians and nurses alike are all human – we all encounter (and I’m sure can all BE) the good, bad and negotiating ourselves, but importantly, we must keep this in mind when we work with others as a team if we want to ultimately help patients.

Speaking of patients…

3) How might patients view nurses?

There is TOO much to capture here. In short, nurses make or break patient experiences. They spend the most time with patients and, depending on the reason for hospitalization or the unit, nurses do everything for them. Nurses can be patients’ angels or …well, people they’d rather not be around. I’d like to think that most of the time they are nothing, but angels. BUT what about how patient’s view nurses as a whole; as a group?

“Every young female medical student/resident/doctor (?) has had the experience of being called a nurse by a patient. Usually these are older patients, and/or male, but not always. Even my father has said something like “I’m sure you’re a great nurse…” to me. This is always quickly followed up by an embarrassed correction, but I find it pretty interesting. It’s interesting that these gender stereotypes are still so pervasive, and I think that’s because we still associate many of the qualities of a stereotypical doctor with maleness (boldness, giving directives, being kurt, fixing problems), and stereotypical nurse characteristics with femaleness (gentleness, nourishing, comforting, following orders with the occasional smart quip). On the one hand, this points out some serious problems with the way our society still makes inappropriate assumptions and demands based on gender. On the other hand, anybody in the healthcare industry can tell plenty of stories about male doctors and female nurses who did not fit these stereotypes at all, often with much humor. As a young female physician, I am thankful that I will have the (slightly) higher level of autonomy and greater breadth of knowledge that goes along with the intense training it took to get here. I also aspire to take on the best of both worlds, to be confident and able to give orders when necessary, but also to meet my patients and colleagues with the kind of gentleness and presence that facilitates healing.”

This may not be the case for all medical trainees, but it’s an interesting and unique perspective to capture.

In an effort to both resolve my writer’s block and remain as unbiased as possible, being both the daughter of a true nurse nurturer, and a medical student who also has been stuck in negotiations with nurses, I post this entry truly to offer reflection. However, I will say 2 closing remarks:

1) Like em or not, doctors wouldn’t be anywhere or anything without nurses in the current system. — So Happy Nurse’s Day.

2) I wouldn’t trade my nurse-mom/mom-nurse or inspirational memories from my grandmother (or the strong constitution of women in medicine I get from each of them) for the world. — So Happy Mother’s Day.

Whether you are or have been a patient, healthcare provider or bystander what are your thoughts? Don’t we all have to do a little nursing, nurturing and negotiating in life? I often do myself – yoga – to nurse my body, – hip-hop – to nurture my artistic soul, and negotiating; well, sometimes that’s the same as inquiry. It’s healthy to question…

So I pose to you… nursing, nurturing or negotiating?

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