How Relationship Band-aids Put Patients at Risk

Read the following items and ask yourself “What do they have in common?”

• Signs are placed in the patient rooms suggesting that the patient has a right to insist that their caregivers wash their hands before and after contact with them.
• Rapid response teams try to compensate for the absence of clinician availability (and now we even encourage the patient or his or her family to activate such an evaluation.)  
• Nurse navigators lead patients through the complex maze of care while positions like “Chief Experience Officer” monitor customer satisfaction.

So, what do they have in common? They are all work-arounds; attempts to patch up a broken and dysfunctional system. No wonder twenty-two patients die an hour from avoidable harm.

Why?The two most important people responsible for our patients’ care frequently never talk to each other, and when they do, the interchange is often dysfunctional.

Humans have a tendency to sensationalize and focus on the negative.  But research tells us that less than 5% of physician-nurse relationships are disruptive. What’s the rest of the story?  Sadly, only 15% of both physician and nurses rated their relationships as collegial; and only 25% were ‘very good’ (Rosenstein).  Considering that the most important factor in a study of 13 ICU’s of patient mortality was the relationship between the nurse and physician, this is great cause for alarm (Knaus, Baggs).

Several structural changes have contributed to the distancing of the traditional physician-nurse relationship over the past twenty years. In fact, you will find both physicians and nurses stating it was ‘better in the old days’.  Why?

Physicians have become progressively more sub-specialized, diffusing responsibility and challenging the ability to integrate care. As margin per RVU has declined, physicians find themselves working ever harder, leaving less time for conversation at all levels.  In order to protect some time outside of their practice, coverage groups expanded reducing the number of days on-call. Now, the primary attending is often unreachable. On-call physicians are reluctant to make decisions for another doctor’s patient. In fact, it is common practice among physicians that weekend call really means placing clinical decisions on hold until Monday morning. Mid-level providers often perform follow-up care, especially for surgical specialists. Rounding in the morning is hurried. There is no time to locate the primary nurse. Sadly, physicians too often don’t even know the names of the nurses who care for their patients. How easy it is to be disrespectful of someone who remains anonymous - especially over the telephone.

Structural changes have impacted nursing as well. Twelve-hour shifts make continuity of care difficult. The number of tasks a nurse needs to perform in an 8-hour shift exceeds 160 and no task takes longer than 2 minutes 45 seconds.  Only 40% of a nurse’s work is actually nursing – the rest of the time they are performing clerical duties, locating missing medications, trying to find equipment or on the telephone on hold.  Nearly 30% of her or his time is spent charting information no one reads.  The result? 80 percent of a nurse’s workday is away from the bedside.

Economic stresses have caused healthcare organizations to rigorously try to control staffing ratios. Historic patient-to-nurse ratios don’t apply in a world where length of stay shortens as patient acuity increases. While a nurse may be assigned 4-6 patients per shift, the number of admissions, discharges, and transfers can comprise 80 percent of the patients. One nurse admits, another gives care and yet another nurse discharges in 48 hours - another example of why failed communication is the number one cause of medical error. 

How can this system of relating to each other be professionally or personally satisfying for either physicians or nurses?  How can it possibly be deemed ‘safe’?

Some structural changes have the potential to reverse this trend. The advent of intensivist and hospitalist physicians is reducing the number of doctors involved in complex patient care. Team rounding is becoming more prevalent, and physician availability for an entire shift improves opportunities for communication. SBAR (Situation-Background-Assessment- Recommendation/Request) communication has been useful. It improves the nurses’ understanding, supports their professionalism, and helps prevent the entrapment of physicians when a lack of necessary information precludes good decision-making.

Most of all, it is essential to personalize the nurse–physician relationship. Physicians must commit to knowing the nurses’ names and nurses must insist on identifying themselves before each encounter. When you know someone, and know something about them outside of their work role, it becomes much more difficult to ignore them or communicate in a disruptive manner and communication flows more freely. One important improvement would be to have a physician present a brief teaching experience to nurses weekly or, at least monthly. Another example would be to have the charge nurse present a case scenario at weekly physician rounds – unheard of at most institutions.

Nothing will change without leadership. Executives must lead this cultural change by insisting on daily communication, physicians knowing nurses names, creating informal structures such as joint educational and celebratory venues and bedside rounding, and actually living the values of the institution by zero tolerance on all disruptive behavior – same rules for all roles. Until the two most critical professionals in patient care can work together for the benefit of the patient, we will continue to send subtle, covert warnings to the general public just under the radar – bring someone with you, ask your caregivers to wash, call Rapid Response if you need to- because the two most important people in your care, physicians and nurses, don’t have the relationship that you need to be safe.

What is your hospital doing to improve relationships between professionals who care for patients?

Fatal Distraction

A manager walks onto the unit and observes the secretary texting, a nurse on Facebook, and a resident on his droid checking skiing conditions.   What’s the most unlikely part of the above situation?  The manager walking onto the unit. 

As I travel across the country one thing is eminently clear: managers are noticeably absent from the front line.  It happened very slowly over a long period of time as their workload increased and changed demanding that they spend more time in meetings and their offices.  Staff complain frequently that “I haven’t even seen my manager for two weeks – and I work day shift!”  While most hospitals have a policy regarding use of IT for personal reasons during work, very, very few actually enforce that rule.

If it’s not enforced, then it’s not a rule. It’s the norm.

A recent email blast from “Plexus” entitled “Do Electronic Devices in Health Care Present New Risks for Patient Safety” resonated with me on a very deep level confirming suspicions gathered from informal conversations across the country.  Fifty five percent of perfusion technicians admitted having cell phone conversations while monitoring machines – and half had texted during surgery.  Then a New York Times story by Matt Richtel highlighted a malpractice case where a neurosurgeon made over ten personal calls during surgery to family members and business associates.   The problem is bigger than leaders realize for several reasons.

Acute changes ping our radar, while gradual changes are more insidious. Their great danger lies in the fact that human beings simply don’t notice small and incremental changes (Human Adaptability Theory).  For example, I was called down to California to teach high reliability skills after the anesthesiologist accidentally drew up 10 cc’s of Epinephrine instead of Toradol.  The eighteen year old patient in an out-patient surgery center coded.  I guarantee you that the norm of bringing a phone into surgery started when someone had an emergency (like a very sick child) and put their phone in their pocket on vibrate…. (and no one was harmed); then another member of the team was waiting for a real estate deal on his new house….(and no one was harmed)….so they all started bringing them in until one day… years later….an eighteen year old in for a simple knee surgery nearly dies.  Little mini-Challenger explosions…

We lost the Challenger because in two successive launches NASA was able to forget their own rules regarding the lowest safe launch temperature and convinced themselves that prior success with deviation insured future success with deviation – a single solitary voice saying “Don’t do this” was overridden. 

Personal use of IT during operations and work time is now rampant because of a lack of awareness of the problem, a lack of leadership and normalization of deviancy.  A new norm that holds that human beings can multitask while driving, operating or performing nursing functions now exists despite the fact that research consistently validates the opposite.   What can you do?

1. Make a decision.  It’s only a rule if it’s enforced.  Ask for your leaders to give examples of how they handled these situations in public meetings.  Are cell phones being used in your operating room?  If so, you are asking for a ruinous verdict.
2. Determine the scope or prevalence with real data. Use survey monkey to craft a brief questionnaire asking staff to anonymously report how frequently they see their co-workers texting, on Facebook or making calls or using blackberries/droids for personal reasons. 
3. Ensure that managers have a sufficient amount of presence on the unit to actually enforce the rule.   Ask them if they have the time – objectively assess their workload.
4. Even then, managers will not act unless HR has their backand they have the skills necessary to hold staff accountable.  Ever try asking a neurosurgeon to stop talking on his/her cell phone in the operating room?   It’s not pretty.  But if staff know you have their back, then you’ll at least have a better chance than the Challenger crew.  

Tell us your story - is technology creating unnecessary distractions in your workplace?

With Arms Wide Open

Eight years ago, when my son was a sophomore in high school, I came home to find his body lying limp on the living room floor.  All 6 foot 2 inches crumbled into a half-fetal position; eyes open, pulse steady, but no response after several attempts to rouse him.  Eventually he mumbled, “Leave me alone”.

It was then that his sister told me what happened.  His classmate from homeroom had committed suicide.  “Go away”, he muttered if anyone tried to speak or touch him, wanting to be left alone in his pain. 

I am like that too.  When hurting, I search out my metaphorical cave and hide from reality until the hurricane of events and emotions pass and I can see where I am again.  And then, I write. Because my son would not listen; because I could not reach him; I wrote a letter to all the children in the newspaper:

“We cannot hear a silent scream.  If you are drowning, reach out your hand.  There are so many of you in this tumultuous sea…these are indeed rough waters.”

I am reminded of this story after hearing about two nurses who committed suicide in the last few months – one related to a medication error and the other related to bullying on the unit.  These are rough waters in healthcare as well.  What can we do so this never happens again?

Stress precipitates depression in working men and women (Melchior et al).  A study by Welsh found that 35% of a sample of medical surgical nurses had clinical depression.  For nurses, the amount of stress due to the workload alone has increased dramatically over the last decade.  Mental Stress?  We know that nurses perform 160 tasks in an 8 hour shift with no task lasting longer than 2:45 seconds; that nurses stack 7 or more items to remember at any given time and that up to 30% of their time is spent charting (Bujak, Bartholomew).  Physical Stress?  Musculo-skeletal disorders are reported in more than 60% of the nursing workforce (Levtak et al).  And then, there are pressures from the system itself.  Yesterday several nurses were told (yet again) by their manager to “clock out first and then finish your charting” – a clear federal violation but an increasingly common practice as managers struggle to crunch the budget.  As the healthcare system transitions from a business to a service model, nurses are clearly feeling the brunt of the impact.

Nurses were found to have “a general lack of knowledge on how to identify and support nurses with health problems.” (Letvak et al).  Respondents in one survey discussed nurses they knew who were working under the influence of drugs to compensate for pain and anti-anxiety etc.  We must become as skilled in approaching each other in these delicate situations as we are in attending to our patients.

As professionals, we are trained to be alert to the signs and symptoms of depression and mental illness.  It is time to expand our perspective, use this psychiatric skill set, and offer the same level of compassion, education and support we would give our patients, to each other. 

Watch for behavioral changes, or changes in thought processes, or moods such as irritability. Don’t consistently chalk it off as a ‘personality problem’.

1. Absenteeism.  Peers who are out of work more than usual – sick days or constant physical illness perhaps complaining of inability to sleep- or get out of bed.
2. Isolation.  Decreased communication or a change in socialization patterns
3. Negative self talk; feelings of unworthiness,  decreased self esteem

And if you know of a nurse who is on medications and feel that it is impacting the quality and safety of care delivered, talk to them first.  Bring up specific observations.

TIP: Don’t know how to begin? 

Remember this: Start with your heart; then say what you see…. 

“I am concerned about you.  I noticed that______.  

Perhaps it is human nature to want to draw inward when stressed or upset.  But these fast passed, stressful times call for just the opposite.  It is time to widen that circle of wisdom, skill and caring to your peers with arms wide open.  From this moment on, let us be known as the profession that nurtures and feeds its young; as the profession that cares deeply and passionately about life, healing, wellness and prevention – starting with each other.  

We are indeed better together.

The Undertow of Nursing Charting a New Course

An experienced charge nurse reviews staffing for the next shift.  She notes that two out of the three nurses coming on have less than a year experience and she is concerned.  In addition, the intoxicated patient in 54 is requiring hourly medications and frequent monitoring to avert DT’s (delirium tremors).  The charge decides that in order to safely staff the floor she needs four nurses - but the staffing office says they are very sorry (sick call or staffing grid), and she can only have three.

A surgical nurse helps her patient to the bathroom and the patient is weak and unsteady on post op day three from a hip replacement.  She foresees the likelihood of this patient falling at home and reports her observations to the physician, recommending that the patient stay another day to gain strength and more physical therapy - but the physician discharges the patient home anyway.  He’s being dinged for his length of stay and can’t afford to look like an outlier.

Another nurse notices on the fourth post op day that the patient has not had a bowel movement for four days; but she can’t give Maalox or even a suppository without calling the doctor first.  The nurse knows the surgeon is in the operating room and doesn’t want to interrupt.  She also knows that the same over the-counter laxative that the doctor would order is currently ten feet away in the medication room.

An undertow is more powerful than a wave. An un-articulated conflict is much more damaging to our esteem than an obvious one.  I could just as easily list scenarios where the nurses’ high level critical thinking, skill, autonomy and experience improved patient care.  But the reason for discussing these situations is to raise awareness of their presence so that the effect can be mitigated.  What effect?

Ambiguity increases self-doubt which in turn decreases self esteem; reinforcing nurses’ feelings of powerlessness.  Raising awareness of these internal role conflicts however, allows us to intervene and change course.  Many nurses take the above situations as ‘part of the job’, and fail to see how these daily conundrums insidiously chip away at their sense of self.  But if we can identify and talk about the undertow that pulls us down, we can chart a different course.  

To read the full article, click here The Undertow of Nursing: Charting a New Course.

Juice has partnered with Kathleen Bartholomew to create a two-part CD/DVD series that addresses the problem of nurse-to-nurse hostility and aims to provide the tools to end it. www.juicehealthcare.com.

Nurses Heal Thyself: A Culture of Silence

When Shelli was a new scrub nurse with only six months experience, she failed to anticipate that the surgeon would need a particular scalpel.Immediately, her preceptor deftly slapped the correct blade into the impatient surgeon’s outstretched hand with a glare in Shelli’s direction.The surgeon said nothing, but a look of disappointment briefly flashed across his face.At that moment, Shelli learned that if she was not on top of the surgeon’s needs, she would end up feeling embarrassed and looking incompetent.Shelli did not find this information in her orientation manual.

We learn these unspoken rules very quickly in order to survive.We know which physician not to ever call in the middle of the night, which nurse talks about us behind our back when we ask a question, and whether we should even bother to write up an incident report or approach a coworker with a concern we have about ‘their’ patient.This knowledge is vital to our survival because it determines whether or not we will be accepted by the group.

To read the full article, click here: Nurses Heal Thyself: A Culture of Silence

Juice has partnered with Kathleen Bartholomew to create a two-part CD/DVD series that addresses the problem of nurse-to-nurse hostility and aims to provide the tools to end it. www.juicehealthcare.com.

Lateral Violence in Nursing: Breaking the Spell

A nurse rolls her eyes at a co-worker as she picks up the assignment sheet that was created by a younger charge nurse. An ICU nurse pretends not to see her co-worker is drowning and ignores her request for help saying she is ‘too busy’. A newly hired RN who was previously a scrub tech finds she is now shunned by both groups. Is this just life as a nurse - or a nurse’s right of passage? Or is it something more insidious?

These behaviors go by several names: lateral or horizontal violence, incivility, nurse-to-nurse bullying, sabotage - “nurses eating their young.” In general, bullying in the United States is a term used to describe uncivil behavior from someone who has power over you – vertical aggression. Rude behaviors from peers are referred to as horizontal or lateral hostility and are defined as: “A consistent pattern of behavior designed to control, diminish or devalue a peer (or group) which creates a risk to health or safety” (Farrell, 2005).

To read the full article, click here: Lateral Violence in Nursing: Breaking the Spell.

Juice has partnered with Kathleen Bartholomew to create a two-part CD/DVD series that addresses the problem of nurse-to-nurse hostility and aims to provide the tools to end it. www.juicehealthcare.com.

Targeted - The impact of bullying and what needs to be done to eliminate it

In Canada, 44 per cent of female nurses and 50 per cent of male nurses report being exposed to hostility or conflict from people they work with, according to the 2005 National Survey of the Work and Health of Nurses. The survey was conducted by Statistics Canada in partnership with Health Canada and the Canadian Institute for Health Information.

Twelve per cent of the RNs, licensed practical nurses and registered psychiatric nurses who responded to the survey experienced emotional abuse from co-workers; however, experts in the field say that percentage is likely vastly under-reported. “It’s a problem at every single level of the entire profession,” says Kathleen Bartholomew, a Seattle-based RN and the author of Ending Nurse-to-Nurse Hostility: Why Nurses Eat Their Young and Each Other.

To read the full article that was recently published in the June issue of Canadian Nurse, please click here Targeted - The impact of bullying and what needs to be done to eliminate it.

Hostility OR Connection

Hostility in the OR:  It's Effect on Teamwork

THE JOINT COMMISSION SAYS HEALTHCARE FACILITIES, labs and other related organizations must establish a code of conduct that defines and sets out a process for handling unacceptable behavior by health care workers, such as rude language, temper tantrums and bullying. The Commission said such behavior can impact patient care by causing breakdowns in provider communication and teamwork.

To read the full article, http://www.juiceinc.com/articles/show/hostility-or-connection

The Silent Treatment

Aligning practice with policy to improve patient care...

Recently, a highly accomplished orthopedic surgeon was scheduled to work on three consecutive cases with his OR team. The operating rooms were state of the art within the medical center’s newly constructed orthopedic hospital, which had not yet celebrated its first birthday. A system of time outs including use of the World Health Organization (WHO) surgical checklist had been in place at the medical center for almost three years now, with multiple checklists for patient identification, pre-op procedures and instrumentation.

To read the full article, http://www.juiceinc.com/articles/show/the-silent-treatment

Stress: The Heart of the Matter

The most critical action you can take to decrease your personal level of stress in the workplace is to raise your own awareness of the emotional work of nursing, and to honor your own feelings at all times.

As the mother of five children under the age of 12 living in a 500-square foot trailer in the south, I thought I knew stress. I had struggled with adapting to single-parent life while attending nursing school full time, working at the university, dealing with financial concerns and spending tremendous amounts of psychic energy to nurture my young family. But I was wrong. The kind of stress I was familiar with was tangible and expected—acknowledged and validated by friends and family. The stress that I experienced in the transition from nursing school to staff nursing was like nothing I had ever experienced before because it was intangible and unnamed.

To read the full article,  http://www.juiceinc.com/files/documents/Stress_The_Heart_of_the_Matter.pdf

Breaking Free From Our Cultural Chains

Human beings rarely, if ever, succeed at accurately perceiving their own culture.

So deeply entrenched is culture that no one talks about it: the unspoken rules and behaviors (called norms) are never written down, and yet everyone knows them. We learn these norms the hard way through the process of assimilation into a culture. For example, when Shelli was a new scrub nurse with only six months experience, she failed to anticipate that the surgeon would need a particular scalpel. Immediately, her experienced preceptor deftly handed the correct blade to the impatient surgeon with a glare in Shelli's direction. At that moment, Shelli learned that if she was not on top of the surgeon's needs, she would end up feeling embarrassed and looking incompetent. Shelli did not find this information in her orientation manual.

Culture also determines what we see – and what we don’t. Scrub nurses do not innately “know” which surgeon tolerates technical questions or joking and which ones do not, or what subjects are acceptable to talk about among their team. They figure this out. Humans quickly pick up on these subtle cues and  then act accordingly. Like any group, operating teams learn norms by induction and trial and error because the need to belong is so strong. So  without a conscious thought (whether scrub nurse, anesthesiologist, tech or surgeon), we mimic the behaviors of those around us in order to be accepted. After a while, no one even notices the subtle, unspoken rules. And why would they? Everyone exhibits the same behaviors. The norms are now downloaded into our subconscious mind.

To read the full article, http://www.juiceinc.com/Cultural_Chains_Kathleen_Bartholomew.pdf

Nurses vs Robots: No Contest

I am very pleased to be able to post a blog entry on the new Juice Blog and look forward to posting here again.  Thank you for the opportunity.

Nurses vs Robots: No Contest

A recent article, Robotic Scrub Nurses Could Boost OR Efficiencies caused quite a stir in the nursing community. 

Of course a "robotic nurse" would create a visceral reaction - the same reaction as if there had been an article on "robotic doctors" or "robotic teachers". The word means ‘automatic, technical, predictable’ and Nursing is anything but – it is dynamic, complex and requires a sensitivity and wisdom well beyond the perceptions of the profession by the general public – or even other members of the health care team.

Just a scrub nurse? Then you have no idea of the skill set which a good scrub nurse utilizes to orchestrate her/his entire OR environment. Even the seemingly simple passing of an instrument is much more than meets the eye.  For when the surgeon asks for the wrong instrument on a bad day, the experienced scrub nurse reaches for the correct one with questioning eyes – eyes that speak volume – eyes that can convey encouragement, support, questions or concerns. Just handling instruments?  I don’t think so.

Of course there are no reality TV shows that truly represent nursing – it’s not entertainment and never will be.  Nursing is one human being’s presence, skill, compassion and energy guarding, advocating and guiding patients through their very complex journey in our dangerous health care system. And the real sore point is that the public doesn’t see or appreciate this critical role.

To read the full article, please click on the following title - Nurses vs Robots: No Contest.