Reflective Practice

The following is a short essay I wrote for a reflective practice assignment way back in OB class:

I have friends who are med students. I work closely with doctors when I volunteer, and to a lesser extent as a tech in the hospital. I don’t think of a nurse’s relationship with doctors as adversarial or subservient, but collaborative. Until a doctor shows me he or she feels otherwise, in my mind we are colleagues. I know it is not quite the same in clinical, because there I am a student first, nurse second.

None the less, when the pediatrician failed to greet me with more than a cursory glance, I admit I bristled. My nurse, who had so far introduced to me to everyone as her “partner in crime,” also remained silent. I was about to introduce myself, but before I could even nod, Dr. M was addressing his patient.

He was not unkind, nor did he do or say anything particularly compassionate.  He had to rupture her membranes and insert both a fetal monitor and intrauterine pressure catheter. While he and the nurse messed around with the equipment, I took the young woman’s hand and told her to breathe. She was still in a lot of discomfort throughout the procedure. Perhaps this is why, after he was done, he asked her if she wanted an epidural for the rest of her labor. Without hesitating, she said no.

“Why not?” he asked her. He sounded incredulous, at least to me. “You’re only dilated 3 centimeters. It’s going to be a long process.”

She didn’t reply, and he didn’t wait for her answer. He was out the door. My nurse followed behind, and I knew I was to go with her, but I couldn’t leave without saying anything. I’d like to say I weighed the pros and cons of speaking up as a student when my nurse had not, but really, all I thought about was the young woman in the bed, and how none of us had any idea why she didn’t want an epidural.  I told the young woman that she shouldn’t let the doctor pressure her into an epidural.

“It’s always an option, but there are other pain meds available as well.” I said. “Just call the nurse if you want to talk about it.”

In retrospect, I would have asked her about her concerns, not in the patronizing way the pediatrician had, but in order to best care for her. Did she want a natural birth? Was she concerned about the drugs’ effects on her fetus? Was she afraid of the procedure itself?

Those are not the only questions I ask myself now. I also wonder what the doctor’s investment is in his patient having an epidural. He could simply want her to experience as little pain as possible. As a physician, he probably holds a lot of value in his ability to relieve pain. But isn’t it also easier to manage a patient with an epidural? This would seem to be more of an issue for the nurse, who is, after all, the one who is present for the majority of the labor. My nurse had not been involved in the conversation at all, and I hadn’t asked her about it.

One thing that I find interesting upon reflection is this: I am a huge proponent of pharmacological pain relief. There are so many myths about opiates that many patients who would truly benefit end up suffering. It was a little odd that I wasn’t more on the doctor’s side. Usually, when a patient refuses pain medications, I really investigate their concerns, with my goal being to alleviate those concerns so they will take their medicine.

On the floor where I will soon be working, the nursing staff follows Watson’s Carative Theory of Nursing. In reading more about this theory, I came across the following:

Essentially, respect is easily acquired until the person disagrees with your recommendations, at which point, respecting the other person’s choices can become more complex(Chantal, 2003).

This is an interesting perspective, because it gets right down to one of our most basic codes of ethics as nurses, respect for human dignity.  Am I respecting someone’s dignity if I encourage narcotics when she has made it clear she doesn’t want anything until her pain is at a 9/10? I like to think I am providing teaching about how medications work best to relieve pain, but is this any different than this doctor?

The patient ended up receiving an epidural. I was attending another birth, so I missed how the final decision was made. In the future, I will be more cognizant about the way in which I speak to my own patients about their choices regarding pain relief.