Chuck Reuter is an army public health nurse in the New Jersey Army National Guard and Virginia Fitzsimons is a professor at Kean University, Union, NJ. Contact author: Chuck Reuter, firstname.lastname@example.org. The authors have disclosed no potential conflicts of interest, financial or otherwise.
Echoes from military and religious history.
The language of nursing has evolved as the profession has matured. The archaic expression doctor's orders, still used to describe the physician's plan of care for a patient, carries an unfortunate connotation of obedience for the nurses who carry out the plans.
The word order was used as early as the 14th century to refer to religious orders. Deep in our history are religious congregations of nurses, both female and male, who took lifetime vows of obedience. Order implies a world that places a high value on rank, class, or special power. We see this perhaps most clearly in the military uses of the word, as in “that's an order!”
Prior to and during Florence Nightingale's time, nurses were trained by physicians to monitor patients and report back. Nursing then was described as “applied hygiene.” This is no longer the case, and it's troublesome that we remain subject to these authoritative commands we call physician orders.
Are nurses diminishing themselves by accepting orders? Enlisted members of the U.S. military take an oath to “obey the orders of the President of the United States and the orders of the officers appointed over me.” Article 90 of the Uniform Code of Military Justice states that it is unlawful to disobey a lawful order from a superior commissioned officer. During times of war, it is punishable by death.
But nurses take no such oath, and are legally and ethically bound to question an inappropriate order from a physician. In fact, many actions described in physician's orders are simply nursing practices that are fundamental to health maintenance: turn and position every two hours, oral hygiene, side rails up.
The term physician's orders has outlived its appropriateness. Nurses have an ethical duty to be members of collaborative teams. Communication, consultation, and interdisciplinary cooperation are the benchmarks for quality outcomes. Other professionals communicate without issuing orders to each other—by continuing to use this phrase, nurses support a linguistic and symbolic discounting of their autonomous and accountable practice.
In accepting such language, nurses condone the underlying view that nurses are subordinate to the wishes of a physician. Physician orders are inherently authoritarian and transgress traditional etiquette. By contrast, nursing practice acts use language such as this from the New Jersey Nurse Practice Act: “executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.”
Virtually everything that is now called an order—all medications, diet, activity, consultations, and so on—can be called a prescription, a plan, or a regimen. When a physician gives a prescription or a recommendation to a nurse rather than an order, it reinforces a model of partnership and collaboration in patient care. Let's watch our language and strive for more descriptive terms.
In order to make other nurses aware of the importance of language and its effects on our image, nurses can advocate for our profession at individual institutions, bringing attention to such practices as referring to nurses as property of a physician, as in “Pat is Dr. Smith's nurse,” or the habit of some physicians in referring to nurses as “the girls on the unit.”
Or begin with asking a physician for the prescriptions rather than the orders when admitting a patient. At the next nursing meeting or roundtable in your institution, ask for the replacement of “physician orders” with “prescriptions” on the admission screen or at the next printing of forms. Acknowledge that these prescriptions aren't just from physicians, but are also from NPs and physician assistants.
We are not a lesser profession to order around. The language we use in everyday practice reflects how we perceive ourselves and how our colleagues and the public perceive and speak about us. We are licensed professionals, educators, leaders, lifesavers, and most of all, nurses. Language is power; change needs to begin here.
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