The Murky Real World

I am a professor at a university School of Nursing but I also continue to work part time as a nurse practitioner in a primary health care centre.  It’s important for me to practice for many reasons. I really enjoy the type of work and the pace of the clinic setting.  Additionally, I need to maintain competency to keep my NP license, but more than that, students can spot a fraud in a second. The murky ‘real world’ provides the best examples of the complexity of nursing practice and promotes learning in a way that guidelines and textbooks cannot.

An issue that I’ve seen often over the years is with cases where patients refuse to follow treatment plans. I’ve seen several different types of responses from health care providers.  Some people think that it is sufficient to indicate in the chart that the patient was informed of the issues/risks etc. and made the choice not to follow the treatment plan. Others have gone as far as to say that the patient should be discharged from the practice for refusing the recommended treatment.

The underlying issue to me is that of informed consent. The dictionary defines consent as “to permit, approve, or agree; comply or yield”.  Nurses are taught that it is important to educate, answer questions and inform in order for patients to fully understand their health issue and the recommendations for care.  However, the expectation that goes along with the practice of ‘informing’ is that the patient will then do what we say and will automatically consent.

There are clear laws in most jurisdictions about the response of health care providers to specific situations such as child abuse or threatened suicide.  Yet, there are multiple more situations where the boundary of accountability of the nurse is blurry.  I don’t have answers to this question, but I do believe that at the core is the nurse/patient therapeutic relationship including mutual respect.  Each situation is different and requires reflection and communication.

This is the type of issue that nursing and NP students find most challenging.  They are uncomfortable with clinical questions for which there is no easy answer and I tell them that it doesn’t necessarily get easier, even when you are an experienced clinician. In fact, this issue is also one of the reasons that I continue to practice….to remind me that I need to learn each and every day.

Roberta Heale




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