NR 393 Week 8 Nursing History Course Reflection Example

The Standing Order I Thought Was Just a Rule: A Reflection on Nursing History

Student Name

College of Nursing, Chamberlain University

NR 393: Nursing History

Instructor Name

Month Day, Year

The Standing Order I Thought Was Just a Rule: A Reflection on Nursing History

The Assumption

I have worked on a cardiac telemetry unit for six years. When a patient's rhythm changes on the monitor, I print a strip, interpret it, and, depending on what I see, follow a protocol: for some rhythms I call the provider, for others I give a medication under a standing order, and for a few I start emergency care before anyone else arrives. When I began this course, I would have said that this is simply what telemetry nurses do. I thought of the protocols as rules the hospital wrote to keep me within limits, and of rhythm interpretation as a skill every nurse on a cardiac unit is expected to have. I did not think of either as something that had ever been in dispute.

The belief came from my training. I learned rhythm interpretation in a hospital course in my first year as a nurse, alongside policies about who may do what, and nothing in that training suggested that nurses had not always done this. The authority was presented as a boundary, not as something nurses had won.

What Dislodged It

The belief was dislodged in the sixth week, when I wrote the historical analysis of the coronary care unit. Reading Fairman and Lynaugh's (1998) history of critical care nursing, I learned that in the early 1960s it was contested whether nurses should interpret heart rhythms and shock patients at all. Physicians and administrators objected that these were medical acts, and some nurses were reluctant to take them on. The first coronary care units resolved the dispute through intensive training and standing orders written by physicians, which allowed nurses to act when a physician was not present. Reading Julian's (1961) proposal for such units, I saw that the argument for nurses taking on this role was practical: fatal rhythms leave minutes to act, and nurses were the ones at the bedside.

The moment the belief broke was specific. I realized that the standing order I follow when a patient develops a dangerous rhythm is not a leash but the instrument through which nurses were first given authority to act in that situation. What I had experienced as a limit was, historically, a grant.

What I Feel About It

Learning this changed how I feel about the protocols I use every shift. I used to find them mildly insulting, as if the hospital did not trust nurses to think. I now see them as the terms of a negotiation that nurses in the 1960s took part in, and I feel something closer to responsibility than resentment. The authority I use was extended to nurses because earlier nurses proved they could use it safely, through training that was more demanding than what I received. That makes me want to know my own unit's protocols better, not only to follow them.

How the Earlier Weeks Prepared the Change

The sixth week would not have landed the way it did without two earlier assignments. In the second week I read Nightingale's Notes on Nursing for its audience, and I saw for the first time that a founding text of nursing was an argument about territory: it staked out the sickroom's air, light and quiet, and the watching of the patient, as work that belonged to nurses. In the fifth week I compared how Nightingale and Isabel Hampton tried to control nurse training, and I saw that nursing's control over its own work was bought or organized, never simply handed over. By the time I reached the coronary care unit, I was already reading history as a series of disputes over who does what, and the monitor on my own unit fit that pattern immediately.

Those earlier weeks also taught me a method I used without noticing. When I read Julian's proposal, I asked who it was written for and what its author wanted the reader to do, the same questions I had asked of Nightingale. The answer, that a physician was persuading other physicians to reorganize care around a new danger, explained why the resulting arrangement kept formal authority with physicians even as the work moved to nurses. Without that habit of reading, I would have taken the proposal as a neutral description of progress.

The Routine I See Differently

The routine I now see as a decision rather than as the way things are is the arrhythmia protocol itself. When our unit's protocol was revised last year, the committee that revised it was made up of two cardiologists, a pharmacist and the nurse manager. No staff nurse served on it, and I did not think to ask why. After this course, I think the absence matters. If the history shows that nursing's clinical authority on cardiac units was negotiated, then each revision of the protocol is a small renegotiation, and staff nurses who use it every shift have a stake in its terms. Reverby (1987) describes how nurses in earlier periods often had their work defined by others; the history of the coronary care unit shows that nurses can also take part in defining it when they are present at the table.

What I Will Do

I have asked our nurse manager whether a staff nurse can join the committee at the next protocol review, and I have volunteered. I have also started reviewing our unit's arrhythmia protocol against the current professional guidance, so that if I join the committee I can bring evidence rather than opinion. A colleague could check whether I followed through by looking at the committee's membership list next year.

What Remains Unsettled

I have not settled whether the standing order model is still the right one. It gave nurses authority in the 1960s by keeping that authority formally under physicians, and that compromise has lasted. Some nurses I work with argue that experienced cardiac nurses should be able to act on their own clinical judgment without a physician-signed protocol. Others value the protection a protocol gives when something goes wrong. The history explains how we got here; it does not tell me where nursing should go next, and I am still thinking about it. What I do know is that I will be part of that conversation on my own unit rather than inheriting its outcome.

References

Fairman, J., & Lynaugh, J. E. (1998). Critical care nursing: A history. University of Pennsylvania Press.

Julian, D. G. (1961). Treatment of cardiac arrest in acute myocardial ischaemia and infarction. The Lancet, 278(7207), 840-844. https://doi.org/10.1016/S0140-6736(61)90738-3

Reverby, S. M. (1987). Ordered to care: The dilemma of American nursing, 1850-1945. Cambridge University Press.