Nursing Orientation-101: Don’t ‘Go Institutional’ With Profiles on Nurse X & Nurse Y

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By Benjamin E. Ruark

Introduction

Formal education, such as it is, takes a hit-and-miss approach in providing career-focused students a broad-brush preview of what their chosen career objectively looks like and how their roles contribute meaningfully toward success in whichever medical field becomes their goal. Moreover, this first-time overview hopefully addresses critical professional buttresses such as ethical standards, clarity of requisite technical and interpersonal skills, insightful profiles on illness and disease types, and perhaps even a psychological and realistic descriptive montage of actually working with affected patients. 

When well crafted—and supplemented with ample discussion, and repeatedly stressed throughout related academic courses—a gripping imprint such as that has the potential to be indelible across an entire career span. The nurse orientation provided herein won’t be nearly as sweeping, also takes a different slant; but hopefully furnishes sufficient clarity for readers to rethink their choices to useful extent, and how they characteristically respond to them.

Orientation to Nursing 101 – Short Version

Few aspiring nurses are given opportunity to reflect on the sociological and psychological ramifications of carrying out their roles in their chosen healthcare field. While patterns of interaction with different patient types vary, the scope of work does not, with only a few presumptive exceptions: the surgery, pediatrics, ER, and intensive care units. In all other hospital, nursing home, and clinical units, nurses are locked inextricably into their regimen of care. Moreover, their regimen’s unmovably situated between the so-called scintillating stuff and (closer to) the so-called menial stuff carried out by certified nurses’ aides, or CNAs. ‘Scintillating stuff’ refers to professional turf practices and privileges restricted to physicians, PAs, and nurse practitioners whose titles also earn them sanctioned holders of express authority.

Thus, nurses must resign themselves to the standing of ‘middle child’ in the healthcare-delivery family. This position forces nurses of both genders to confront the challenges of personally working through a number of ‘either/or reconciliation themes:’ 

▪ Derive satisfactory meaning and purpose from the usual day-to-day oscillations between confronting challenging health complications and mostly routine multitasking drudgery or otherwise adopt a hardcore attitude of performing heartlessly cum mechanistically; 

▪ Whether they’re able to derive personal gratification from, or grimly tolerate at best, serving strangers under their care; 

▪ Whether they will allow themselves to feel genuine empathy (assuming the capacity for it is there) or ill-advisedly mimic physicians’ stereotypic posture of ‘detached concern;’ 

▪ Whether they allow themselves to feel and express compassion, or prefer to reserve expression of personal feelings outside of work, only for family and close friends;

▪ Whether they ignore or surrender to fierce multitasking routines which force them to give scant thought and time to patients, thus pin-balling nonstop from one healthcare malady to the next—sans the disembodied patients secondarily suffering the added insult of impersonal care;

▪ And finally, whether they choose to retain autonomy of individualistic thought and action or willfully choose to ‘follow the herd’ through blanket adoption of their work culture’s way-of-thinking, ‘how we do it here,’ replete with built-in biases (aka, the over-assimilation trap).

Continuing the present theme: newly-hired nurses get the ‘how we do it here’ indoctrination while testing the waters of their peers, which at times is oddly only spuriously centered on healthcare. More succinctly, they have to learn to navigate through big-ego and ‘don’t-question-me’ minefields without setting them off. They’ll also need to get up to speed by adapting their behavior to be commensurate with their position within the organizational (hierarchy) chart. And decide whether they’ll seize opportunities for exhibiting a degree of rightful ‘pushback;’ of demonstrating their individual prowess: that they’re not readily swayed to reflexive action when here-and-now pressure to comply is most daunting. Because, to surrender in the ways just elucidated is to show up to work as essentially one more medical device, an automaton, functioning chiefly as programmed by the local culture. 

This surely has never been any aspiring nurse’s intention when the idea and cost of four or more years of formal schooling were being seriously contemplated. 

Far from providing a comprehensive overview, this brief coverage has hopefully been nonetheless enlightening and inspirational for beginner and seasoned nurses alike. And it promises to get more incisive the further along its readers progress.

Profiles on Nurse X & Nurse Y

Of note, the real-world is punctuated with gradations of exact match with Nurses ‘X’ and ‘Y’, the most common types of vocational personalities found throughout healthcare settings everywhere. Their critical distinctions are exhibited in tabular format, below. To some extent each type more or less represents the polar opposite of the other. Each has their own set of core values, principles, and customary comportment.

FactorNurse ‘X’Nurse ‘Y’



Administration of CareDaily no-nonsense approach sus-tained by a matter-of-fact business-as-usual attitudeDaily fulfillment of a calling re-peatedly sustained by satisfying the need to contribute



Professional ConfidenceComing from acting out percep-tions of what confidence must look like; usually feigned without inci-dent unless when threatenedComing from within: self-effi-cacy gained by taking moderate risks and learning from one’s actions; is always evolving



Professional DemeanorAloof, overworked, immediate-goal directed; tendency towards bossy or imperial displays; goes by-the-book; readily assumes institutional powerPersonal, unassuming, smiling on the inside (percipience); naturally radiates approachable-ness and bottomless compassion



Signature Work ApproachReflexive, seeing only black and white, care gets rationed based on temperament and a subjective lika-bility for select patientsActively listens and applies well-honed instincts to identify and address their patients’ full complement of health concerns



Professional IdentityA neediness for opportunities to ‘be in charge’ of others. To have the respect and (co-)dependency of patients also in need (of help) A need for making actionable contribution through the nurs-ing profession as a personally satisfying expression of living

Those are the primary differences between these two vocational personalities. But more needs to be said about personal calling, imperial manner, identity (with respect to crisis), and need fulfillment.

Personal Calling – Women and men who’ve experienced the need pangs of devoting their lives to nursing see it as something they must do; no matter the personal sacrifices required—long hours, stress on family, missed ‘firsts’ with their children—their core values dictate that their incomparable level of giving takes priority. To the degree that personal day-to-day service contribution satisfies this need tells them whether they’d made the right choice. One can only hope their employer does everything possible to (1) facilitate their personal drive, and (2) not get in their way with annoying institutional roadblocks to effective service. These individuals are walking ‘placebo effects;’ they emit their need and capacity for giving care, and for bringing relief and better outcomes to patients, many of whom are able to sense just that. 

Imperial Manner – Regrettably, just as law enforcement attracts a certain undesirable element (authoritarian, power-crazed, overt aggression) to its ranks, so does healthcare: persons with unblemished yet cryptic resumes (past employer’s ploy to be rid of them), looking to make their vocational home in any healthcare facility. Getting hired affords them an outlet for expressions of domineering, pushy, and quickness to demonstrate (ascribed) ruling power. In their tone, manner, and behavior they act commanding, perform their work dispassionately, and personally care not one whit for patients entrusted in their care. Care is superficial, strictly by the book, and a matter of what’s printed on a patient’s care plan. Even though all health-related concerns that are ‘ongoing for any particular patient’ are not printed in black and white.

Identity Crisis – Not all Nurse-Ys complete their vocational metamorphosis; nor develop far along enough to attain full and mature career potential. For those that don’t, their ‘calling’ likely wasn’t as patently obvious. Nor is the need to contribute to a level demanding personal sacrifice. Once they’ve earned their degree and been hired, they’re now conferred a relative position of institutional power and authority, with equal expectation of exuding it. Which may feel incompatible with their core values and previous identity before earning the nurse title. Their sameness of personality may seem to dissipate with each donning of nursing scrubs. 

They may interact uncomfortably with various patients. Feel estranged from non-docile patients when carrying out certain duties; feel disconnected when performing certain healthcare tasks. Deep down, they may distrust themselves. Specifically, whether their vocational choice is as true of heart as it is of mind. Regardless, their personality-transition to ‘I’m a nurse’ is now stymied. If, however, they’ve generated some truly remarkable moments in nursing, then they’d be prudent to use these to build on; to view their journey as still a work in progress. Then identify the more daunting situations they’re still confronting, and assertively problem solve their way to a more mature, singularly professional persona they deem both worthy of self-respect and provides them a sound foundation.

Need Fulfillment – Regarding nurses victimized by incomplete metamorphosis— hence, remain stymied as alluded to a moment ago. For a particular segment of this same group, that they derive personal energy and purpose from patients isn’t reason enough to embrace their profession. No, for this particular segment the validity of their personal ‘calling’ comes from outside sources, not from within. Their insatiable ego investment muddles what normally is a drive to achieve meaningful fulfillment, to a heedless point of overflowing: hence, a craving to be affirmed, validated, sought out, and attended to by appreciative patients in their care. They’ve polluted whatever intrinsic motivation they had with an outward quest to stack up repeated incidents of recognition-of-service by any and all. In a word, they’re extrinsically motivated. 

The only condition more extreme (and ill-suited) than this is the nurse whose chosen their profession solely because it was promoted as a financial lure and the job security hype about there being great demand for nurses over the next several decades couldn’t be passed up.

The Don’t ‘Go Institutional’ Clause

In theory, healthcare institutions are a necessary and sufficient answer to provision of quality care under benefit from economies of scale. Amassing large patient populations under one roof while administering care with an obstinate eye on efficiency makes absolute rational business sense. When the theory gets inlaid in sober reality, however, it quickly loses traction. Because, once installed, the concept of institution takes on its own over-the-top reality, trumping individualized attention to patients, the essence of quality care, and realization of individual potential and contribution from nursing and other medical staff. Once institutional mentality is unleashed and sets in, a new paradigm altogether has taken over.

Although a 3-part series of articles on institutional healthcare flaws could do it justice, only a few relevant-to-nursing pieces of evidence are given as prime examples of a proclivity for Big Brother’s right-of-way mentality subverting the administration of care.

Signature we-them dichotomy with patients – telltale use of patronizing labels is evident when addressing patients: ‘dearie,’ ‘poor darling,’ ‘little package of joy,’ and so on. Also the tendency for staff to objectify (dehumanize) patients into objects of illness and disease: the broken hip in room 130, the fourth stage Alzheimer’s patient, etc. Thus the once innocuous use of we-them pronouns takes license to cross pejorative boundaries while bifurcating staff-patient relationships along institutionally self-serving dimensions such as superiority-inferiority, powerful-powerless, responsible-irresponsible, knows what’s best-knows nothing, and so on.

Lowest common denominator (LCD) approach to service at mass scale – akin to ‘a chain’s no stronger than its weakest link:’ especially skilled nursing home facilities serve patients as though one size and one service approach fits all situations | conditions | patients. Hence, each patient is expected to possess low intelligence, awareness, and communicativeness, and resultantly is mainly feeble; each patient has minimal capacity to worry about their individual rights getting violated; is too debilitated to worry about being granted anything more than minimal autonomy and control while under managed care.

There’s our way… – Never to be discovered is ‘and then there’s The Best Way.’ But staff will never get to find that out. No one ever challenges the validity of current practices in force. There’s very little renewed forethought going into procedures. Just follow the old protocol. Abstract thought is a virtual stranger to the premises. Worse still, narrowness of thinking leads to restricted capacity for insight: no nurse would dare ask about possible exceptions to the rule, and so the contingencies needing to be in place when exceptions happen, don’t exist.

LCD equally applies to staff and facility overall performance – Performance standards (like water) seek the lowest level possible; despite theirs being such a complex, high risk, and high stakes industry. Just completing a task is considered satisfactory enough. In many cases there are no qualitative and quantitative criteria affixed—medication doses notwithstanding—with the possible exceptions of medical standards related to surgery and ER operations. All manner of action slips and memory lapses have been sufficiently identified in reputed journal and magazine articles to put the spotlight on institutional care’s many unaddressed shortcomings and vulnerabilities for doing harm.

Perform by reflex – Nurses and other medical professionals get so inured to performing routine healthcare tasks—which rely mainly on habit memory, or colloquially, ‘function on automatic pilot’—that they’re prone to be inattentive to whatever task is at hand. Their conscious minds are free to daydream, focus on socially conversing with peers and aides, or reflect on the next task intended; or be easily distracted by background noise and foreground clutter. 

In short, they and other workers are prone to miss the most obvious external cues right before their eyes: a nearby patient desperately in need of assistance; critical and salient information on posted warnings and caution signs; task-related details that get overlooked, and so on. Extraordinary service to combat Covid-19 aside, under routine care they and their aides are also culpable of committing the most vacuous acts out of a tunnel vision tendency that renders most environmental stimuli virtually invisible. So much so that, even in public areas it wouldn’t be a stretch to overhear a nurse or aide call out to a passing patient, “Brenda, have you had a bowel moment today?” and not get how uncivil and insensitive it is on several levels.

Going Institutional, then, means to allow oneself to wholly assimilate into the local work culture without reservation. Full-out institutional conformity reduces the loftiest of nurse callings to threadbare enthusiasm and aptitude for one’s chosen career. Such a facility’s trademark giveaway trait is their introverted character: staff will know they’ve been ‘institutionalized’ if their facility is obsessively focused inwardly on internal matters. Expect staff meetings to overly indulge in discussion of internal concerns, ambitions, problems, latest crises, and personnel issues. These matters take precedence to the detrimental extent of unceasing inattention to patients’ overall needs, overdue current medical and support service improvement targets, plans for service/facility enhancements and expansion, and so on. 

In short, their customers—the market they serve—not surprisingly finish second in each year’s annual report on outcomes achieved. Nurses who therefore find themselves ensnared in an institutionally-ingrained work culture must use their wits to demonstrate conformity without sacrificing autonomy of thought, voice, and action. Those who might find that goal too daunting, too risky, need at minimum to be more skeptical before adopting all proffered methods of practice; and before engaging in blind acceptance of various codes of conduct as well. 

The upshot: healthcare doesn’t happen in a vacuum. In order to best serve the interests of their patients, nurses (with intact identities) will have to put to rights an unrelenting tendency for human error to invade all organizational levels—no matter how well-intended people’s actions. And since institutions don’t come with built-in safeguards against groupthink and kneejerk performance, they’re the best candidates for standing in as a surrogate solution. Each nurse therefore constitutes a check and balance on themselves, their peers, their management, and their work culture. This is how institutional heavy-handedness, systemic error, and concomitant harm get prevented from infiltrating a workplace.

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