Today I went to a conference in Baltimore on legal issues in obstetric nursing. It was right up my alley, and an enjoyable day. However, I came away with two major themes: 1) Conferences like these are really just preaching to the choir, which can be satisfying but ultimately not change much; and 2) Like I concluded back in law school, the legality of being a nurse is a zero-sum game. Until power structures change, until physician attitudes change, and until hospitals force physicians to be accountable for their actions AND their words, both to nurses and patients, we will continue to be in a no-win position: one in which we're expected to follow the doctor's orders, yet somehow get him/her to change the game plan when we know it's unsafe. Oh, and we don't have any authority whatsoever to do so. Sure, there's the chain of command (notifying the charge nurse who will notify the supervisor who will notify a hospital administrator who will call a meeting with the chief of OB, who may or may not be the doctor in questions), but there's no real time to activate it in true emergencies--and no real reason (we're told) when it's not. Which means that you have to wait until things get really bad, as opposed to when they just look like maybe they could get bad, before you might get backing for your stance.
To be fair, the speaker was funny and smart and engaging, and it was nice to go to a conference that specifically addressed our specialty and our challenges. It was refreshing to have such targeted content, if not a whole lot of actual advice. But, I think most nurses come to such things hoping that there is some "magic bullet" you can put in your charting that will prevent you from being sued. There's not. There's not even a way to practice--not even safely, conscientiously--that will prevent that, because you can still have a bad outcome with good care, and also because there are other people (not to name any or anything) directly affecting the patient that you don't have any control over. Yet because the it's the hospital which has the "deep pockets" (not necessarily the physician or his/her insurance company, which is generally separate), there's a real interest in keeping a hospital employee (read: THE NURSE) named in the lawsuit.
So at one point, I felt the familiar helplessness and despair rising and I thought, what is even the point? How can the system (medical? legal? take your pick) be so broken, and where can we even start?
But then. I realized that if it doesn't make a difference one way or the other--that you could be sued for doing what the doctor orders and sued for not doing it, sued for giving excellent care as easily as bad--I realized that there's really a great freedom in that. If it really doesn't make a difference, then shouldn't we just be practicing to the best of our ability and intuition, and letting the chips fall where they may? Shouldn't we feel comfortable to forge relationships with our patients, advance their interests, and advocate for their safety--regardless of whether that alienates the physician? Because if you can end up in a court of law either way, I'd rather have it to say honestly, "I may have made a mistake, but I did what I thought was the best, safest thing at the time" than "Well, I kind of knew that that wasn't the right thing to do, but hospital policy/the physician said to do it anyway. So I did." At the end of the day, the only thing you can really defend, with certainty, 18 years later, is if you're committed to always following your conscience. And when you put "I didn't turn up the Pitocin because I was afraid of fetal injury, uterine rupture, and/or a lawsuit that would bankrupt us and cause us to lose our licenses," next to the argument (unspoken, of course) that if we turn it up, we might deliver a baby 30 minutes sooner looks awfully pale and weak in comparison. Right?
Plus, I've seen what "defensive medicine" amounts to: a lot of unnecessary C-sections and other interventions. The medicalization of what should normally be a loving family event. Women who are worried that their bodies are defective, and that mindset carrying over into their lives and parenting. Mountains of paperwork which hospitals think will protect them legally, but which likely really won't and which only distracts nurses and doctors from their primary roles at the bedside. And physicians and nurses who are burned out and alienated because rather than forging relationships with their patients, they look at them all as potential litigants who might be out to get them.
No, thank you. If I risk getting sued either way, I'll take my chances listening to my heart and my patients and by crossing that bridge if I come to it. Otherwise, I'm not going to let fear (mine or anyone else's) and intimidation (by anyone) guide my practice.
On a related note, I'm just getting into Spiritual Midwifery by Ina May Gaskin, and feeling so grateful and excited to be meeting Ina May Gaskin at a Farm workshop this month! I can't wait. I love her positivity and enthusiasm about childbirth--instead of always pointing out what's wrong with "the system," she's just established an alternative system. And now, midwives with higher educational degrees come to her--because she's become so incredibly advanced in her knowledge and skills, which have all been gained through experience. I thought today on the way home from this conference that it's so sad that nurses and doctors are losing a lot of their skills and analysis by simply resorting to technology ever time there's a bump in the birthing road. I'm glad that there are still a few out there like Ina May that are committed to promoting that wisdom so it isn't lost forever.
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