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My latest column is out —

What Makes a Great Nurse?

There’s more to nursing than experience alone

By Genevieve M. Clavreul, RN, Ph.D.

In recent years, there’s been a lot of talk in the nursing world about education: advanced degrees, certifications and training in the latest technologies. However, this nurse has long believed that all the certifications and degrees in the world are no substitute for good basic nursing skills, including attention to detail, listening and, most important of all, a deep and abiding compassion for all the patients under your care.

I recently received a dramatic reminder of this point when my eldest daughter Patricia was unexpectedly hospitalized. Her experience left me simultaneously impressed and frightened about the state of nursing in the Golden State. (Before I begin this tale, I should note that Patricia has given her consent to my sharing her story with my readers, but I’ve redacted the names and certain details to protect the innocent — and the guilty.)

Unexpected Surgery

Patricia’s hospital “adventure” began with an emergency trip to her primary care physician. Patricia had seen the doctor earlier in the week about a persistent rash and swelling in her feet. Blood tests revealed that her hemoglobin count had dropped to 8.0; since 12.0 to 15.5 is considered the normal range for women, such low levels were serious enough to merit immediate hospitalization.

After Patricia was admitted, her hemoglobin count continued to fall even after she received several full pints of blood. A CAT scan eventually revealed a large abscess that had displaced her right kidney from its normal position to the front of her abdomen. As if this weren’t bad news enough, the scan showed that the kidney was basically a shriveled mass and no longer functioning.

To make a long and painful story short, Patricia underwent a six-hour surgery to remove the abscess and the nonfunctional kidney, after which she was intubated for several days. She also ended up in isolation after a nasal swab came back positive for MRSA. As of this writing, she’s still in the hospital, but her white blood cell count is back to normal, most of the tubes have been removed and she is once again allowed solid food. She’s looking forward to going home.

The whole spectrum


The quality of nursing care my daughter received throughout this ordeal ranged from superb to truly lousy. Here are just a few examples from both ends of the spectrum:

Good: One of the day nurses was consistently attentive and thoughtful, making a point of always speaking to Patricia each and every time he needed to perform any action that affected her, from taking her blood sugar (like me, Patricia is diabetic) to more invasive procedures like checking her two No. 19 BLAKE drains. It was a small gesture that made a big difference.

Extraordinary: When Patricia received her diagnosis and was told that her kidney needed to be removed, she was understandably overwhelmed and began to cry and fret. One of the nurses, aware of the situation, disappeared down the hallway for a moment and returned with a harpist who offered to play several songs for Patricia to help her relax.

Bad: After Patricia was moved from the ICU to a regular room, the nurse who received her made it clear that she considered Patricia a burden. When my daughter complained of feeling warm and flushed after starting a new, more powerful antibiotic, the nurse could barely find the time to answer a call light and refused to take my daughter’s temperature again until asked to do so by the charge nurse. Appallingly enough, the recalcitrant nurse was mentoring a student nurse at the time. So much for modeling good nursing practice!

Worse: Since Patricia has very fragile veins, her doctors decided she needed a peripherally inserted central catheter (PICC) line to continue her antibiotics. The nurse who was sent to insert the PICC line insisted that I leave the room during the procedure because she needed a sterile field, but seemed oblivious to the gnats flitting about her so-called “sterile field.”
To my dismay, she then proceeded to pick up items that had fallen on the floor and put them back on the top of her cart without cleaning them first. I finally ordered her out of the room and requested a different PICC nurse.

Some of the nurses were very nice, but seemed worryingly inept. For instance, when I asked one young nursing graduate what dosage of morphine she was about to give Patricia, the nurse had to leave the room and reread the order before she could answer — hardly a reassuring sign. So much for making sure you’re giving the patient the right meds!

Some of the nurses shaped up noticeably after they learned I was an RN myself and thus was keeping an extra-sharp eye on them. It was good to know they were paying attention, but it suggested that they had grown a little slack and lazy when they didn’t think they were being “graded.”

Even the best nurses on the hospital’s staff had their off moments. One RN, an excellent nurse by most standards, had the bad habit of picking up the trash can lid each time he disposed of something and then continuing with his patient care. This didn’t make him a bad nurse, but it was a bad habit that could have negative consequences for patients.

What really counts

It struck me during Patricia’s hospitalization that there wasn’t an obvious correlation between the nurses’ levels of experience and the quality of care they provided. There were seasoned nurses who acted like they were going through the motions and veterans who still behaved as if each patient was as unique and important as the first patients they cared for when they begun their careers 20 years ago. There were new nurses who seemed out of their depth, but some of the finest nurses we encountered had only been RNs for a few years.

There were also patient care assistants (PCA) who provided care as good as or better than the RNs they supported. One PCA was so attentive and conscientious that I was heartened to learn she had just received her RN license that night. It gave me hope for the future of nursing.

What made the difference was not so much each nurse’s experience or level of training, but his or her personal commitment to patients and determination to practice to the best of his or her ability. Simply put, some of the nurses cared for my daughter as if she were their own loved one and others did not. Speaking as both a nurse and as a worried mother, it wasn’t hard to tell the difference and it had a meaningful impact on my daughter’s experience.

upholding the principles

I know there’s no such thing as a perfect hospital and even the best healthcare professionals make mistakes or have bad days — we’re only human, after all. I also don’t wish to downplay the importance of education and the judgment that comes with experience. However, it’s important for us to remember that education and experience are not a panacea. Teachers and mentors can tell us over and over again about the importance of compassion and patient advocacy, but it’s up to us to uphold those principles at every stage of our careers.

We must never forget that we often see patients at their most vulnerable and those patients’ families and friends are counting on us to help restore their loved one to health. Our profession demands that we challenge ourselves to always provide the best care we can and not allow ourselves to compromise patient outcomes with bad habits or a poor attitude. When that happens, it tarnishes us all.