*I want to preface this re-post of something I wrote back in 2010 by saying the Future of Nursing report and much nursing research has helped push more educated and autonomous nursing practice forward at the advanced practice level primarily (24 states and counting). However, I feel that we are continuing to restrict bedside nurses from using the brains and education they have and thus we have created sometimes powerless new nurses who don’t know any better and fail to be proactive for patients precisely because we have not allowed them to make their own decisions in patient care. I could be wrong about that, strictly my opinion.

Years ago, when I went back to school to obtain a bachelor’s degree, I read a thought provoking book entitled “The Physician’s Hand” about nursing history from the paradigm of nursing culture and the dominance of medicine (strictly my interpretation). Even the author, placed nursing as ‘subordinate to physicians’.

Being the rabblerousing heretical feminist that I am, I have always sought to think of nursing as part of the medical ‘team’ where all professionals provide input to build the best care of the patient. I am beginning to wonder if my pie-in-the sky view and push to have nurses see themselves as independent professionals with a unique body of knowledge is accurate?

In one of the health systems that I interface with nurses can no longer document that they held a patient’s medications based on ‘nursing judgment’. Such an instance might be when a patient had hypotension from pain medication and thus the morning anti-hypertensive is held. Instead, they need an order from a physician to hold such medication. Further, something like ‘Tylenol’ on a patient’s medication record ordered for fever could not be administered by the nurse for a headache if the patient requested it because that would be ‘practicing medicine without a license’.  A nurse cannot order a social services consult, flush a urinary catheter should it become clogged, refer a patient for diabetes education, etc., etc., without an order from the supervising physician. Although we have been trained to recognize these things, we carry an independent license, sit for an examination to obtain that license, and have had years of education. Perhaps nurses really cannot do any of these things without a supervising physician to tell them?

Physicians, are critical components of the health care team there is no doubt, but why send a nurse to school and give him/her an independent license, scope of practice, and make them answerable to a board of nursing but then limit their usefulness?

I was reminded of this overriding ‘subordinate’ mentality when I spoke to a group of nurses this week and encouraged them, in light of the winds of health care change in the U.S., to consider starting their own business to increase access to preventative services. My suggestion was specifically that nurses should look at developing independent diabetic foot clinics at a lower cost. My thinking was, since Medicare is going to quit paying for these services, that hospitals will quit providing them, but this will in no way decrease the need for good diabetic foot care, monitoring, and preventative education. Nurses are primed to fill that gap.

I was enthusiastically speaking about this possible place nurses could exercise their knowledge to provide care to a group of people who need it when a woman to the side of the room raised her hand and said… “We can’t do that. We need a physician’s order to get someone’s toenails cut inside the hospital. Not anyone can just walk in somewhere and get services for foot care. I mean, if you did it wrong someone would come and take your license.”

Thus the mentality continues. Until nurses recognize their  knowledge set, research, health management skills, education, and license as their own then health care will never change and these big gaps in prevention and health maintenance will remain; so will the continued air of ‘hierarchy’ among health care professionals.

Become a certified diabetic foot care provider – http://www.wocncb.org/become-certified/

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