The first time I heard “It’s not in my job description” invoked was during an interaction with a colleague in my very early days as an RN. Although I can’t recall what instigated the retort, I knew it was a reprimand rather than a reminder. That interaction made me think about my own job description, which for my entire 19 years as a bedside nurse I never got around to reading. The American Nurses Association’s website lists the key responsibilities of an RN as perform physical exams and health histories before making critical decisions; provide health promotion, counseling, and education; administer medications and other personalized interventions; and coordinate care in collaboration with a wide array of healthcare professionals. Implicit in this job description is the mysterious alchemy of random acts of kindness, courage, generosity, and compassion—collectively described as going above and beyond for the patient. In short, if we simply toed the dotted line of the nursing care plan, the hospital experience would be less bearable.
“A” is for above and beyond
Once upon a time nurses proved their mettle in the performance of a professional bed bath, akin to a rite of passage. In my nursing school days, I had to do a graded return demonstration with a classmate as patient. I recall how I sweated so profusely that I needed a bath myself after the skills test (I did not get an “A”). Bed bath and its close cousin sponge bath are cherished for what they are, and more notably for what they stand for. Although giving a bed bath is no longer the highlight of a nurse’s day, it can be a symbolic gateway to going above and beyond for our patients.
Years ago, I assigned a nursing student to care for a 21-year-old, non-English speaking patient who endured crossing the Arizona dessert for days and ended up with skin infections. After morning meds, the student started teaching the patient how to speak “hospital” English. By the end of the shift, the patient could already say, albeit haltingly, “I have less pain.” I suspected it had less to do with pills and more to do with the student taking the extra mile—not on foot, but sitting at the bedside—and time to tutor the patient.
One summer evening, I ran into one of my former students leaving a supermarket in Koreatown in New York City. He was in his scrubs, on the way to work, but had made a detour to buy Korean food for one of his patients—of his own accord and with his own money. The patient was a 20-something Korean immigrant who had terminal cancer and missed Korean comfort food. The patient passed away a couple of weeks later. I share this not because I’m sentimental, only to say that patient care is so vast and can, at times, be dreadfully impersonal. But, as nurses, we’re given the wonderful opportunity to move and be moved by our patients. Korean food didn’t cure the patient’s cancer, but I have no doubt it brought joy to moments that even cancer can’t take away.
My own discovery of going the distance happened when I took care of a 77-year-old priest who was receiving tube feedings. During routine rounds (I worked nights), I found the patient awake in the darkness of his room, with a ponderous look on his face. He said he couldn’t sleep. In the course of our small talk, I asked him what he usually does at home when he can’t sleep. “I drink a Diet Coke” was his reply. So, I excused myself, went to the vending machine, and purchased the patient’s carbonated choice of sedative. Minutes later, I poured half a can of Diet Coke via the nasogastric tube (yes, I had the head up at 30 degrees). Half an hour later, the patient was asleep. To this day, I’m still unsure if what I did could have cost me my job. But, I figured, if a canned formula can be given via a feeding tube, why not a Diet Coke? In any case, the patient had a good night and I had a good day.
All in a day’s work
Is going the extra mile an exception or should it be the rule? I think the latter is the preferred reality in healthcare. Behavioral job interviews for nurse applicants include questions such as, “Tell us a time when you went above and beyond to understand the patient’s needs and surpass their expectations?” It’s hard to define what it means when a nurse goes above and beyond the standard of care. But consider this Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS ) survey question “How often did nurses listen carefully to you?” To be able to fully and actively listen to the patient requires a tremendous amount of time, intentionality, follow up, and emotional investment. The Centers for Medicare and Medicaid Services, which administers the HCAHPS survey, reminds us that what some might consider extraordinary is in fact a minimum expectation in patient experience satisfaction.
The well-traveled road
Nurses have been going the extra mile since the dawn of modern nursing. The COVID-19 pandemic has demonstrated nurses’ enthusiasm to provide the best care outran even their own caution of self-preservation. So, what motivates nurses to outperform themselves, apart from being reminded by their nurse manager that the hospital’s bottom line depends on a very satisfied patient-customer? Experts tell us that belonging, inclusivity, a sense of purpose, and empathy are intrinsic motivators. Tangible extrinsic motivators, such as monetary rewards, can paradoxically undermine intrinsic motivation. Interestingly, these negative effects are particularly observed among professionals who undertake complex tasks requiring cognitive agility, creativity, and problem solving. We can all agree that nursing is among those professions. Money is practical and appealing, but it won’t necessarily make us better clinicians and happy nurses. Going above and beyond is a reward in and of itself. Doing well what is expected of us is a testament to our sense of duty; going above and beyond is a proof of our devotion to care.
Gagné M, Deci EL. Self‐determination theory and work motivation. J Organ Behav. 2005;26(4):331-62.
Fidelindo Lim is a clinical associate professor at New York University – Rory Meyers College of Nursing.