In response to my latest newsletter posting, I got this wonderful email from an MD, OB/GYN Rob Olson. Rob wrote the following and told me I could post it on my blog. It is a perfect example of mature, reflective leadership, how to form a team, support a team member, and create psychological safety. So here it is:
I had a 42-year-old patient having her first baby who was transferred into me after being stuck at 7cm for over six hours in an outside birthing center. She was post dates and clinically had a large baby with the head not engaged at a -2 station. She did not want pain medication nor an epidural. I felt she had adequate uterine contractions but was planning to check with an internal pressure transducer until I examined her and found she was at 8cm. An hour later she was at 9, then she did not make any further progress and I ordered a primary cesarean section 3 hours later.
The young charge nurse questioned me and wanted to discuss both the possibility of Pitocin as well as an epidural. This irritated me but after I explained myself, she accepted my clinical judgment. The surgery went well for both the mother and the 9 lbs. 5 oz. infant.
However, the next day, upon reflection, I realized I should not of been irritated but instead I should have welcomed the inquiry from the charge nurse as she was just demonstrating patient advocacy and safety. So I wrote an email to her supervisors praising her behavior as a demonstration of a “culture of safety”. We should all welcome discussion of our patients so we can encourage teamwork.
Rob Olson, MD, FACOG
Society of OB/GYN Hospitalists
Rob’s website is http://www.obgynhospitalist.com/
If more physicians, nurse managers, professors etc reacted in this way and thought about their actions we’d be out of the woods when it comes to people speaking up to protect patients.
Hippocrates may have said “first do no harm” centuries before Florence Nightingale reiterated the injunction, but nurses really believe that they are morally superior to physicians or many others in healthcare when it comes to protecting patients from danger. As the American Nurses Association Code of Ethics assert in its Provision 3, “The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.”
Nurses may disagree on many issues, but on the definition of the nurse as THE patient advocate, they actually do speak with one voice. I have seen – and written about –many nurses who, in fact, tirelessly advocate for their patients. What these nurses do is embody true advocacy. Advocacy, as I have written in When Chicken Soup Isn’t Enough: Stories of Nurses Who Stand Up for Themselves, Their Patients, and their Profession, is not simply hoping things go well for the patient. An advocate, as the dictionary defines it, is “a person who argues for or supports a cause or policy: a person who works for a cause or group: a person who argues for the cause of another person in a court of law.” Being an advocate, by definition, thus means speaking up to defend or argue for another person. Thus to be a patient advocate, by definition, involves speaking up to protect a patient from harm. It involves, again, by definition, the willingness to take risks to protect a patient from harm.
It has been with increasingly greater distress that I have heard nurses, over the years, simultaneously assert that they are patient advocates, while also insisting that they cannot possibly risk their jobs if they see a patient about to be harmed by a physician or by some hospital policy, or by some action by someone who has the power to discipline or punish the nurse who is observing potential harm. In July the online publication Nurse Together posted an article entitled “Medical Errors: Why Don’t Nurses Speak Up?” It discussed the fact that, in nine out of ten cases when there is a medical error someone knows something or sees something that could prevent the error. Rather than speaking up, they remain silent. They do this because they believe physicians are “untouchable,” or because they receive no management support – but only discipline, when they speak out.
The simple fact is that the majority of nurses I have met believe that speaking up will get them into trouble. The problem starts in nursing schools. While the visible, explicit curriculum in nursing schools teaches nurses that they should advocate for their patients, it does not teach them how to advocate in real life situations where the odds are stacked against advocacy. They are also not taught how to confront and overcome the hidden curriculum of nursing, which they encounter the minute they hit the wards. In too many instances, nursing students who enter hospitals or other healthcare institutions for their clinical rotations are instructed by preceptors who have no training in conflict resolution and negotiation and who teach them to shut up rather than speak up. These nurses are, in turn, supervised by managers who similarly have no conflict resolution skills and whose default position is discipline and punish rather than coach, teach, and support.
The other day, for example, I was giving a lecture at a four year university nursing program. I asked students – who ranged I age from 20 to 50 – whether they would speak up, if they saw a patient about to be harmed. With no exceptions, they all said they were afraid to speak up. Ditto the working nurses in the room. The students also told me that their preceptors all advised them to shut up, when they told their preceptors of problems in patient care. “That’s just the way it is, what can we do about it? “ they said. “You don’t want to be thought of as a know-it-all do you?” was the response of another.
So I have a modest proposal. Instead of teaching nursing students that they are patient advocates, why don’t nursing students teach students how to advocate for patients in the face of what might seem to be insurmountable odds? Why don’t they choose preceptors more carefully so that students are always paired with nurses who actually know how to speak up in the face of such odds and could thus help nurses learn a skill which they will have to master and refine throughout their careers? And why doesn’t hospital nursing management create an environment in which patient advocacy and protecting patients from harm can actually occur so that we finally move from aspiration to reality when it comes to patient care?
Last week the Boston Globe reported more bad news about patient safety. In an article entitled “Mass Hospitals’ Mistake List Widens”, the Globe reported that, “Massachusetts acute-care hospitals reported 753 serious medical errors and other patient injuries last year, a 70 percent annual jump that health officials attributed mostly to expanded definitions of what constitutes medical harm.
“So-called serious reportable events in other types of hospitals, including those that provide psychiatric or rehabilitative care, rose 60 percent from 2012, to 206.
“Instances where patients underwent a procedure on the wrong body part, were burned by an operating room fire or a too-hot heating pack, or were subject to contaminated drugs or improperly sterilized equipment saw some of the largest increases in reporting since 2012.
“Hospitals also reported more patient falls, serious bed sores, assaults, and suicides and suicide attempts.”
The article did not delve into the reasons for these disturbing statistics, except to suggest that perhaps increased reports were due to increased reporting. Is that supposed to be a plus? Asked whether this report was a sign that things are somehow getting better because hospitals are reporting more problems, Allan Frankel, (former head of patient safety at Partners Healthcare and now Chief Medical Officer at the wonderful Safe and Reliable Healthcare, along with my colleague Michael Leonard), responded candidly and emphatically,”No!”
Frankel is right. The questions that need to be asked when statistics like these are revealed are the following:
Are the hospitals in question doing team training in a systematic recurrent way?
What are their nurse to patient staffing ratios, the patient loads of their physicians, laboratory techs etc?
Who sleeps and when? Do nurses routinely work 12-plus hour shifts. Are resident physicians hour restrictions routinely violated? Are people afraid to speak up when they see a patient safety problem– like when they think a surgeon is about to operate on the wrong body part? Do hospitals use SBAR (see my last two blog posts) and other predictable patterns of communication? Do they use use surgical checklists, time outs, not just sometimes but all the time, not just sort of but really.
The list of questions could go on and on. The problem isn’t more reporting, the problem is less of the right kind of consistent systematic action on patient safety.
Since writing my rant on SBAR last week, I want to pursue the issue of standardization of communication in healthcare. As I said in my earlier post, many patient safety experts insist, correctly, that healthcare is a very complicated endeavor. There are many many factors, that people trying to deliver healthcare services cannot control. They can’t always control the larger system, they can’t control the patient’s genetics, anatomy, physiology, psychological response, home environment, etc. They can’t control the finances of their institution. As I said earlier, the list goes on and on. There are, however, things they can control and how they communicate with one another is one of them. When one considers people’s response to communication techniques like SBAR – a technique that has been promoted by TeamSTEPPS and many other organizations and institutions, the fundamental question is what is the purpose of communication? Put another way, what is the primary goal of communication between those who work in healthcare.
When a physician explains that physicians do not like to use a technique like SBAR because that’s how nurses talk, not only does this evince a total misunderstanding of the genesis of SBAR (which was developed as a safety technique on nuclear submarines not in schools of nursing), it also suggests that the primary thing being communicated in healthcare is the difference in status between professions and occupations rather than the communication of critical information about the patient. Physicians have been socialized to view nurses as inferiors and thus in the hidden curriculum of healthcare, they are taught to distinguish themselves from nurses by using different language than nurses use and by forbidding nurses to use medical language. As we describe the history of this linguistic discrimination in our book Beyond the Checklist:
“In the health care workplace, the professional lexicon of medicine is the talk form, whose use is recognized by physicians to signal possession of authoritative knowledge and professional expertise. For well over a century now, nurses have been firmly instructed—both in their professional educations and in the policies and norms of their workplaces—to refrain from using such “medical language.” This proprietary language has been reserved for physicians because its use, in some circumstances, constitutes diagnosis (“the patient has pneumonia”), a function and privilege assigned by law as well as by long and carefully enforced custom to physicians only. On the basis of this legal privilege, nursing has been classified and categorized as subordinate to medicine, and its activities have been rendered largely invisible through what Geoffrey C. Bowker and Susan Leigh Star, authors of Sorting Things Out: Classification and Its Consequences, describe as the valorization of one point of view, which often renders another entirely invisible.
“Under penalty of disciplinary action, nurses have been enjoined, for instance, from saying or noting in a patient’s chart that that the patient “has developed a respiratory infection” or a “urinary tract infection,” or is “hallucinating.” This is medical-speak. Rather, nurses must report in descriptive terms the indicators that lead them to their suspicions. Thus a nurse would say, “The patient is experiencing frequency of urination and burning,” or “The patient is seeing little white elephants.” They are taught to leave the doctor to reach the diagnosis and apply the correct medical label. Both physicians and nursing managers reinforce these lessons by reprimanding or disciplining nurses who violate these linguistic norms. Nurses can even lose their licensure if found to be “practicing medicine without a [medical] license” (which includes making medical diagnoses). This penalty for “practicing medicine” (vs. practicing nursing) is explicit in states’ nursing practice acts.
“While physicians do routinely ask nurses to tell them about observations the physicians select as relevant, they do not generally read nursing notes in the patient record, which one junior faculty physician in an Ivy League academic medical center told Bonnie were “noncontributory” to essential patient care. Residents in one New England hospital characterized nursing notes in their patients’ charts as “not worth the time it takes to read them” because they are “way too wordy” and “never say anything useful.” In another New England teaching hospital where we have worked, nursing notes are in fact kept in an entirely separate chart from the one used by physicians to record medical actions and patient progress. (In a perhaps unconscious symbolic statement, the physicians’ charts are in gray-blue notebooks, while the nursing charts’ binders are a subdued rose color.)
“Neither the residents nor the faculty physicians in this hospital, participating in a 2007 discussion of strategies for improving interprofessional communication, had any inkling that nurses were actually not permitted to use the language they as physicians would have preferred, respected, and found authoritative; nor could they use the same shorthand forms (such as SOAP notes) for communicating their clinical impressions and recommendations. As this hospital made its transition in 2010 to electronic medical records, two separate electronic systems were put in place for physician and nursing patient records, thus further ensuring the separation of the two professions’ assessments, plans, and activity records, and reinforcing for physicians—by making them now physically invisible—the sense of the nursing notes’ irrelevance to patient care. The two systems are not linked electronically, and for the first six weeks or so of their deployment physicians could not gain entry into the nursing note system if they wanted to because they had not been issued password access.
“The lack of a common language and communication medium—or at least of mutual professional intelligibility—both creates and sustains friction between nurses and physicians, and the cumulative irritation runs in both directions. Nurses resent having their knowledge, expertise, and competence shrugged off by physicians, while doctors resent having to wade through written chart notes that do not come succinctly to the point with respect to patient data and the treatment directions they may indicate. Medicine continues subtly and not so subtly to at- tempt to laicize nursing knowledge and expertise, as nursing continues to create and implement structures to professionalize its knowledge and fully incorporate it into the inpatient health care environment.15 Given this lack of a shared language, it is difficult to imagine the members of any so-called multidisciplinary team creating a shared purpose and a shared mental model. This failure can have serious consequences. According to the 2012 report by the inspector general of the U.S. Department of Health and Human Services, Medicare estimates that 86 percent of adverse events in hospitals in the United States go unreported. Why? Not because staff are afraid to admit mistakes but because they actually do not share common understandings of what an adverse event is, who should report it, and what should be done about it.”
SBAR has been a way to correct this problem. But it seems it is now victim of the same kinds of dynamics that created the problem in the first place. So the real question is again, what is the purpose of communication – to communicate who is above and who is below in the medical hierarchy or to create predictable patterns of communication and behavior so that there is less chaos, disrespect, and confusion in the healthcare setting? The entire edifice of patient safety depends on the answer to this question.
The other day I was interviewing a physician who is an expert in patient safety and who teaches medical students and residents at a major teaching hospital. We were discussing the virtues of various safety models both inside healthcare and in high reliability industries outside of healthcare. As usual, the physician gave a thoughtful but by now typical commentary on the relevance of the aviation safety model to healthcare. He argued, as so many do, that healthcare is so much more complex than any other human endeavor that it is difficult to adapt a model that has been developed for another industry to healthcare. He then proceeded to catalogue the variables that are outside of the physician’s control. These included variations in the patient’s anatomy, physiology, genetics, and thus response to treatment. He went on to talk about patients’ different personalities, social circumstances, family, etc. His list also included the fact that so many people — so many more than in any other endeavor apparently – are involved in healthcare that it is difficult to control all of them as variables. The list went on and on. Added to it, of course, there are the stakes in healthcare, which include harm – or death – to the patient or patients. Read more >>