Pushing through barriers to advocate for a patient

AORN Journal, Sept, 2004 by Patricia Stein

Perioperative nurses play an important role in patient advocacy. By applying their nursing assessment skills and judgment, they can help with early medical diagnoses and definitive treatment for surgical conditions.

PATIENT ADVOCATE SKILLS

My role as a nurse coordinator at the University of Minnesota Physicians' colorectal surgery clinic, Minneapolis, is to be the point person for all patient-related surgical needs. Essentially, I am at the hub of a wheel with many spokes.

I am not an advanced practice nurse, but I am a perioperative nurse with an advanced degree. As such, I serve as a patient advocate by assessing, monitoring, and evaluating patients' subjective complaints and objective symptoms. I also coordinate and communicate with the surgeons, as well as link nursing and medical diagnoses, care, and treatment.

When I first started in this role, I had to ask the surgeons about every patient situation. With time, however, I have begun to think more critically, and as I move from novice to expert in this role, I better understand which situations require rapid attention and which ones can wait.

In the past, I worked in medical/ surgical and psychiatric nursing, in vocational rehabilitation, as an industry representative, as a consultant, and in the OR as a perioperative staff nurse and educator. These experiences have taught me to pay close attention to what people say and how they say it. I am a careful observer of body language and the unspoken word. In fact, my favorite course in nursing school was physical assessment, which taught me to listen, feel, smell, and observe. My assessment skills are put to good use on a regular basis in my current role.

I was hired to complement the work of the surgeons in the practice and assist with patient care. The patient caseload was increasing, both in quantity and complexity, such that the judgment and experience of a professional RN were required. Patients no longer could wait to be helped at the end of the day when the surgeons were available to answer messages and attend to issues that arose. The surgeons wanted to bridge the gap between patients who required immediate care and those who just needed advice until their next clinic visit.

In retrospect, I believe I was hired because of my problem-solving skills and perioperative experience. My graduate work was in organizational leadership. I studied how systems function and how people function in them. This, coupled with my nursing experience, has helped me make patient care decisions more easily.

DEALING WITH PATIENT PROBLEMS

Fairview-University Medical Center, Minneapolis, draws patients from the surrounding areas of Minneapolis and St Paul but also from neighboring states. It is a tertiary care center and, as such, attracts patients with complex health problems because of the variety of specialty care offered. Often, patients have had or are awaiting transplantation. Additionally, technically challenging surgery is performed on patients whose surgical treatment has failed. Often, more than one surgical specialty is required to care for patients intraoperatively.

I often am the first person to receive a call when a patient needs to be seen. I see to all the details involved in

* ensuring that patients are thoroughly cleared for surgery by all involved services,

* scheduling their procedure,

* performing preoperative teaching,

* seeing them postoperatively in the hospital, and

* following up with them in our clinic.

Sometimes, I scrub on the procedure. Patient contact is frequent and intense. I am the person patients call when issues they are unsure about arise. The following example demonstrates patient advocacy in my role as patient coordinator.

ADVOCATING FOR THE PATIENT

I received a call from a patient, Ms G, who we had been following for some time because of her history of sigmoid diverticulitis. She also had an unusual history of experiencing numerous intussusceptions near her ileocecal valve, but diagnostic x-rays were unable to demonstrate this. She had experienced three diverticular attacks in the past, which put her at risk for perforation. She needed to have a sigmoid colectomy to manage this. To complicate matters, Ms G also had undergone lung transplantation, so she takes a variety of antirejection medications that depress her neutrophil count.

When she called, Ms G complained of severe right lower quadrant pain. This was atypical for her and did not match the location of her diverticular segment. She was moaning and having trouble catching her breath. I believed it was imperative to get her into the health care system so that she could be assessed thoroughly and treatment could be initiated quickly. I insisted on sending an ambulance to bring her to the emergency department (ED), but she refused, saying that it would cost too much money and "They never believe me when I'm in pain anyway. It's a waste of time!"

Ms G was rapidly losing her ability to cope and was becoming increasingly anxious. I reiterated that it was critically important that she come in for diagnosis and treatment and offered to enlist a family member for support. Ms G relented and said that her daughter might be able to bring her to the ED. I told Ms G that I would call her daughter, and Ms G finally agreed. I believe that it calmed her down to let someone else take charge.