Nurse as Advocate
What is an advocate, and how does this apply to nursing?
Good
question! In nursing school the professors spent a lot of time discussing the
role of the nurse as patient advocate. There are advocacy questions on
every exam. It's something to which we, as students, couldn't really
relate. We generally found it boring and unimportant.
According to Merriam-Webster Online, advocate is defined as follows:
1 : one that pleads the cause of another; specifically : one that pleads the cause of another before a tribunal or judicial court
2 : one that defends or maintains a cause or proposal
3 : one that supports or promotes the interests of another
Synonyms include:
- exponent, advocator, apostle, backer, booster, champion, expounder, espouser, friend, gospeler (or gospeller), herald, hierophant, high priest, paladin, promoter, proponent, protagonist, supporter, true believer, tub-thumper, white knight
My attitude about patient advocacy didn't change until the first time I actually had to fight for a patient's best interests. Then I got it!
I had an elderly patient that had come in with pneumonia. He got better, and was almost ready to be discharged. However, the nursing team, as a whole, was concerned because he seemed to cough a lot during meals. This was brought to the doctor's attention and she wrote for a swallow study to determine if the patient had developed pneumonia because he was aspirating his food during meals. The doctor told me to call her with the results of the swallow study and, if they were negative, to send the patient home. Unfortunately, the order was written late in the day on Friday. I work at a relatively small hospital and our speech/swallow team leaves by 3pm on Friday and does not work on the weekend. That meant that the patient would have to spend the weekend in the hospital if he was to have the study. This study can be done as an outpatient. However, often when elderly patients are discharged with a prescription to follow up as an outpatient, they never do. Transportation is often an issue and insurance will often pay for things done as an inpatient that they won't cover if done on an outpatient business. This is because our medical system is seriously dysfunctional.
Meandering Moment: For my opinions and insight (or lack thereof) on why the United States' medical system is so warped please read my March 13, 3013 blog. It's completely uninformative, but full of useless insider opinion!
The doctor was quite rightly concerned that the patient would not follow up and would be back within a month with the same diagnoses if, in fact, his pneumonia was caused by aspiration. In the long run, it would be cheaper to keep the patient in the hospital for a couple extra days than it would for him to be readmitted in a week with repeat pneumonia. The swallow study was scheduled for Monday.
I had the patient back on Monday morning. All he needed was the swallow study and he could be released back to his retirement facility. If his pneumonia had been caused by aspiration, the doctor would send him home with careful instructions on what and how to feed him to prevent him from aspirating.
By 10 a.m. no one had come to take him for the study, so I followed up and called the receptionist in our Speech and Swallow Center. I was told that they did not have him on their schedule and they insisted that the study had not been ordered. I told them that I was sure it was because I was standing next to our unit secretary when she scheduled it for Monday. The receptionist told me that she would get him on the list.
Noon rolled around and still no one came. Knowing that the Center would close at 3 p.m., I became worried and called again. The receptionist informed me that her boss said that my patient was not on their schedule because he was not supposed to have a swallow study, that I was in error and he was probably scheduled for a swallow evaluation, which is a different test. I explained that my patient had already had a swallow evaluation and that the speech therapist who had done the bedside test agreed that he needed to have the swallow study.
Believe it or not, there are so many very similar sounding tests and studies that it is very easy to get them confused. I am sure that the nurse who runs the Swallow Center gets tired of nurses sending their patients to the center for what is supposed to be a bedside test. But, in the case of my patient, I knew I was not mistaken. The receptionist told me that she could get my patient on the schedule for the next day. I explained to the receptionist that we had purposely kept the patient over the weekend and scheduled the test for Monday. She said they couldn't fit my patient in, their schedule was already full.
I notified the doctor who was irate. She told me that they had to do the test that day and keeping the patient over night because they made an error was not acceptable, that it was not fair to the patient and would cost the hospital money. She was polite to me, but clearly frustrated by the situation.
So, I walked to the swallow center and spoke directly to the receptionist. She acquiesced and gave me her boss's phone number. I called immediately and left a message explaining the situation and that the doctor was insisting the test be done that day.
1 o'clock. No response. At 1:30 p.m. I called and left a second message. (This woman apparently dose not answer her phone but lets every call roll over to voice mail so she can pick and choose with whom she wants to speak. Must be nice.) 2 o'clock. No response. I called and left a 3rd message.
At 2:15 p.m. a very irate woman in a white lab coat (the director of the Swallow Center) stormed onto my floor and demanded to know which nurse was Sybil. I was at the nurses' station at the time and introduced myself. She started yelling at me, explaining that a swallow evaluation is NOT the same thing as a swallow study and that what the doctor ordered was a swallow evaluation and I needed to learn the difference because I was wasting her time and I needed to STOP calling her phone!
Deep breath...
I explained that my patient had already had a bedside swallow evaluation by one of her highly trained speech therapists, and had failed which is why the doctor ordered the swallow evaluation. She continued to yell at me, "Well, the order was NEVER entered into the system! It is YOUR responsibility to check your orders and make sure they have all been entered! If they aren't entered, they don't show up on our schedule! You can't just call and demand a study - we have to have a doctor's order!" and so on.
Be calm...
I looked her right in the eye and said, "It's order #127. I have checked it 3 times today and had my charge nurse check behind me to make sure it was entered correctly."
She went over to a computer, pulled up my patient's chart, and scrolled to order #127. And there it was... the order that was placed on Friday. "Well, it must have fallen off the list over the weekend. There must be some sort of computer glitch," she stammered.
I am sure she was right about that. I don't believe the mistake was in any way intentional.
It was at that point that she started to realize that she had just belittled me in front of my peers and several doctors. I could see her wheels spinning. Would I write her up?
Meandering Moment: At my hospital, I can be written up by any hospital employee, from the surgeons right on down to the house keeping staff, for treating ANYONE with disrespect. Likewise, I can write up any staff member who treats me disrespectfully, even the CEO. I think this is appropriate. Everyone who works there plays a vital role. No one should be abused and no one should be allowed to be abusive. It's unnecessary, unprofessional, and interferes with patient care. In this profession, it is best to leave your ego at the door.
The Director of the Speech and Swallow Center stood up and said loudly, "Thank you, Sybil, for being such an outstanding patient advocate. You were right to call me because you were acting in your patient's best interest. We will get the study done right away!" She the left the unit.
In less than 5 minutes an orderly from the swallow center appeared with the special chair they place the patient in to do the study and rolled my patient off the floor.
I don't tell you about this to toot my own horn. Nurses are required to be pushy on a daily basis. It's just part of the job. But this situation made me realize that my role as a patient advocate is just as important as my role as a nurse. It's not enough to carry out doctors orders at the most basic level. Nurses are required to fight for the patient's best interest, even if this means disagreeing with the doctor.
I remember a situation in which one of the surgeons wanted to do surgery on a 97 year old patient. The surgery wasn't absolutely necessary to save the patient's life. All of the nurses on the floor were concerned. Older patient's typically don't do as well after surgery as those who are younger and this particular lady was already frail. The family and the patient were also nervous and second guessing their decision to move forward with surgery. They were afraid to tell the surgeon they weren't sure if they wanted to go ahead with the procedure. They voiced their concerns with their nurse (not me), who then voiced them to the charge nurse. When the surgeon arrived on the floor the nurse and charge nurse asked him for a moment of his time and explained the situation. The surgeon heard what they had to say and spent some time discussing the pros and cons with the patient and family. They decided to proceed. We were all so worried for the patient, but she came through the surgery and did just fine. In this case, the nurse and charge nurse both advocated for the patient and the patient's family by interceding with the surgeon. It is not uncommon for patients and families to be intimidated by and believe it is wrong to question the doctor. It is the responsibility of the staff to intervene on the patient's behalf.
The point is that we do whatever we have to do to make sure our patients get the care they need. This is certainly not limited to nurses. A couple of weeks ago my Clinical Care Partner (CCP) came to me and told me that one of my patient's had a very high blood pressure. I was in the middle of taking care of a patient who was vomiting excessively and ended up having to place a nasogastric tube (NGT). I am ashamed to tell you that I completely forgot about the patient with the elevated blood pressure. My CCP didn't, though, and reminded me once I was done placing the NGT. She was being a patient advocate and I was grateful.
Advocacy is vital to competent, safe, appropriate patient care and it is not confined to the staff. Often the patient's family is the best patient advocate, but more on that another day.
Until then, I remain,
Meanderingly Yours,
Sybil
Meandering Moment: For my opinions and insight (or lack thereof) on why the United States' medical system is so warped please read my March 13, 3013 blog. It's completely uninformative, but full of useless insider opinion!
The doctor was quite rightly concerned that the patient would not follow up and would be back within a month with the same diagnoses if, in fact, his pneumonia was caused by aspiration. In the long run, it would be cheaper to keep the patient in the hospital for a couple extra days than it would for him to be readmitted in a week with repeat pneumonia. The swallow study was scheduled for Monday.
I had the patient back on Monday morning. All he needed was the swallow study and he could be released back to his retirement facility. If his pneumonia had been caused by aspiration, the doctor would send him home with careful instructions on what and how to feed him to prevent him from aspirating.
By 10 a.m. no one had come to take him for the study, so I followed up and called the receptionist in our Speech and Swallow Center. I was told that they did not have him on their schedule and they insisted that the study had not been ordered. I told them that I was sure it was because I was standing next to our unit secretary when she scheduled it for Monday. The receptionist told me that she would get him on the list.
Noon rolled around and still no one came. Knowing that the Center would close at 3 p.m., I became worried and called again. The receptionist informed me that her boss said that my patient was not on their schedule because he was not supposed to have a swallow study, that I was in error and he was probably scheduled for a swallow evaluation, which is a different test. I explained that my patient had already had a swallow evaluation and that the speech therapist who had done the bedside test agreed that he needed to have the swallow study.
Believe it or not, there are so many very similar sounding tests and studies that it is very easy to get them confused. I am sure that the nurse who runs the Swallow Center gets tired of nurses sending their patients to the center for what is supposed to be a bedside test. But, in the case of my patient, I knew I was not mistaken. The receptionist told me that she could get my patient on the schedule for the next day. I explained to the receptionist that we had purposely kept the patient over the weekend and scheduled the test for Monday. She said they couldn't fit my patient in, their schedule was already full.
I notified the doctor who was irate. She told me that they had to do the test that day and keeping the patient over night because they made an error was not acceptable, that it was not fair to the patient and would cost the hospital money. She was polite to me, but clearly frustrated by the situation.
So, I walked to the swallow center and spoke directly to the receptionist. She acquiesced and gave me her boss's phone number. I called immediately and left a message explaining the situation and that the doctor was insisting the test be done that day.
1 o'clock. No response. At 1:30 p.m. I called and left a second message. (This woman apparently dose not answer her phone but lets every call roll over to voice mail so she can pick and choose with whom she wants to speak. Must be nice.) 2 o'clock. No response. I called and left a 3rd message.
At 2:15 p.m. a very irate woman in a white lab coat (the director of the Swallow Center) stormed onto my floor and demanded to know which nurse was Sybil. I was at the nurses' station at the time and introduced myself. She started yelling at me, explaining that a swallow evaluation is NOT the same thing as a swallow study and that what the doctor ordered was a swallow evaluation and I needed to learn the difference because I was wasting her time and I needed to STOP calling her phone!
Deep breath...
I explained that my patient had already had a bedside swallow evaluation by one of her highly trained speech therapists, and had failed which is why the doctor ordered the swallow evaluation. She continued to yell at me, "Well, the order was NEVER entered into the system! It is YOUR responsibility to check your orders and make sure they have all been entered! If they aren't entered, they don't show up on our schedule! You can't just call and demand a study - we have to have a doctor's order!" and so on.
Be calm...
I looked her right in the eye and said, "It's order #127. I have checked it 3 times today and had my charge nurse check behind me to make sure it was entered correctly."
She went over to a computer, pulled up my patient's chart, and scrolled to order #127. And there it was... the order that was placed on Friday. "Well, it must have fallen off the list over the weekend. There must be some sort of computer glitch," she stammered.
I am sure she was right about that. I don't believe the mistake was in any way intentional.
It was at that point that she started to realize that she had just belittled me in front of my peers and several doctors. I could see her wheels spinning. Would I write her up?
Meandering Moment: At my hospital, I can be written up by any hospital employee, from the surgeons right on down to the house keeping staff, for treating ANYONE with disrespect. Likewise, I can write up any staff member who treats me disrespectfully, even the CEO. I think this is appropriate. Everyone who works there plays a vital role. No one should be abused and no one should be allowed to be abusive. It's unnecessary, unprofessional, and interferes with patient care. In this profession, it is best to leave your ego at the door.
The Director of the Speech and Swallow Center stood up and said loudly, "Thank you, Sybil, for being such an outstanding patient advocate. You were right to call me because you were acting in your patient's best interest. We will get the study done right away!" She the left the unit.
In less than 5 minutes an orderly from the swallow center appeared with the special chair they place the patient in to do the study and rolled my patient off the floor.
I don't tell you about this to toot my own horn. Nurses are required to be pushy on a daily basis. It's just part of the job. But this situation made me realize that my role as a patient advocate is just as important as my role as a nurse. It's not enough to carry out doctors orders at the most basic level. Nurses are required to fight for the patient's best interest, even if this means disagreeing with the doctor.
I remember a situation in which one of the surgeons wanted to do surgery on a 97 year old patient. The surgery wasn't absolutely necessary to save the patient's life. All of the nurses on the floor were concerned. Older patient's typically don't do as well after surgery as those who are younger and this particular lady was already frail. The family and the patient were also nervous and second guessing their decision to move forward with surgery. They were afraid to tell the surgeon they weren't sure if they wanted to go ahead with the procedure. They voiced their concerns with their nurse (not me), who then voiced them to the charge nurse. When the surgeon arrived on the floor the nurse and charge nurse asked him for a moment of his time and explained the situation. The surgeon heard what they had to say and spent some time discussing the pros and cons with the patient and family. They decided to proceed. We were all so worried for the patient, but she came through the surgery and did just fine. In this case, the nurse and charge nurse both advocated for the patient and the patient's family by interceding with the surgeon. It is not uncommon for patients and families to be intimidated by and believe it is wrong to question the doctor. It is the responsibility of the staff to intervene on the patient's behalf.
The point is that we do whatever we have to do to make sure our patients get the care they need. This is certainly not limited to nurses. A couple of weeks ago my Clinical Care Partner (CCP) came to me and told me that one of my patient's had a very high blood pressure. I was in the middle of taking care of a patient who was vomiting excessively and ended up having to place a nasogastric tube (NGT). I am ashamed to tell you that I completely forgot about the patient with the elevated blood pressure. My CCP didn't, though, and reminded me once I was done placing the NGT. She was being a patient advocate and I was grateful.
Advocacy is vital to competent, safe, appropriate patient care and it is not confined to the staff. Often the patient's family is the best patient advocate, but more on that another day.
Until then, I remain,
Meanderingly Yours,
Sybil
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