Full text of DOI:10.1046/j.1440-1800.2002.00131.x

Nursing Inquiry 2002; 9(1): 57–61
I n v i t e d C o m m e n t a r y
Blackwell Science, Ltd
Thinking like a nurse: you have to be
a nurse to do it
Suzanne Gordon
Before 1998, I thought I understood nursing. I had followed
nurses as they cared for patients, interviewed them, read
nursing texts, books, and journals, and worked with nurses
to help them make their important work more visible. I
understood what in Life Support: Three Nurses on the Front Lines
In February of 1998, I went to California to give a lecture
and stayed with my friend Kathy Dracup, who was at that
time a cardiac critical care nurse, editor of American Journal
of Critical Care, and professor at the University of California
at Los Angeles School of Nursing. About a week before I
arrived, Kathy called to ask me if I’d do her a favor. She had
a knee injury and needed arthroscopic surgery. Suddenly,
her surgeon called to tell her he had a slot open and wanted
to schedule her surgery during my visit. Her husband was
going to be away on a business trip. She asked if I could pick
her up at the hospital, bring her home and take care of her
after the operation. She would get to the hospital by cab, but
she wasn’t allowed to drive or take a cab home. It would all
be the proverbial piece of cake, she reassured me (and her-
self). All I’d have to do was get her a meal, bring her a cup
of tea, or water and help her to the bathroom. Nothing to it.
Of course, I agreed. I even joked that playing nurse for
a day would give her the opportunity to judge if I’d learned
anything in my years studying nurses.
—
a book about nurses at Boston’s Beth Israel Hospital —
I called nurses’ tapestry of care, the combination of domestic,
intellectual, technical, social, communal and other activities
that go into making the package that is nursing the sick
and vulnerable. I understood the caring components of
nursing work
vulnerable, in pain and suffering. I also understood nurses’
participation in the process of cure something the care
— the attentiveness to human beings who are
—
versus cure dichotomy unfortunately conceals. And, of course,
I knew that nurses prevent errors, and injuries and other
catastrophes.
Caring for a friend taught me that being a nurse is much,
much harder than even I had assumed. It involves not only
acting like a nurse, but thinking like a nurse and viewing the
world through the eyes of a nurse. That different vision is
critical, as I discovered the hard way.
As instructed, Kathy had left the house that morning
to be at the outpatient surgery center of a large teaching
hospital by 6:30 am. Thirty minutes later, she was in the OR.
At 9, a nurse called and told me to be at the recovery room
precisely at 9:45. From there, I would be dispatched to the
pharmacy to get Kathy’s pain medication and then return
to go over the discharge instructions. We’d be out by 10, the
nurse said. What brisk efficiency, I thought, as I drove to the
hospital. This should be easy.
In conversations with one of my cherished mentors, his-
torian of nursing Joan Lynaugh, I often engaged in conver-
sations about nursing. When Joan and I talk, she always
emphasizes the role nurses play in keeping patients safe,
‘Yes, yes,’ I would always think. Of course, of course, I would
agree, conjuring up images of nurses double checking dicta
like ‘right dose, right time, right patient, right route’.
But in the winter of 1998, I came smack up against my
own ignorance, smack up against just what it means to be a
nurse and think like a nurse, smack up against the complex-
As I walked through the recovery room, I began to have
second thoughts. In curtained off cubicles, I saw blitzed out,
exhausted looking patients just out of the OR and still
hooked up to IVs. I wondered how they, like Kathy, could
possibly be well enough to go home. I hoped that I would
find my friend in better shape and, sure enough, she seemed
quite cheerful as she reclined in bed and gave me the
good news. Her doctor had found less knee damage than
expected. ‘I can’t tell you how happy I am,’ she smiled ebul-
liently. ‘My knee was so swollen and painful,’ I thought for
ity of what nurses do to keep people safe from harm
thing that, stupidly, I had not fully grasped before.
—
some-
I learned this when I became a ‘nurse for a day’
—
two
really taking care of a friend who had ambulatory surgery.
—
Correspondence: Suzanne Gordon, 11 Ely Road, Arlington, MA 02174, USA.
E-mail: <ISupport@aol.com>
© 2002 Blackwell Science Ltd

S Gordon
sure the surgery would be much worse and that the surgeon
would find more damage. I left to get Kathy’s prescription at
the pharmacy. As the pharmacist handed me the bottle of
pills, I asked him if there were any special instructions I
needed to know before giving them. No, he said, offhandedly.
Just make sure she takes one every four hours. Back in
the recovery room, I asked the nurse the same question and
she repeated the same instructions. Then she went over the
discharge instructions: remove the bandage 24 – 48 hours
after surgery. Don’t be alarmed if there’s some blood on the
bandage. Because of the danger of osteomyelitis, Kathy
shouldn’t swim or take baths. She also shouldn’t try to put
any weight on her bad leg for the next 10–12 hours because
the nerve block used prior to surgery had completely
deadened it.
5′11′ and 130 pounds. She had no mobility. I didn’t have
enough strength. What were we to do?
Looking for help, I raced over to the next door neighbor’s
and rang the bell. No answer. I started for the next house.
‘Don’t bother,’ Kathy shouted, ‘She’s too old to help.’ In this
suburb of Los Angeles, few people are home during the day.
I came back, stymied. God, what a predicament. It was
her leg or my back. To try to save both of us, I crouched down
carefully in between her legs and put her hands around my
waist. Slowly, ever so slowly, as if I was a tree trunk, she
climbed me and I supported her until she was standing.
It was now clear to me that the combination of dehydra-
tion plus the anesthesia she still had on board meant she
could not be counted on to stay upright. To make sure she
was safe, I would have to stick to her like glue. As we walked
up the driveway, I held her waist from behind and gradually
we navigated our way to the front door.
The nurse asked Kathy if she’d ever used crutches
before. ‘Oh, yes,’ Kathy blithely responded. The nurse
probed no further. Instead, she said, ‘Okay. You don’t need
a lesson in crutches’.
She stood at the base of the three front steps while
I opened the door. Okay, I said, and went to help her up the
three steps to the front door. She didn’t move. She lacked all
kinetic problem-solving ability and simply couldn’t figure
out how to negotiate the steps with her crutches and dead
leg. I tried to support her but I just wasn’t strong enough.
I have often written that nurses help patients scale the
molehills that illness has transformed into mountains.
Standing there, at that front door with its three steps, think-
ing about going through the door and meeting the next
The anesthesiologist came in to make Kathy’s discharge
official. After putting my friend in a wheelchair, the nurse
and the doctor waved us out. An escort wheeled Kathy
down to the parking lot where a hefty guard helped her into
the car.
Great, we both said, smiling. As we drove away, I was
again impressed
— or perhaps I should say lulled — by my
friend’s good spirits and alertness. She seemed totally her-
self. There didn’t seem to be any lingering effects of the
anesthesia. She chirped on about how relieved she was that
the surgeon hadn’t found more damage in her knee, that
she wouldn’t have a lot of scarring and thus greater risk for
arthritis later on in life.
obstacle
— another step to the living room — and a flight of
stairs up to the second floor and her bedroom, I felt like we
were staring up at Mount Everest. The hospital had given us
some climbing gear, but not the expert guides.
Just as I was contemplating the two of us standing here
all day, a truck pulled up across the street and two gardeners
got out and began mowing the lawn and clipping hedges.
I had to risk it. ‘Hold on! I’m going to get help.’ I made sure
Kathy was firmly stabilized on her crutches and begged her,
‘Please, please don’t move, don’t fall,’ and I ran across the
street.
When I pulled up to the curb, we got her out of the car
and standing up on her crutches without mishap. Rather
than going up the front walk, with its numerous steps, we
walked to the driveway.
Then I made my first mistake: I left Kathy alone and went
up the slight incline of the driveway to open the gate that
would allow her to access the front door.
The gardeners were Hispanic and fortunately I know
Spanish. ‘Please help me, please,’ I begged, pointing to the
After opening the gate, I turned around I saw my beau-
tiful friend lying in a heap, crutches splayed out to the side,
at the bottom of the driveway. I raced down to her crumpled
figure. ‘God, are you all right?’ I asked, bending down by her
side. ‘Did you hurt your leg? Did you hurt your other leg?’
Completely dazed, she said, ‘I don’t know what happened.
I was fine one minute and then the next I felt so dizzy. I just
went down. Feeling her body, she muttered, ‘Okay, it’s okay
I think I’m fine.’ I bent down to try to help her up. But she
did not budge. I tried to pull her up, but she was dead
weight. I’m five foot six inches and have a bad back. She’s
woman on crutches
— thankfully still on her feet — and prac-
tically dragged one of the gardeners across the street. He
accompanied me and helped Kathy up the steps and into the
living room. As Kathy was hobbling across the living room to
the stairway, one of her crutches hit an unanchored throw
rug. The crutch started to skid out of control. By this time
I was on red alert and leaped over to hold it down.
She didn’t fall again, at least here.
Kathy ascended the stairs on her bum. After heartfelt
thanks, the man left the house.
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© 2002 Blackwell Science Ltd, Nursing Inquiry 9(1), 57–61

Thinking like a nurse
Dripping with sweat, shaking with anxiety, I helped Kathy
off with her clothes and into her pajamas, tucked the requi-
site pillows under her injured leg to keep it elevated, and
went down to make her some tea. It was only 11:30 in the
morning, but I felt like I needed a stiff drink.
a wave of nausea. I ran to get a plastic bowl and some towels.
The nausea passed without vomiting. But it was clear the
pain medication was not agreeing with her.
Later, when Kathy talked to her sister, who was a real
nurse, we learned why. That particular medication is appar-
ently notorious for causing nausea. Kathy needed to eat
before taking it, but all she’d had since midnight the previ-
ous night was a banana. Why hadn’t anybody told me this at
the hospital, I wondered. I’d asked both nurse and phar-
macist if the medication had any side-effects. Neither had
mentioned a word. Had I known she needed to eat to stay out
of pain, I would have force-fed her like a French goose.
As I got Kathy to sleep and me into my bed, stress and
worry had turned my back into a spastic knot. I felt over-
whelmed by the responsibility of trying to keep my friend
safe. I was also afraid that she would wake up in the middle
of the night to go to the bathroom, fall again and that this
time our luck would run out.
In the afternoon, her daughter came over and I went out
to do a few errands. When I came back, Kathy had some bad
news. With her daughter’s help, she had gone to the bath-
room. In the process of turning around to get on the toilet,
she’d again become dizzy and again she had fallen.
Again, by sheer accident, she hadn’t hit her bad leg, bro-
ken a hip, cracked her head, or injured her daughter.
I immediately marched into the bathroom to survey the
scene. Only then, after the fact, did I see the problem. This
was no hospital bathroom, with non-skid linoleum floors,
plenty of room for two people to maneuver, and grab bars
near the toilet. The floor was tiled and quite slippery to
stockinged feet
— and she had to wear support hose for the
next few days. There was another treacherous throw rug
near the sink. Not surprisingly, the room was designed with
fashion, not illness, in mind.
My friend Joan Lynaugh has described the dilemma that
characterizes the entire history of nursing. Nurses, she says,
have been given the awesome responsibility of the care of
the sick, without being given the education and resources
necessary to fulfill that mission. As I went to bed, I felt that
I was living out that dilemma. I was asked to be a substitute
for the nurses in the hospital, but I had not been given the
education and resources necessary to protect my friend from
danger. Indeed, I was being set up to fail or, at the very least,
to feel like a failure.
‘You shouldn’t go into the bathroom without shoes on,’
I told her. ‘You can slip too easily. In fact, when I go with you,
I need to wear shoes too. We have to be careful,’ I said. ‘We
can’t let you get hurt. I tried to sound calm, but inwardly
I was a wreck. Too many accidents were happening.
Finally, when Kathy’s daughter left, she took a nap. As
she was sleeping, her husband John called to find out how
she was. Of course, I told him the operation went well,
but feeling isolated and anxious, I also recounted all the rest
of our mishaps in full Technicolor and stereo surround
sound. Not surprisingly, he panicked. ‘Should I get on the
next plane and come home? I can be there late tonight.
I don’t care about missing the rest of these meetings,’ he
insisted.
Although Kathy was doing much better the next day,
I could not help but ruminate on what had transpired. What
taking care of Kathy taught me is the enormous complexity
of keeping patients safe from harm. What we so easily forget is
that illness and treatment make people enormously vulner-
able
— not just to the side-effects of drugs, to hospital borne
infections, to surgeons who may operate on the wrong limb,
or to residents, and now nurses, who are overworked and
I hurriedly tried to take it all back, insisting that nothing
else untoward would happen and that I’d call him if the
slightest problem occurred. ‘All right,’ he said, and reluc-
tantly hung up.
overtired, but to daily life itself. Sick and infirm people
—
even people who are sick and infirm for only a short time are
—
at risk from all those things that are unproblematic when
they are well. Suddenly, the normal activities and accoutre-
ments of life become threatening, if not lethal. To nurses,
I know this must sound banal. But believe me, to those who
do not regularly care for the sick and vulnerable, it is not.
What nurses know and do, I suddenly realized with
stunning clarity, is view the world through the prism of that
human vulnerability and capture, in their educated glance,
the dangers of the ordinary. And they combine that educated
After putting down the receiver, I hit myself in the head
once again. ‘You idiot,’ I said to myself. ‘Why weren’t you
thinking like a nurse. A real nurse would never have lain all
that on to an anxious husband who already felt guilty
because he wasn’t home with his wife. A real nurse would
have had the experience to know how he would react.’ But,
of course, I realized I was not a real nurse and thus could not
possibly think like one.
This became clear once again, as I was making dinner. In
the middle of cooking, Kathy shouted out to me. I raced
upstairs. ‘Excuse me,’ she apologized, suddenly overcome by
glance with another crucial nursing skill — the ability to pro-
tect patients from danger without making them feel endan-
gered. I had failed utterly to do that when I talked to Kathy’s
© 2002 Blackwell Science Ltd, Nursing Inquiry 9(1), 57–61
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S Gordon
husband. When he called, my anxiety and stress level was so
great that I didn’t have the emotional energy to reflect on
my actions. I did not understand that this was not the time
to tell Kathy’s husband about my terrible experience and to
teristics of nursing care is protecting patients from harm.
Why didn’t this nurse protect her patient from that harm?
Was it because she was a bad nurse? An unethical nurse? Was
it because she failed her moral mandate?
expound on the flaws of the American healthcare system
—
I don’t think so. Nurses today often work in healthcare
systems that value profit, cost-cutting or efficiency more than
patient safety. In ambulatory surgery centers, the imperative
one that now routinely puts a patient and their caregivers at
such risk. I did not have the professional discipline to do
this, not because I am not a caring person, but because I am
not a nursing professional.
is through-put
— getting patients in and out. Because, in
reality, most nurses work for institutions not patients, the
mandate to speed up the process of treatment and care may
override the individual nurses’ concern for her patients.
And indeed, the next day, when a nurse from the out-patient
surgery center called to inquire about Kathy, that came
across quite clearly. When she asked if Kathy was doing well,
I told her the whole story.
Caring for Kathy also highlighted the contextual nature
of nursing itself. The statement ‘a nurse is not a nurse is not
a nurse,’ is accurate not only because nurses, through their
education and experience, may be expert in different areas
of practice. It is true because nursing is an activity that occurs
in a specific context. Although many nurses, like other
professionals, like to claim a special moral position that is
transformative, the fact is that being a ‘nurse,’ depends on
whether one is acting in the role of a nurse just as the success
of nursing care depends upon the context in which it is
delivered.
About the first fall, she remarked defensively ‘But didn’t
you read the discharge papers, it says patients might feel
dizzy?’
‘Might feel dizzy
— that’s not good enough,’ I retorted.
‘You need to tell us to stick to the patient like glue. You need
to insist that patients have a lesson in crutches. You need to ask
When I told another nurse friend about my experience
taking care of Kathy, she remarked that Kathy should have
better prepared and advised me. ‘After all,’ my friend said,
‘she’s a nurse’.
about the lay-out of their house
— if they have steps.’ Those of
us helping patients need to know how to help them maneu-
ver up steps when they are dehydrated, have had anesthesia,
and have a dead leg. You need to ask about throw rugs.
‘Well, you know, I hate to say it,’ she admitted, ‘but she
isn’t the first person who’s fallen.’ Then she backtracked,
insisting it was the patient’s and family’s responsibility to
check the house for dangers like throw rugs. Finally, she
mused, ‘Maybe, we should advise patients to have two people
available when they go home’. ‘That’s great,’ I thought, ‘We
pay for nursing care in our healthcare premiums. Then we
have to deliver that care ourselves to our loved ones at home,
and now you’re asking two people to take off work. If the
system isn’t going to let people recover adequately in the
hospital or ambulatory surgery center, it’s the system’s
responsibility to make sure they are safe,’ I wanted to shout.
But I didn’t.
Well, yes and no.
The minute Kathy walked into her doctor’s office to con-
sult about her knee, the minute the surgeon called and told
her when her surgery would be scheduled, the minute she
walked into that ambulatory OR, she shifted identities. She
became a patient, adopting the attributes that characterize
most patients. She minimized the impact of her surgery
on her immediate postoperative recovery. She accepted her
nurses’ cavalier comment that because she’d used crutches
before; she didn’t need a run through in order to use them
safely again. She was exuberant about her operation
because, as patient, she was more concerned about whether
or not her injury and its repair would limit her later in life
than she was about the details of her home care. These con-
cerns shifted her gaze. She was looking at the world through
the eyes of a patient. Although she is extremely knowledge-
able as a nurse, as a patient she had difficulty applying her
nursing gaze to her own environment and could not possibly
protect herself from danger.
Why? Because I realized that despite nurses’ contention
that they are patient advocates, patient advocacy is also con-
text dependent. As much as nurses may want to advocate for
patients, too many do not have the on-the-job time required
for effective patient advocacy. In countries plagued by
cost-cutting and shortages, many nurses are so depleted by
intolerable patient loads that advocacy is a hope not a reality:
at a certain point in their day, they simply don’t have the
energy to fight any longer. Moreover, many nurses work in
institutions that do not value their insights and concerns.
Nor do some have the on-the-job protection that would
encourage them to buck the system when it’s necessary.
What is even more interesting about this episode is how
the nursing care she received in the hospital was also context
driven. Why you might ask, didn’t her nurse insist that she
have a lesson in crutches? Why didn’t she advise me about
pain management, when I asked? Why didn’t she ask Kathy
or me about the obstacles we would have to navigate when
we were back at home? After all, one of the central charac-
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© 2002 Blackwell Science Ltd, Nursing Inquiry 9(1), 57–61

Thinking like a nurse
And others are too passive or too burnt out to engage in the
kind of political action necessary to change the workplace
environment. Even more distressing, as Marie Heartfield’s
new research is pointing out, still others have embraced the
bottom-line values of their institutions and view their job
not as advocating for patients, but as successfully getting
patients into and out of their units as quickly as possible.
I believe the moral and political dilemmas that so many
nurses face today is one of the by-products of our social
failure to understand the complex nature of the work of keep-
ing patients safe from harm. As I walked around Kathy’s
neighborhood a few days after her operation, I kept asking
myself why it took me so long to grasp the importance of the
ostensibly trivial issues that grew to be so important when
Kathy returned home from the hospital. For this failure, I
think we are all to blame. Our society is to blame for its per-
sistent inability to reckon with all the minute consequences
of illness and its unwillingness to give nurses the resources
they need to adequately care for the sick.
of illness and the myriad dangers that patients face either in
hospital or home. Similarly, when nurses focus assiduously
on themselves as purveyors of ‘health,’ the content of the
work they do when dealing with sickness (which is, after all,
what the vast majority of nurses actually do in their daily
work) seems to be almost entirely eclipsed.
This is unfortunate, because, as I learned the hard way,
many non-nurses need to hear far more about nurses’ safety
work. We need to hear more nurses explaining how they pro-
tect patients from the dangers of their vulnerability. We need
to hear more of them tell us that nurses keep patients safe
during illness
— and how they do this. We need to hear nurses
explain that they pay attention to the so-called little details
(which they then describe in sufficient detail) that seem so
banal but that make the difference between life and death,
recovery and safety, and we need to learn what kind of
resources they need to assure patient safety. We need more
nurses to tell us that nursing isn’t a matter of TLC, but of life
and death.
But this social problem is exacerbated because nurses
are so often silent about the content of what I’ve come to
think of as their safety work. When I read the descriptions
of nursing work articulated by nursing organizations or
Although I have been writing about nursing for over a
decade and had a very good head start, I had to wait until
a friend got sick before I gained a better understanding of
the complexity of nurses’ work. If our societies are to provide
the resources to make nursing a long-term satisfying career,
those of us who are not nurses need to learn to appreciate
the facts of illness and vulnerability before we, our friends,
or ourselves and relatives get sick. I was lucky. By sheer good
fortune, my failure to ‘think like a nurse’ didn’t kill or seri-
ously hurt my friend Kathy. When it comes to the care of the
sick and vulnerable, luck isn’t good enough. At some point,
it always runs out.
by individual nurses, I find that they are long on jargon
—
about ‘patient advocacy,’ ‘patient education,’ ‘coordination
or management of care’ ‘prevention of illness’ and ‘health
maintenance’
nurses ‘caring.’ But the content of this ‘caring’ ‘coordinat-
ing,’ ‘education,’ ‘advocacy’ work is hard if not impossible
to grasp. That’s because nurses provide very few concrete
— as well as on diffuse and vague accounts of
—
—
details that allow us to really understand the consequences
© 2002 Blackwell Science Ltd, Nursing Inquiry 9(1), 57–61
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