I have been thinking about trust and competence a lot recently. Nurses get a lot a credit for being trustworthy and that trust is certainly well deserved. But I worry that sometimes we run the risk of getting by with trust without competence.

Colleagues have heard me say many times that I don’t particularly like hearing APRNs say “my patients love me.” Being loved is not a correlate to being competent. I know this from lived experience. I am at the end of my clinical career. I still love seeing my patients and they certainly “love” me, but I am keenly aware that my competence is on a downward spiral. Some days I find myself taking the easy way out, taking the easy way out by prescribing an unneeded antibiotic because the patient expects it rather than engaging in the battle to convince my patient of why they don’t need to medication. On those occasions, which are fortunately rare, I am aware that I am only “batting 300” on healthcare’s Triple Aims.  My patient is happy because they got the treatment they wanted (rather than needed) so I am good on satisfaction (Aim 1), but I haven’t provided quality care (Aim 2) and certainly haven’t been cost effective (Aim 3).

The other day as part of a new grant (more on that in future blogs), we had our first community meeting with RNs to explore the role of the nurse in primary care. We had lots of input but the one “on the ground” RN in the meeting said it best…”patient safety must be first, you must be competent”. She went on to add, “and you must be present!” What a wise woman and great mentor for our students. I suspect the Pareto 80/20 rule applies here; our goal should be to focus 80% on presence and relationship but to never lose focus on the fact that without the 20% of competence we haven’t done our jobs.

I am not saying APRN’s aren’t competent, far from it. Over 40 years of data are clear, APRN’s practice and outcomes for primary care are as good as or better than physicians; they are highly cost effective) and patients are highly satisfied. But as individual clinicians, we can’t let “satisfaction” be sufficient. We must, on a day to day to basis, blend our strong relational skills with competence. We must stay up-to-date with national standards, back up our work with thorough documentation, and pay attention to our outcomes.

Maintaining rigorous competence is hard, and that challenge is the main reason I am transitioning out of practice; I just can’t keep up with my other responsibilities and still practice competently. I can see that my strong intuitive skills are no longer sufficient. But for those of you still in the trenches doing the good work, feel free to bask in the sunshine of your patients’ love, I know that is what kept me going every day! But, never lose sight of the need to be rigorously competent. Hidden in our patients’ love is a deeply held assumption that we know what we are doing and have earned their trust. Let’s not let them down.