The 3am Repositioning

I have repositioned patients at 3am.

The work has stayed with me longer than most of what I learned in medical school. That is not a sentimental claim. It is a description of how clinical knowledge moves into a clinician's body and how it stays there.

The argument of this essay is that some of what nurses know is held in the body. Not stored in the body the way memory is stored in the brain — held in the body in the operative sense, as the body's own capacity to act. This kind of knowledge has a name in the literature. It is called formation. It is what happens when sustained practice in a clinical role rewires the practitioner's instincts, reflexes, and perceptions until the practitioner is, at the level of body, a different kind of clinician than they were before.

Medical training produces formation too. Just not the same formation.

The Work

At 3am the patient cannot reposition herself. She has been on her left side for two hours. The call light goes off. You come.

The mechanics are precise. Lower the bed rail. Place a hand on her shoulder. Tell her what you are about to do. Lower the head of the bed. If a slide sheet is in place, use it; if not, position your forearm beneath her hip and your other hand at her shoulder, and move her toward the far side of the bed in two coordinated motions so that when she turns onto her other side she will not roll off the edge. Roll her gently toward you. Tuck a pillow behind her back so that she does not roll onto her spine. Pad the bony points. Lift the heel off the mattress with a small wedge. Check the line, the catheter, the dressing. Pull the blanket up. Lower the bed. Raise the rail. Tell her the call light is at her fingertips.

This takes a few minutes. It is one of many things you will do at 3am.

The patient is alert. She thanks you. She apologizes for the inconvenience. You tell her there is no inconvenience, that this is what you are here for, that the work is small. You do not tell her that this work is, in a sense she will not need to know about, a kind of training. A kind of formation. A kind of knowledge being deposited in your hands and your back and your timing and your judgment that will not leave you when you become a different kind of clinician twenty years later.

What the Body Learns

Patricia Benner, drawing on Hubert Dreyfus, described the movement from novice to expert as a progression in the kind of knowledge a clinician uses. The novice uses rules. The expert uses pattern recognition built from accumulated bodily experience. The expert does not consult a list. The expert sees the patient and knows, before they could articulate why, what is happening and what to do.

The transition is not abstract. It happens in specific physical encounters, repeated, until the body itself learns. The repositioning is one of those encounters. You learn the weight of bodies. You learn the geometry of vulnerable joints. You learn how a person holds tension when they are afraid and how that tension shifts when they trust you. You learn what skin looks like in the first hour of a pressure injury and what it looks like in the third. You learn the smell of decomposing tissue and the smell of recovering tissue, which is not the same smell.

Michael Polanyi called this kind of knowledge tacit. We know more than we can tell. The novice nurse cannot articulate why a patient's color is wrong. The experienced nurse can hardly articulate it either. But the experienced nurse can recognize it at five paces and act on it before the resident has read the chart.

The repositioning is one of the encounters that builds the tacit layer. The nurse who has repositioned five thousand patients over twenty years has a kind of clinical knowledge about the human body that no textbook describes and no curriculum delivers. The knowledge does not feel like knowledge. It feels like instinct. It is not instinct. It is the residue of five thousand patient encounters held in the body of a clinician who paid attention.

Why Medicine Has Less of This

A physician's training is also a formation. A specific set of physical encounters — the operating room, the procedural rotation, the procedure-heavy specialty training — produces a different kind of body knowledge. Surgeons know things in their hands that internists do not know. Cardiologists know what a thready pulse feels like in a way that pulmonologists do not. The body-as-knower is real for physicians too.

But the physician's body-formation does not include sustained presence at the bedside. The physician's body is not the one that has repositioned the patient five thousand times. The physician's hands have not held the weight of a thousand vulnerable hips. The physician's back has not learned the geometry of a 4am safety check.

The asymmetry is not a moral failure. It is a structural feature of the work. The physician is not in the room. The nurse is. The body knowledge that comes from being in the room belongs to the body that was there.

What this means clinically is that the experienced nurse possesses a layer of patient knowledge — embodied, tacit, instinct-shaped — that the physician cannot acquire any other way than by asking. The asking is not an interprofessional courtesy. It is an attempt to access knowledge that exists only in someone else's body.

What It Changes

The argument of this publication has been, from Issue 001, that medicine should access this knowledge. The argument of this essay is that the access depends on understanding what kind of knowledge it is.

If a physician thinks the nurse is offering opinions, the physician will weigh those opinions against their own and arbitrate. If a physician understands that the nurse is offering body knowledge built across thousands of encounters, the physician will treat the nurse's instinct the way they would treat a high-sensitivity diagnostic test: not as opinion, but as data with a known production process.

I have repositioned patients at 3am. The work has stayed in my body. When a nurse tells me that something is wrong with a patient, and they cannot quite say what, I do not ask them to justify the impression. I act on it. Then we figure out together what the impression was reading.

This is what formation looks like in practice. Not theory. The body remembers. The body acts. The patient is the one for whom the body of every clinician in the room remembers something different and brings that difference to bear.

That is what the 3am repositioning teaches. That is why it matters that someone has done it.

About the author

Peter Schindler, MD, PhD is an Assistant Professor of Medicine and Associate Program Director of the Community Health Center Family Medicine Residency Program at the University of Nebraska Medical Center. He practices at Winnebago Comprehensive Health System, OneWorld Community Health Center, and Nebraska Medicine. He completed a Primary Care Research Fellowship at McGill University and holds a BSN from the University of Wisconsin-Oshkosh, an MS and PhD in nursing from Emory University's Laney Graduate School, a Diploma in Tropical Medicine from the Liverpool School of Tropical Medicine, and an MD from the Medical College of Wisconsin-Green Bay. He is board certified by the American Board of Family Medicine. The Interprofessional publishes new essays every week at the intersection of medicine, nursing, and the clinical knowledge that lives between them.

Disclaimer. The views in The Interprofessional are Peter Schindler's own and do not represent the official positions of the University of Nebraska Medical Center, Winnebago Comprehensive Health System, OneWorld Community Health Center, Nebraska Medicine, or any other affiliated institution.