I read an article today that said CNMs can be great, but they have been trained as nurses first so are indoctrinated to the Doctor-Nurse hierarchy, and I had to scratch my head. Hierarchy? As in the doctor is the boss and the nurse follows orders? This is a very common misunderstanding of the doctor-nurse relationship, and if you believe it you risk not helping your clients utilize the best services from a nurse.
Each nurse is an independently licensed professional with a scope of practice that determines her role. Nurses deal with responses to illnesses and conditions while the doctors and advanced practice nurses deal with the illness or condition. What is a response to illness or condition? Might be pain, altered nutritional status, emotional distress, educational needs or other similar things. It is the role of the nurse to address each client holistically, assessing risk and addressing these responses. The nurse does this regardless of how the physician chooses to treat the illness or condition.
In a hospital birth system, the nurse is hired by the hospital and is answerable to the hospital for her actions. In the US, physicians are independent practitioners who are credentialed to be able to use the hospital facility. At no time is the physician in a role of authority over the nurse. The nurse answers to the nurse manager. The nurse’s responsibilities are defined by the policies and procedures of the hospital, and most of her clinical decisions will be made following these policies (such as if a patient should be using an oxygen mask or how often a patient will be monitored).
The physician is responsible for managing individual patient illnesses and conditions. This means it is the physician responsibility to order medications, treatments or surgeries necessary for the health of the patient. The nursing staff will maintain a record of the patient while in hospital and this information is used by the physician to make clinical decisions. The nursing staff can also recommend additional management options to the physician based on the risks seen in the patient, but it remains the physician responsibility to order anything. The nurse, as an agent of the hospital, can provide the treatments or medications ordered by the physician, but cannot order them.
So what does this really mean?
A nurse has great power to influence the care of laboring women.
- A nurse has great power to provide non-pharmacological emotional and physical relief measures.
- A nurse has great power to choose how she presents a patient when updating a physician.
- A nurse has great power advocate for the wishes of her patient.
- A nurse has great power to advocate for policies and procedures that provide natural birth friendly birth spaces.
- A nurse even has the power to refuse to provide a treatment ordered by a physician if the nurse believes it is not in the patient’s best interest or will cause harm.
A nurse will never be in the role of deciding on and ordering medical treatment for a patient, that role is always designated to the physician. But that does not make the physician “in charge of” the nurse. While you may expect this role differentiation to mean the doctor is in control and influences what the nurse does, it is often other way around with nurses at the bedside making decisions about what to share with the physician and influencing how the physician manages the labor.
So this relationship is a balance. The nurse influences how the physician manages the labor and the physician influences how the nurse works with and advocates for the patient. But even the best nurse may not be able to salvage a patient’s natural birth wishes if they have chosen a physician with a 60% cesarean rate; and even the most natural birth friendly physician cannot prevent a patient from being assigned to a nurse who would rather be at the desk than in the patient’s room.
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