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July 2 , 1998 No certification, no license, no degree is worth much if we don’t use good judgment. In fact, that seems to be a central concept in the definition of a profession: the ability to exercise independent thought and action. The hundreds of pages of policies and procedures developed by most hospitals and health systems are designed to prevent mistakes by guiding people through proven steps and providing clear rules. Yet every once in awhile the rule books tragically get in the way, and they may have gradually eroded the emphasis on using good judgment. Last month, a 15-year-old boy in Chicago was shot while playing basketball; his friends brought him to an emergency department’s front door. Hospital policy prohibited staffers from leaving the hospital premises to help the boy. When an ambulance failed to arrive, police finally brought the boy into the ED. Not long afterward, he died. What would you have done? Would you have decided to violate hospital policy and talk your colleagues into helping you bring the boy into the ED for treatment, or would you have been on the phone, begging the ambulance company to hurry? The fear of litigation and the fast pace of work that has developed over the last 10 years have made everyone leery of veering too far from any hospital policy, or clinical guideline, for that matter. It seems so much safer sometimes to just stick by the rules. But for all our policy and procedure manuals, health care is actually the worst place to be if you like rules. Things happen in ways no rule book writer could ever imagine. That’s why we need professional nurses around, people who can exercise quick judgment in a flash, who know when adaptability is necessary and when someone’s life could hang in the balance. In the wake of the incident in Chicago, the American Hospital Association issued a "quality advisory" recommending that hospitals check their emergency department policies to see whether they allow flexibility for staff to use their best judgment. They also reminded administrators that federal regulations require that staff in any area of a hospital campus screen all patients who request care to determine if they have an emergency medical condition. Those who do must be stabilized or appropriately transferred. Exercising judgment that goes against a hospital policy can take a lot of courage. Imagine what it would have been like to direct several other staff members to help you bring the bleeding boy into the ED from the parking lot. Picture the risk you might have been taking if gang members were hanging around the scene. But, then again, think what it would have been like to watch him die because you didn’t. Barbara
Bronson Gray, MN, RN |
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Illustration by Malcolm Garris/PhotoDisc
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