Discretion and care

In which I try to appreciate nurses in line with what they deserve

In my less bleak moods I like to think of what I’m doing here as a kind of fieldwork. After all I’m getting to observe a complex institution from the inside, watching and trying to learn how it functions. And one thing I’ve now had extensive opportunity to ponder is the job that nurses do in a hospital like this, and some of the crucial dynamics involved. Or at least what can be gleaned about such things from a patient’s point of view.

On a personal level, one of the many revelations I’ve had since spending several months entirely dependent on the care and assistance of other people is just how incredibly good some nurses are. Prior to being bedbound in hospitals, I complacently assumed that nurses were just the dogsbodies, whilst doctors did “the real work”. Well, I certainly don’t think that anymore.

For a start, I would simply be dead without teams of nurses having cared for me for months. Doctors and surgeons saved my life in the immediate aftermath of my catastrophe, but it is nurses who have kept me going afterwards. More generally I’m blown away by how hard they toil, for 12 hour shifts on poor pay, whilst being constantly overworked and under resourced. Then there is the fact of how much they know and how expert they are in delivering specialist care, without which a hospital would simply cease to function entirely. And this all matters not least because nurses make a colossal difference to how unbearable or not any given day turns out to be for someone like me.

One way to see this is to appreciate the different ways that rules operate in a hospital, and the crucial importance that discretion and personal judgement can play in how those rules affect a patient’s welfare. Nurses, I’ve come to understand, are central to this dynamic.

Some of the rules that nurses operate under are entirely strict.  For example, if a medication is not on a patient‘s prescription sheet, then a nurse is forbidden to give a patient the medication. On the one hand this seems entirely sensible: doctors are the ones who prescribe medicines, nurses are qualified only to administer them. But it can lead to unfortunate situations. Take for example the time some doctor decided to simply remove from my prescription the sleeping pills I was then entirely dependent on as part of overcoming PTSD. At 9pm that night the nurse on duty expressed surprise that I had completely come off my usual heavy dose. This was news to me, and not exactly what I wanted to hear given my history of night terrors and insomnia. I did not react especially well, I must admit. But in terms of changing things, the nurse was bound by the rules - indeed, should she break them and just give me my usual dose as per the day before, she would be open to legal prosecution, or at least being sacked. Lacking a prescription, I could not be given the pills.

But here is where judgement and discretion come in, even in a hard and fast case of strict rule following. Faced with my distress at having to cold turkey on sleeping pills with no warning, the nurse had at least two choices. Option one was to shrug and say this is just what the doctor decided, so you’ll have to live with it. The other option was to try and change things. Luckily my nurse opted for the second outcome and tried getting a doctor on the phone and asking them to update the system, restoring my sleeping pills. Unfortunately, no doctor would pick up the phone. As time wore on I became increasingly demented with panic. What saved me that night was the senior ward nurse taking it upon himself to travel eight floors down to physically find a doctor and getting them to change my prescription immediately. He didn’t need to do that. He could have just shut the door and ignored me until I exhausted myself into quiet. But I am still hugely grateful that he went out of his way like that for me. Then and there, it meant everything.

There are other cases however where even minor rules and their application can make an enormous difference. For example, on my current ward whatever medications you have been prescribed for each morning ought officially to be doled out around 6am. In my case that leaves whichever nurse is on duty with a choice. Either follow the rule strictly and wake me up at 6am to force me to swallow the pills, or appreciate that I’m in desperate need of sleep (not least because hospitals are such awful places to sleep, and I am in such terrible physical condition) and leave me be. After all it doesn’t really matter if I take my medication just before breakfast around 8am, as opposed to first thing in the morning according to the hospital timetable. But you can probably guess which nurses I’d rather be looked after by when I’ve endured yet another night in this living hell.

Then there are the cases where nurse discretion is vital because the rules don’t give advice one way or the other. The night before I had a minor surgery two weeks ago I was “nil by mouth” from 2am. That meant no food or drink until the surgeons decided it was my turn, however late in the day that might turn out to be (4pm, as it happened). Luckily one of the absolute best nurses on the ward was looking after me that night. She accordingly took it upon herself to set me up with an IV drip to ensure I would at least get fluids throughout the night and day, avoiding the worst nastiness of prolonged dehydration. This involved the not easy task of finding an accessible vein in my emaciated arm, and must have been a significant drain on her time when she had many other jobs to do. The rules were completely silent in this case about proactive measures. She could easily have just left me as I was, knowing that the dehydrated me of the next day would be the problem of whoever came on shift in the morning. But she used her discretion to help me rather than simply following the barebones rules.

The problem with discretion, unfortunately, is that it can also go the other way. Take for example the nurse who decided that her immediate priority was filling out some paperwork despite having just observed that I had (as they put it round here) “opened my bowels”, an hour and a half after I had first asked her to check me. Leaving you to lie in your own shit also counts as something where the judgement of a nurse is key. Luckily for me this kind of example has been the exception rather than the norm - but it only takes a couple of cases like that for your confidence in the system to get shaken, meaning that fear rather than trust becomes your default approach to the day. (Unluckily for the nurse, she timed this to coincide with my dad coming in to visit me. He’s not a man who expresses anger frequently, but on this occasion nobody was left in any doubt as to where things stood. Mercifully that nurse has not been near me since, not least as it was not the first time she had done something like this.)

Ultimately, as a patient you don’t just want good judgement and discretion - you want to be looked after by somebody who seems to care. And the very best nurses manage to combine exactly these things. However, I think I understand why not all do.

As far as I can tell nurses tend to fall into one of two main camps. First are the ones who never make you feel like you’re asking for too much, who show empathy whenever they talk to you, and who seem genuinely to want you to be as comfortable and happy as possible. Then there are the ones who do an entirely efficient job and can be trusted not to neglect you, but with whom there is a marked emotional gap: they will make sure there is nothing to complain about, but the human touch is kept firmly at arm’s-length. (We can ignore for now the small number of ones who leave you lying in your own filth.) From a patient point of view, rather unsurprisingly it’s the former kind of nurse that you hope is on duty. But I genuinely worry about how much the job must take, in terms of psychological and emotional toll, from those nurses that do so evidently care.

I simply cannot imagine what it is like to work a 12 hour shift surrounded by suffering and pain, misery and despair, and then somehow go home and live a normal life. Looking after children, seeing friends, having a romantic relationship; all the other normal things people enjoy so as to make life worthwhile. My guess is that those nurses who put up an emotional wall with patients do so because it is an entirely reasonable way to stay sane. And I can’t begrudge them for it. I sincerely worry, though, about how the nurses who combine effective discretion with sympathy and care, and who do such a good job of looking after their patients, manage to also look after themselves.

Or perhaps there’s no great mystery here. Maybe this is just a long-winded way of saying that I finally understand that some people are much better at being caring and selfless models of good humanity than I have ever comprehend was possible, let alone myself lived up to being. At any rate those excellent nurses (and I’ve been lucky enough to have more than a few of them) seem somehow to manage it. I can only guess that for them it is not just a job, but a vocation in the deepest and truest sense of the word.

I can’t help but think, however, that as a society the least we could do is pay them properly.