Set the Nurses Free

A nurse is a specialist in caring for sick and injured patients and an invaluable weapon in the arsenal against disease. If you have ever been a patient, you don’t need me to tell you that a nurse is your best friend and most supportive ally as you journey through the frightening and often painful maze of the health care –industrial complex.

When I was in medical school, I was having some weird upper respiratory symptoms and eventually my doctor ordered a test called a bronchoscopy. In this procedure, a flexible camera is placed in the mouth, down the throat, past the vocal cords, and into the upper branches of the respiratory tract. In some cases, this requires general anesthesia; however, my doctor and I decided that I could manage being awake for it. The sensation, I think, must be similar to being water boarded, as my airway became obstructed by this device while the pulmonologist evaluated my bronchial tree. So distressing was the sensation, so unnatural the experience, I was certain that something was going terribly wrong as I gagged for air and imagined my imminent death. Tears rolling down my cheeks, the nurse – whom I hadn’t really even noticed up until that point – while assisting the doctor, gently grasped my hand and began whispering to me that I was doing fine, what I was experiencing was normal, and that the procedure would only last for a short time. Without these soothing words, I probably would have ripped the bronchoscope out of the doctor’s hands in a panic.

That is what a nurse is.

JHACO (the Joint Commission on Accreditation of Healthcare) is an organization hired by hospitals to provide accreditation which is required by the federal government. A hospital must pay this organization a fee to obtain its blessing in order to continue operating. Not surprisingly, each year the organization expands its list of requirements in the manner of all self-perpetuating bureaucracies, thus ensuring its relevance and longevity.

JHACO believes that a nurse is a data entry specialist. Therefore, out of some combination of fear and acquiescence to administrative and legal pressures, the powers that be have determined that the best use of a nurse’s time and expertise is sitting at a computer and charting; endlessly charting. In addition to important information that anyone involved in a patient’s care needs to know and easily access – such as vital signs and test results – nurses must document mundane and largely irrelevant data with staccato frequency and tuck it furtively into the electronic chart where, even if I wanted to know a patient’s weight the day after fixing his broken wrist or the serial number of the plate I used to fix it, I wouldn’t know where to find that information. (Note: I do not want to know.)

As frustrated as physicians are about this distraction from patient care, nurses are more so; especially those who have been around for a while. They recall a time when a nurse’s place was at the patient’s bedside; examining, comforting, and…well, nursing. Newer nurses are trained to chart, chart, chart. Maybe it’s not my place to remind them of the good old days, but I have always had trouble keeping my mouth shut.

The reality is, even new nurses don’t need me to remind them of the value of their profession or to encourage them to spend their time interacting with the patients and communicating (in a meaningful way that is, not via some obscure flowchart in the electronic medical record that no one except JHACO auditors will ever look at) with physicians, therapists, and aids. The problem is, they are evaluated almost exclusively on the quality, fidelity, and efficiency of their charting. Imagine that. Nurses are predominately, if not exclusively, evaluated based upon duties about which their patients and colleagues do not care. The nurse I mentioned in my case might be a mediocre box checker but she is an excellent health care provider.

Obviously, there needs to be documentation of patients’ complaints, medical histories, and interventions. But the asinine details and sheer magnitude of minutiae have become burdensome. Moreover, patient care – as well as communication between nurses and doctors – has suffered enormously. I am fortunate to work with nurses who are committed to rising above this bureaucracy and make every effort to be present when I am seeing my patients, but it is easy to lose sight of the relevant details of their care when data entry requirements become overwhelming.