I’ve been thinking a lot lately about punitive cultures in healthcare. It seems that the mantra of both nursing and medicine is that “nurses eat their young,” and that “doctors eat their young.” Don’t know about pharmacy, PT, OT and others, but it seems that no one is eating lunch but they everyone is nonetheless stuffed because of this professional canabalism. Well, we know that hungry people are also irritable and unpleasant and we also know that feasting on one’s professional young is neither a recipe for professional satisfaction nor for high quality performance. Read more >>
The other day I had the privilege of being interviewed for a podcast by RN Suzie Farthing. Suzie took the initiative to do her own series of podcasts on healthcare and nursing. She’s a model for all nurses and those in healthcare who have something to say and decide to say it, and who also act to help others find their voices. She wrote this:
From Silence to Voice to Podcasting
by Suzie Farthing RN
Nurses need healthy professional relationships with nursing leaders and mentors. Having a mentoring support system is critical for talking out and thinking through the ethical, professional, and other matters that are unique to nurses. I believe that without the benefit and fulfillment of a healthy mentoring relationship with a leader or colleague, any nurse could quite easily stumble into a professional void. I know this from personal experience.
Several years ago, I went through a period where I doubted my contributions as a nurse and the overall importance of the nursing profession. I had lost my perspective. Since I was working on a small post surgical unit where there was primarily one “rock star” mentality surgeon admitting patients and minimal interaction with our nurse leader, I sank into a professional depression. I can remember thinking, “What difference do nurses really make? Anyone can do what we do.” Read more >>
I met Michelle Swift at a performance of our play Bedside Manners that I put on recently for the Utah Society of Risk Management. Michelle is an RN and attorney who works in Patient Safety and Risk Management for The Doctors Company. After the performance, she told me a great story that happened when she worked briefly as a flight attendant. As you read it, ask yourself how these tools could be applied to healthcare to enhance patient safety and eliminate medical errors and injuries. The lessons are totally applicable which is why I asked Michelle to write it up so that I could share it with those who follow this blog. Here it is:
Crew Resource Management (CRM) is a set of training procedures for use in environments where human error can have devastating effects. CRM is used primarily for improving air safety while focusing on interpersonal communication, leadership, and decision making in the cockpit and between the entire flight crew. One important aspect of the training is to recognize that, when issues are reported– regardless of the source, regardless of the question of credibility– all reports must be taken seriously without repercussions to the flight crew.
I want to share a true story that illuminates what happens when you have strong direction from leadership so that everyone understands that all reports must be respected and acted upon, without minimizing people’s concerns or retaliating against the crew member. Read more >>
Blame Richie Incognito. In fact fire him. Blame his coach. Fire him too. Then move on to the folks in Nebraska, the All –Big 12 Conference, the Rams. Blame them all. But if you do then you’ve missed the entire point. When it comes to bullies and bullying, it’s never just the bully and the team (school, company…) leaders that are the real enablers. It’s all those spectators who stand by and watch the fights, the whispered innuendos, the sneering looks, the jeers and sarcastic comments – or now in the world of the internet – who log on to the stalking emails, Facebook postings, or Youtube videos – and do anything to intervene.
The people who stand by and do nothing – they’re the real problem when it comes to bullying. It’s like Edmund Burke supposedly said in 1777, “The only thing necessary for the triumph of evil is that good men do nothing.” (Today, finally recognize that women of good will can be equally guilty). Read more >>
Everyone interested in patient safety and patient care should read this article on the Washington Post blog “How Healthcare.gov looks to a health IT Pioneer.”
The interview with Fred Trotter, the IT pioneer in question is very revealing. According to Trotter, a lot of things that seem obvious in retrospect were not done. But what really hampered the Obamacare effort, he says, is the failure to pay attention to the mundane but critical details of launching such a complex venture. Also, the government would have had to do a lot of inventing to do something new.
Here’s what Trotter says about the details: “When you get a certain amount of traffic going to any site on the internet a single computer can’t handle it. In order to handle tremendous amounts of traffic you have to have more than one computer sharing a task. At modern sites like Amazon and Ebay and Google, the main innovation they’ve pioneered is using lots of computers at the same time to answer one query to the web site.
But it’s a different problem for different tasks. If the federal government wanted to sell billions of books online that’s fairly understood. They could just look at Amazon. But they’re trying to do something entirely new. And that means that what they’re talking about is the invention of something new. The way Congress looks at software is that there are these sites that do these amazing things and we should do that, too. They don’t realize that a tremendous amount of invention has gone on at these scaled web sites to handle these processes.”
Here’s what he says about invention: “They screwed themselves twice. The first thing they did that was very foolish was to go at scale. Usually when the government understands the problem of that they do things in phases. They didn’t draft everyone for Vietnam all at once. That’s the model they should’ve used. They should’ve said people born in January can now get health insurance. Then it should’ve expanded to everyone born in the first quarter. And so on. But they presumed scale was easy. That was the first mistake. The second was assuming invention was easy. And scaling something that hasn’t been invented yet — that’s technological suicide. ”
When I read this, I was reminded of other areas of healthcare where the devil is also in the details and people are both overly optimistic and overly simplistic about what it means to create changes that are enormously complex. I think for example of nursing care, where people think it’s all very simple and don’t understand the complexity of the banal. They think it’s easy to feed someone who can’t feed themselves, but forget that it’s actually not so easy to feed someone who’s had a stroke. And if you don’t know how to do it the person can become malnourished and not recover. Or consider the new facts that have been discovered about the prevention of ventilator associated pneumonia (VAP). Turns out the one of the best ways to prevent VAPs in ICUs is to do oral care. Who does oral care? Critical care nurses. And it’s not so easy to do this, Canadian critical care nursing expert Craig Dale who has studied this complex activity tells us. Brushing the teeth and providing oral care for those with a ventilator snaking down their throats is not the same as brushing your teeth or doing oral care on a healthy person. Again, it’s all about putting theory or grand ideas into practice, which is always tricky and much harder than you think. (Let me tell you, after writing 17 books and hundreds of articles, I know that getting a great idea, and turning it into a book or even 750 word oped always turns out to be a lot harder than I think it will be. And all that pales in comparison with the changes we want to implement in healthcare.)
What is missing in our great plans is often what I think of as an imagination for practice. This is particularly true when it comes to patient safety and the prevention of medical errors and injuries. We think about some grand scheme and simply ignore what it will take to put it into practice. Part of this failure of imagination may be the amazing human capacity for denial. If we really imagined the complexities of doing something, we might end up getting so discouraged we would do nothing. Part of it is a way of dealing with naysayers, or those who present obstacles in our path. Don’t worry, we shrug off objections, it will be way easier than you think. But I again come back to our failure to respect the complexity of practice and what seem to us the fascinating complexity of what we often think of as something simple or banal. In healthcare, it is often the simple or the banal that kills or injures people. The surgeon does a great job in the OR but the patient is harmed because no one walked them and they got a DVT, or no one did mouth care and they got a VAP, or no one washed their hands and they got a hospital acquired infection. When nurses or non-physician healthcare professionals or workers tell their stories, they often begin by saying that what they do are the “little things,” in healthcare. When I hear that phrase “little thing,” my ears always perk up because I have learned from years of observation, that when it comes to healthcare there is literally no such thing as a “little thing.” The little things often turn out to be the big things that hurt and we need to respect them and pay as much attention to them as we pay to what we consider those “high level” acts of medical heroism. When it comes to patient safety and medical errors, medical heroics don’t work if the little things don’t reserve the respect they deserve.