D. Being ‘native’
2. Nurses in the position of being ‘disciplined’ and/or ‘docile’
The review of documents in both hospitals revealed that there are brief job descriptions that describe the role of nurses of different grades, but no official document was found which describes the roles of nurses and doctors. This observation provoked the question of how nurses learn about their roles in pain management in Jordanian hospitals. One potential answer was university education. However, the document review of nursing syllabuses in both universities showed that nurses learn about pain for less
than 30 minutes during the whole four years of study, and there is a severe lack of information regarding nurses’ role in pain management within multidisciplinary teams. Thus, and as interviews revealed, interacting with other professionals during daily work life seemed to be the primary way through which nurses learned their roles and boundaries. In other words, examples of nurses being disciplined through interacting with others were captured.
Doctors’ responses to nurses’ suggestions or attempts to make suggestions clearly embodied attempts at enforcing discipline through berating and marginalization:
“Because I spend more time with patients, I would like to make suggestions regarding their progress. However, the doctors’ view of nurses prevents me from doing this. I feel I am being marginalized each time I talk with doctors. I see in their eyes that they say, `you are nothing. What do you know about my work?’ Thus, I keep silent all the time in the presence of doctors. If they ask, I answer. Just that.” (S.N P(24); F; S.F; M.H)
“We do not discuss anything with doctor. We might draw their attention to something. Personally I avoid embarrassing myself with doctors by making a suggestion upon which I might be berated, or will definitely be ignored.” (S.N P(63); F; S.F; P.H)
The continuous exposure to doctors’ disciplinary power seems to have made some nurses more obedient, or docile. Nursing docility appears in many nurses’ practices, such as referring to doctors in all matters whatever the significance of the situation; applying doctors’ orders without questioning, and not referring to other nurses’ knowledge or expertise for help before calling doctors:
“Researcher: What happens if a patient is in severe pain while the doctor is unavailable for any reason?
S.N: I call him by telephone, and ask him what should I do. If he does not answer, I keep calling him.” (S.N P(21); F; S.F; M.H)
“When nurses came and measured my temperature, I told them that I have severe pain, but they said, ‘wait for the doctor. He will come within a few hours. I do not know what he will order for you’. Until the present moment, I have severe pain, and neither has the doctor come, nor have the nurses given me anything to decrease my pain.”(P.T F(P-23): S.F; P.H)
“Patient’s son: ‘When my father complained of severe pain, the nurses did not dare to give him a painkiller. They only waited for the doctor's order... I want to say that nurses here, like machinery, are acting according to what is written on paper, not according to the patient's condition or the progress of his case condition.” (M.Relative (P.T M(P-11); S.M; M.H)
The nurses’ docility also seems to be reflected negatively in their self- development and learning, and in their settling for orders given by doctors:
“I do not think that I need any further information regarding pain management since pain can be simply relieved by a doctor's order of a painkiller.” (S.N P(11);F; S.M; M.H)
The hierarchical nurse-doctor relations based on marginalization/domination hindered effective management of patients’ pain by prolonging the time the patient had to wait in pain without action by nurses who preferred to wait for guidance from doctors.
This hierarchical relationship also hindered pain management outcomes by reinforcing missing patients’ pain complaints and interfering with the communication of these complaints between doctors and nurses. This happened because nurses did not make suggestions or discuss patients’ pain complaints or other affairs with doctors because of interiorizing marginalization and inferiority. This was also a result of fear felt by nurses about provoking conflicts with doctors:
“Some doctors might not fully listen to nurses’ suggestions, or do not take them seriously, although the suggestion might derive from a patient’s complaint during the shift. Thus, the patients’ complaint goes into the air.” (S.N P(6); F; S.M; M.H)
“The patient called the nurse and told her to tell the doctor that his operation was hurting him because of his flatulence saying, `would you inform the doctor that I have pain on the incision because of flatulence?’. The S.N replied, `If he is calm, I will tell him...” (Observation (1):S.M; M.H; Shift (A); 9:45am)
The problem of failing to pass on patients’ pain complaints was not only overt in the communication between nurses and doctors, but also between members of the nursing team themselves in both hospitals. There are many examples in the collected data which show that patients’ complaints were not communicated between nursing team members on different shifts. Findings regarding the content of the discussions that took place in nursing rounds between different shifts showed that patients’ complaints of pain were not passed from one shift to the next shift:
“The main problem here is the nature of the nurses’ shift work, since nurses do not communicate patients’ pain complaints. They only talk about procedures done to the patients, results of lab tests, and medications. In other words, if there was a patient at midnight complaining of severe pain, nurses will not talk about this patient’s complaint together at the nursing morning round. Hence, patients’ complaints will fail to be passed from a shift to a shift, and will be lost.” (D.R (41); M; M.H)
“I accompanied the nurses in their round. The nursing round was finished within six minutes. The S.N of the finished shift (A) informed the S.N of the starting shift (BC) about patients’ names, cases, and if they will undergo operations the next day or not.” (Observation (8): S.M; P.H; Shift (B); 2:55pm)
The reader might question whether nurses or doctors communicated messages regarding patients’ pain by documenting them on patients’
profiles. However, the document review of patients’ medical profiles, with emphasis on nursing and doctors’ notes, showed that neither doctors, nor nurses in both hospitals regularly documented patients’ pain complaints. Nurses in the military hospital only documented the Pethidine injections or narcotics given on a separate prescription sheet, and this sheet was placed in the narcotics locker. Thus, only the staff nurse in charge, who had the keys to the locker, could see these prescriptions. The same thing, with a relatively small difference, happened in the public hospital. In addition to documenting it on the prescription sheet and narcotic locker notebook, nurses in the public hospital documented the narcotics injections given to patients on nursing note sheets, with no other additions. These notes did not give any indication about patients’ pain severity, or characteristics; and because there was an absence of re-assessment skills, as will be shown in the following section, the documented notes did not give any indication about the response of patient to the given painkiller.