CE: A Historical Review of Nurseâ€“Physician Bedside Rounding
CE: A Historical Review of Nurseâ€“Physician Bedside Rounding
In 1913, Dorothea Gothson, RN, expressed her opinion about challenges nurses faced in making bedside rounds with physicians: CE: A Historical Review of Nurseâ€“Physician Bedside Rounding
â€œThe most important fact about the work at our hospital is that we are given a chance to be ready for the daily rounds and dressings. We know when the chief is coming, and we can adjust our work accordingly. There is nothing more distressing to either patient or the earnest hardworking nurse than to be surprised by the attending doctorsâ€¦. Equally annoying is the experience of patients and nurses being ready, waiting for the doctors, and their not appearing for one or two hours after the appointed timeâ€”perhaps not at allâ€”thus upsetting the order of the hospital.â€
Her problems were not unique. Throughout much ofÂ nursingÂ history, nurses were expected to adapt their schedules to accommodate physiciansâ€™ needs when making bedside rounds. Today, as we strive toward interdisciplinary collaboration and away from a hierarchical health care structure, itâ€™s important to understand how nursesâ€™ perceptions of bedside rounding and their involvement in that process have evolved over the past century and a half to allow nurses to redefine the role they play in bedside rounding and achieve a more collaborative approach.
BACKGROUND AND SOURCES
The purpose of this analysis is to describe the nature and historical context of nurse involvement in bedside rounding from 1873 to 1973, thereby illuminating some of the challenges nurses and physicians face in implementing constructive, collaborative bedside rounding practices today. Using historical sources, both primary and secondary, and a social history framework, this article addresses the following questions as they relate to various periods within this 100-year span:
- In what capacity did nurses participate in bedside rounding?
- What were the perceived goals of rounding?
- What was the perceived role of the nurse?
- What conditions or circumstances promoted or impeded nurse participation in bedside rounding?
Primary sources included manuals for head nurses andÂ nursingÂ journals of the various eras, with theÂ American Journal ofÂ NursingÂ (AJN), the worldâ€™s oldestÂ nursingÂ journal, serving as a major source of nurse commentary on bedside rounding.Â AJNÂ has the most continuous and comprehensive archive in U.S.Â nursingÂ literature, as most other U.S.Â nursingÂ journals werenâ€™t launched until the second half of the 20th century. In accordance with norms of the time, the termsÂ sheÂ andÂ herÂ were mainly used to reference nurses during this 100-year period, asÂ nursingÂ wasâ€”and largely remainsâ€”a predominantly female profession.
The history of bedside rounding.Â Medical education has long depended on bedside rounding. This tradition of teaching medical students on the units formed the basis of medical studentsâ€™ education and was a source of pride for distinguished physicians. Sir William Osler, a renowned physician at Johns Hopkins School of Medicine in the late 19th and early 20th century, remarked, â€œI taught medical students in the wards, as I regard this as by far the most useful and important work I have been called upon to do.â€Â While itâ€™s easy to understand that the medical education of physicians is rooted in rounding practices, the connection between bedside rounding andÂ nursingÂ practice is best understood within the context of early hospital units and the makeup of theÂ nursingÂ staff during the late 19th and early 20th centuries.
THE ERA OF OBEDIENCE
With the development ofÂ nursingÂ schools in the United States after 1873, many hospitals relied onÂ nursingÂ students as a primary labor force. In fact, it was widely accepted that nurse â€œtraining schoolsâ€ provided cheap labor to meet patient care needs.Â With the exception of head nurses and a few operating room nurses, most graduate nurses left hospitals for work as private duty nursesâ€”a trend that continued until the early 1930s.Â The head nurse helped define the training experience ofÂ nursingÂ students.Â That training was rooted in strict rules and a military-like discipline, which would be embraced by many in theÂ nursingÂ profession well into the 20th century.Â As an early popularÂ nursingÂ textbook explained, â€œThe organization and discipline of the hospital resembles that of the army. The so-called military discipline may be criticised or by some condemned, but it must continue to hold sway, for the reason that in a hospital as in warÂ human life is at stake.â€Â The text goes on to stress the importance of â€œunquestioning obedience to superiors.â€ Central toÂ nursingÂ education was a culture of deference toward physicians:
â€œTo the doctor should be accorded the respect due a superior officer. Absolute loyalty must be given him, whether the nurse has confidence in him or not. She must not, by word or look, reveal to the patient any animosity which she may feel toward him or his methods; she may have misjudged him, and have reason later to change her mind. Whatever her personal opinion, it is not within the province of a nurse to criticize a doctorâ€™s ability or lack of it.â€
â€œThe nurse should stand while speaking with a doctor or taking an order from him. She should follow, not precede him. She should not state to him her opinions, nor should she make remarks unless requested.â€
The culture of obedience greatly influenced the way nurses viewed their role in physiciansâ€™ bedside rounding practices. In some respects, however, the military analogy allowed nurses to feel as though they had a higher status in the hospital structure:
â€œThe physician was the commander, and the nurses were the lieutenants. But the analogy of the trained nurse as lieutenant also implied a significant amount of powerâ€¦. She wouldâ€¦ have the knowledge and the trainingâ€¦ to take effective and immediate charge in the chaotic moments of the unexpected crises and emergencies that occurred in the absence of the physician commander.â€
The military analogy with its strict hierarchy and protocols inevitably affected both nurse-to-nurse and nurse-to-physician communication. Head nurses expected nurses in lower positions to demonstrate a deference in communicating with them. Similarly, nurses were not expected to question physician orders. CE: A Historical Review of Nurseâ€“Physician Bedside Rounding
BEDSIDE ROUNDS ANDÂ NURSINGÂ EDUCATION
In the early 1900s, hospitals functioned as training sites, with bedside rounds serving as educational activities forÂ nursingÂ students and new nurses. Head nurses took responsibility for studentsâ€™ overallÂ nursingÂ education, as well as the delivery of patient care, and making rounds with physicians providedÂ nursingÂ students an additional learning opportunity. In 1923, Mary Power discussed this method of clinical instruction inÂ AJN:
â€œ[L]et the pupils individually make rounds throughout the whole visit with the chief and his staff accompanied by the [nursing] supervisor. Make [theÂ nursingÂ student] responsible for all questions by the chief. He may object to this at first but, as a rule, when he comes to know [the] object [of the head nurse] he will not only agree to it but will include [theÂ nursing student] in his instruction. The pupil in this way not only gets the actual knowledge transferred but catches the spirit of a great physician.â€ CE: A Historical Review of Nurseâ€“Physician Bedside Rounding
THE HEAD NURSEâ€™S ROLE IN BEDSIDE ROUNDS
From its inception, the head nurseâ€™s role was to accompany physicians during rounds, documenting new orders and notes about patient care. Bedside rounds were seen as part of the routinized system. Patients themselves recognized the different roles physicians and nurses played. As one patient noted: CE: A Historical Review of Nurseâ€“Physician Bedside Rounding
â€œThe doctor, his assistant, and the head nurse go the rounds together just after breakfast. There is a certain order of procedure which is, I believe, invariable. The doctor raps, enters, shakes hands with the patient, sits down; the nurse stands at the foot of the bed, instruction book and pencil in hand.â€ CE: A Historical Review of Nurseâ€“Physician Bedside Rounding
While the head nurseâ€™s role on rounds was primarily supportive in nature, it was an important part of her job and was not to be interrupted. The following account describing a studentâ€™s hesitancy at interrupting rounds, even for what could have been a critical change in a patientâ€™s vital signs, demonstrates the importance head nurses placed on their involvement in bedside rounds: CE: A Historical Review of Nurseâ€“Physician Bedside Rounding
â€œOne morning a patient had just come down from the operating room. I thought her pulse was bad. The head nurse was having rounds with the doctors. I knew sheâ€™d be through in 10 minutesâ€¦. The last time I called her from rounds for what I thought was important, she scared me most to death, telling me never to do it again. I just couldnâ€™t decide. So I waited. The patient didnâ€™t die, but I got sent to the front office.â€
During the early decades of the 20th century, head nurses were determined to receive the professional respect and recognition they deserved, which meant dedicating themselves solely to the physicians during rounds. From her position of power within the hospital, the head nurse focused with military discipline on obedience and streamlined efficiency.
As late as 1962, head nurses saw medical rounds as an opportunity for the nurse â€œto gain insight into the thinking of the medical group relative to the patientâ€™s care and prognosis.â€Â But while the role of the head nurse in the mid-20th century had developed well beyond its humble origins, many head nurses still considered medical rounds a forum in which they could observe and learn, but not necessarily engage in the discussion of care planning.
NURSE PARTICIPATION IN BEDSIDE ROUNDS
A major part of nurse participation in bedside rounds involved preparing for the physiciansâ€™ arrival under the direction of the head nurse. As oneÂ AJNÂ author noted in 1923:
â€œIf the students have a time limit within which all beds must be made, in order that the ward may be swept before the time for rounds for physicians, the result will be clean, orderly wards and dignified medical and surgical rounds when all attention is focused on patients.â€
TheÂ nursingÂ studentsâ€™ role was thus largely ceremonial. They were meant to set the stage for rounds, take notes, provide assistance, and answer any questions posed by the physician, not offer opinions or question his judgments. However, despite the outwardly subservient position nurses held in the hospital hierarchy, by some accounts, nurses and theÂ nursingÂ profession were gaining respect in the eyes of physicians. In one of his classicÂ AequanimitasÂ addresses, William Osler described theÂ nursingÂ profession as having once been â€œunsettled and ill-defined,â€ noting that it â€œtook, under Florence Nightingaleâ€”ever blessed be her nameâ€”its modern position.â€Â He later described nurses as â€œone of the greatest blessings of humanity, taking a place beside the physician and the priest, and not inferior to either in her mission.â€
THE BUREAUCRATIZATION OFÂ NURSING
An increasing professionalism inÂ nursingÂ created a need for more bureaucracy. As the role of head nurse became more clearly defined over the first two decades of the 20th century, head nurses and hospital administrators called for support from assistant head nurses. In 1931, Marian Rottman expressed her concerns: CE: A Historical Review of Nurseâ€“Physician Bedside Rounding
â€œWith the increasing demands made on the head nurse, one woman can no longer be held responsible for the proper maintenance and upkeep of supplies and equipment and forÂ nursingÂ service on her wardâ€¦. [T]he time has arrived for assistant head nursesâ€¦ one to administer and lend her cooperation to the frequent demands and â€œroundsâ€ of the medical staff, the other should superviseÂ nursingÂ care and instruction of the patients.â€
Nursing was coming into its own as a profession, but an increasingly complex health care system made new demands on nurses. CE: A Historical Review of Nurseâ€“Physician Bedside Rounding
BEDSIDE ROUNDS AND STAFFING ISSUES
During the early 20th century, nurses often made their own bedside rounds to ensure that all patients were receiving excellent care. Not only did head nurses make rounds when coming onto their shifts, but they also made rounds throughout the day for the purpose of clinical instruction. As nurses spent more time meeting the needs of physicians and medical students, often serving as chaperones during patient examinations, it became increasingly difficult for them to complete their own work in addition to the work the physicians expected of them. In her 1933Â AJNÂ article, â€œNursingÂ and Medical Education: A Study on the Disposition ofÂ NursingÂ Time with Reference to Medical Education,â€ an RN named Blanche Pfefferkorn spoke out about the unrealistic demands imposed on nurses, given physician expectations, insufficiently sizedÂ nursingÂ staffs, and erratic scheduling of teaching clinics: CE: A Historical Review of Nurseâ€“Physician Bedside Rounding
â€œTo adjustÂ nursingÂ service needs to meet medical education needs, and at the same time to maintain goodÂ nursingÂ standards, becomes practically impossible unless anÂ adequate staffÂ of nurses is provided, and clinics are scheduled in advance and carried outÂ according to schedule.â€
Medical students and staff often visited the units during the morning, the busiest time of day forÂ nursingÂ services. As increasing numbers of medical students joined the hospital ranks, nurses had to be constantly vigilant of their activities in order to ensure patient safety.
THE SHIFT FROM PRIVATE DUTY TO HOSPITALÂ NURSING
HospitalÂ nursingÂ underwent significant turbulence in the years following the onset of the Great Depression in late 1929. As work opportunities in private dutyÂ nursingÂ dwindled in the early 1930s, graduate nurses increasingly sought employment in hospitals.Â Hospital administrators found they could employ experienced graduate nurses who â€œcould manage the care of several patients, serve as head nurses on the wards, or care for the most seriously ill patientsâ€ for lower wages.
The introduction ofÂ nursingÂ aides also changed the hierarchy and power dynamics on the units.Â With the majority ofÂ nursingÂ work performed or supervised by graduate nurses, rather than by students, the role of the nurse on the hospital unit was primed for a change.
EFFECTS OF WARTIME STAFF REDUCTIONS
World War II brought many challenges to theÂ nursingÂ profession, both in the military and on the home front. Hospitals, newly accustomed to employing graduate nurses, had to adjust to staff reductions as large numbers of nurses left the hospitals for military service. Some hospitals were forced to close units, even though the beds were needed. A 1944 article inÂ AJNÂ highlighted steps taken by one American hospital to adjust to wartime pressures: â€œWe are living from day to day doing what we can to facilitate and improve theÂ nursingÂ service.â€Â Some of the steps taken included adjusting salaries, reducing lengths of shifts, changing clinical teaching procedures, and adjusting policies for clinical procedures. As hospitals significantly reduced the number of general staff nurses and increased their reliance onÂ nursingÂ students, large numbers of RNs moved away from the patientâ€™s bedside and turned instead to taking on supervisory roles with aides and LPNs (seeÂ ).
Cooperation from the medical staff eased the adjustment to wartime pressures for nurses. With the reduction in the numbers of graduate nurses and increased demands on nursesâ€™ time, physicians often conducted rounds without nurses.Â In an attempt to improve efficiency,Â nursingÂ participation in rounds gradually diminished during the 1940s. Later in the century, nurses would find it difficult to resume their involvement in that process.
POSTWAR MOVES TOWARD INTERPROFESSIONAL COLLABORATION
After the war, a thinly stretched and overburdenedÂ nursingÂ workforce began to show signs of stress. With many nurses returning to their roles as homemakers and a growing discontent among nurses overÂ nursingÂ duties, those who remained advocates for the profession rallied for stronger nurseâ€“administrative and nurseâ€“physician relationships.Â NursingÂ leader Marguerite Manfreda wrote:
â€œWe must recognize the staff nurse as a truly professional person and we must strengthen the interrelationship between the physician and nurseâ€¦. I honestly believe that, because staff nurses have been thwarted in their attempts to achieve satisfaction of their innermost needs, they have become frustrated in their work and desire to escape from it.â€
Historically, head nurses had accompanied physicians during bedside rounds. In the late 1940s, however, staff nurses were clamoring for a higher status on hospital units and a return to greater interaction with their physician colleagues. Some nurse leaders advocated for a reorganization, in which RNs would assume direct responsibility for patients rather than reporting to a head nurse. In a 1947Â AJNÂ article, Constance White outlined the â€œgroupÂ nursingâ€ model, which had been introduced at a New Orleans infirmary:
â€œEach nurse is directly responsible for the care of her three patients. This means that she has direct contact with the patientâ€™s physician, can discuss the patientâ€™s care with him, accompany him on his rounds, and receive his orders directlyâ€¦. [T]here is time for the nurse to give qualityÂ nursingÂ to each patient, with the resulting satisfaction and pride that come with the knowledge of work well done.â€
Nurseâ€“physician collaborative efforts were described by Marguerite Manfreda as mutually beneficial. To â€œhave the responsibility of discussing these patients with the physician, making rounds with him, and in general workingÂ withÂ him to provide the best care for the patientâ€ was seen as a way to increase the nursesâ€™ status.Â According to Manfreda, â€œ[T]he physician would come to know the real value and contribution of staff nurses, and the patient, in turn, would have higher regard for them.â€Â While muchÂ nursingÂ discontent at the time surrounded salary and hours, advocates like Manfreda argued that recognition as a professional nurse was the only way to produce a generation of satisfied nurses.
EFFECTS OF SEX-BASED STEREOTYPES
While roles for women were changing rapidly in the postwar United States, most of theÂ nursingÂ workforce was still primarily female, while physicians were typically male. In fact, nearly 98% of theÂ nursingÂ workforce was female in 1950.Â Meanwhile nurses were beginning to question their role in relation to the physician. Writing inÂ AJNÂ in 1947, oneÂ nursingÂ student made her position clear:
â€œThe respect given doctors has been overdone. In the first place, itâ€™s unnatural to treat a fellow worker like a god. Courtesy is desirable at all times, butâ€¦[w]hy should busy nurses have to attend doctors routinely on the floor? During the war in one hospital, the doctors were told to request a nurse if they needed one to help with an examination. If they were just making roundsâ€¦ the nurse was not expected to accompany them. Someplace along the way a compromise must be made.â€
By the middle of the 20th century, it was apparent that working conditions needed to improve for theÂ nursingÂ profession to attract the type of workers it needed. This idea laid the groundwork for recognizing the contribution of nurses as valuable members of the health care team.
THE HEAD NURSE: A LINK BETWEEN NURSE AND PHYSICIAN
By the mid-1950s, the head nurse had resumed her early 20th-century role as the link between hospital physicians andÂ nursingÂ staff. In 1954, Helen Graves explained the importance of the head nurseâ€™s role:
â€œWhen she makes rounds with the doctors, she has an opportunity to learn about the medical plan of care and how it is to be carried out. She is often called upon to interpret the plan to the patient or reinforce the plan. In turn she is expected to interpret to the doctor the patientâ€™s problems, as theÂ nursingÂ staff have noted them, and thus help the doctor to develop better medical care plans.â€
Nurses were aware that communication with physicians was critical to good patient care and that information obtained on rounds allowed the head nurse to make administrative adjustments for the staff she supervised.
TEAMWORK FOR BETTER QUALITY CARE
The growing focus on improving patient education provided new opportunities for nurses to participate in rounds. In 1953, Virginia Streeter interviewed nurses to determine which factors they felt inhibited effective patient teaching. According to Streeter, â€œ[A]lmost all nurses interviewed expressed difficulty in teaching because they did not know what the doctor wanted taught.â€Â Patient rounds were seen as an opportunity to increase nurseâ€“physician communication, even if it was a one-way process, with the physician speaking and the nurse listening. At the very least, such teamwork helped nurses gain clarity on the most appropriate educational content to impart to patients.
With rapid medical advancements and a growing ancillary workforce, nurses began to understand and accept that â€œteamÂ nursingâ€ might be the best means of providing quality patient care.Â Using this approach, the unit staff at someÂ nursingÂ schools began to assemble themselves into teams of nurses, ancillary staff members, andÂ nursingÂ students. SeniorÂ nursingÂ students served as â€œteam leaders.â€Â One â€œnursingÂ internâ€ remarked on her participation in the clinical rounds:
â€œMaking rounds with the doctors helped me to understand the plan of care for the patients, and I learned what to teach the patients, and consequently I was better prepared to do an effective job. I found the patients more receptive to my teaching, too, since they were aware that I knew exactly what the doctor wanted them to do.â€
While her account reveals the hierarchical hospital structure in which nurses were viewed as nonauton-omous caregivers, it also demonstrates that nurses and physicians participating in the rounding process together could improve patient care.
In the 1950s, nurses invited social workers to join the team. It was becoming increasingly clear that interdisciplinary rounds promoted interdisciplinary teamwork. Writing inÂ AJNÂ in 1955, Minna Field, a social worker, noted:
â€œWhere the group making medical-social rounds includes the nurse as well as the physician and social worker, these members of the three professional groups are seen by the patient as a team, all of whom are equally concerned with his progress. Problems which are upsetting to the patient can be aired, a joint evaluation of these problems achieved, and the necessary steps taken to mitigate them.â€
As Field explained, integration of all disciplinary perspectives was necessary to achieve comprehensive patient care:
â€œIf the team approach is to accomplish what it is designed to do, it must be based on a give-and-take relationship among the members of these groups who have an understanding of each otherâ€™s function and specialized skills as well as respect for each otherâ€™s competence. As our skills in the use of such relationships increase and as we gain better understanding of each otherâ€™s roles we will be able to work together with ever-increasing effectiveness, utilizing to the fullest the contribution each profession can make toward the ultimate goal of teamworkâ€”the patientâ€™s welfare.â€
A NEWFOUND RESPECT FORÂ NURSING
By the 1960s,Â nursingÂ had carved out its place in the world of modern health care alongside other health care disciplines. In 1970, the American Medical Association (AMA) released a position statement acknowledging the significance ofÂ nursingÂ as a primary component in the delivery of health care, recognizing that nurses had taken on additional responsibilities and technical procedures formerly carried out by physicians and noting that increased administrative demands on nurses were disruptive to the nurseâ€“physician relationship:
â€œThe AMA supports the additional concept that the professional nurse should share authority with the physician. The nurse contributes to management decisions in patient care, carries out those decis