A Nurse's Advocacy: Finding Meaning behind the Action

I was 6 months into my first job as a registered nurse when my coworker turned to me at the handwash-ing sink and said, “What did you think about your first code?” We had just finished postmortem care on a patient following 15 unsuccessful minutes of CPR. After our task was done, it was over to the sink to make sure we cleaned ourselves before resuming our care for our other patients. I looked back at her as I scrubbed underneath my nails and replied, “That wasn't my first.”

My first code happened almost a year prior, while in nursing school, and the care I witnessed from my preceptor brought the classroom principle of advocacy to life, and shaped the way I care for my patients (I have changed names here to protect privacy).

The parents of my patient Martha could not take their eyes off her. An hour before, I had been part of a team attempting to resuscitate their child, and now I am doing my best to preserve her memory by stamping her handprints onto pieces of construction paper. Martha is delicate, her skin still soft and pliable. I copy my preceptor Ann's technique: Take one small hand, firmly press it onto the ink pad, firmly press it onto the paper, and wipe the ink residue off the hand with an alcohol pad.

This is the most peaceful the room has been all day. I notice some of the ink still on Martha's finger-tips, deep underneath her nails. With the tiny corner of the alcohol pad I gently scrub the ink off. Never until this moment had I realized how difficult it is to clean underneath fingernails. It is a simple act that many of us were taught as children, but one I had never fully appreciated until I had to perform it under the close watch of grieving parents. I take my time to ensure that the nails are completely cleaned. This is the least I can do for my patient, especially after witnessing how much Ann had done for Martha.

My preceptor's frustration that day began during the handoff from the night nurse. Martha had been Ann's patient in the Critical Care Unit for several weeks; her condition had been well documented, vitals frequently monitored, and labs drawn morning, noon, and night. But on this day, the report from the night shift contained elevated liver function lab results, so it was imperative that Ann speak with the medical team during their morning rounds, calling out the need for Martha to be watched even closer.

Unfortunately, communicating her concerns on rounds did not help, as the attending physician could only assure her that Martha would be watched carefully. Martha was sick, but not as sick as others on the floor. Even after Ann's pleading, the skeleton crew and reprioritizing of resources in the hospital meant that doing more would be up to her. Ann checked in with the various members of the team, including her nursing manager. There had to be another way for her to prove that Martha needed closer attention. I hustled behind her as she consulted as many of the staff as she could, asking the resident physicians for advice, inviting a second nurse to observe Martha, and conferring with the perfusion and respiratory team about Martha's lab results. Looking back on the experience, it is clear to me that she was attempting not to override the watchful-waiting decision made by the attending physician, but to ensure that she covered all the standard procedures for a patient whom she knew well,

While we may spend time and energy adapting to the culture of our new workplace, we need to remind ourselves of the experiences that got us to this point.

providing more than just standard care that Martha and her family had come to expect. That way, when Martha's condition worsened rapidly, which it did, Ann could run toward Martha's room, taking solace in the fact that she had done all that was in her power to fight for the best interests of her patient. Ann ran into that room fully versed on reporting Martha's condition, and delegating CPR tasks to her panic-stricken preceptee.

As we sat outside Martha's room, distraught and covered in sweat and tears, I began to wonder why Ann had acted the way she did. How did she know to expect the worst? I can imagine a multitude of experiences in school, in clinicals, or in various patient rooms before Martha's, that influenced her actions. Ann demonstrated a textbook definition of one of the many facets of nursing: She gave me the privilege of witnessing the truest example of advocacy. One thing I took away from this experience is that we don't always verbalize the meaning behind what we do for our patients, but that meaning is what motivates us to use all our resources for our patient's care, to pool together expert opinions, and to go beyond what is just standard care.

The experience I have described is not something that a new nurse puts on his resume, and not a conversation piece when starting his first job. Each shift presents an opportunity for us to go beyond current care. While we may spend time and energy adapting to the culture of our new workplace, we need to remind ourselves of the experiences that got us to this point. After all, those experiences influence our behavior and become a part of what we do for our patients. No matter how simple the task, how much extra time or effort they may take, they are the reason why a nurse cleans underneath his fingernails before the start of his shift. They are the meaning behind the action.