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 >>
Does anybody read the New York Times. I do and today a really important picture was on the first page. It looked like this. Check it out carefully. Here is the caption: “Pope Francis had lunch with Vatican workers on Friday after he walked into the cafeteria unannounced and lined up, tray in hand. A cashier told the Vatican newspaper L’Osservatore Romano that she “didn’t have the courage” to hand him his bill.” Imagine the message about status and hierarchy that would be conveyed in hospitals and healthcare settings all over the country if the Pope served as a model for physicians, administrators etc. Imagine, if tomorrow the chief of surgery wandered into the cafeteria at a major teaching hospital, bought his/her lunch and sat down with some RNs and began schmoozing. Imagine if nurses sat with aides, or janitors, if MDs mixed it up with everyone. Or imagine if RNs, PTs, etc and all sorts of staff at every level walked into the cafeteria and sat down with a group of docs and the docs welcomed them and stopped chatting with each other and began a real interprofessional/interdisciplinary conversation. Read more >>
The other day a reporter from Nurse Zone called me to tell me she was doing a story on things nurses can do to improve relations with physicians. Her name is Jennifer Larson and she is committed to the issue, which is great. When we discussed the issue, she mentioned the idea that nurses could be physician whisperers, kind of like horse whisperers who calm down skittish horses. I pointed out that the very idea of a”physician whisperer” is a total replication of the age old nurse doctor game which Leonard Stein wrote about several decades ago. rain which nurses placate or otherwise indirectly manage physicians rather than dealing with them in a respectful but assertive manner. Larson wrote a very good article about dealing with physicians but I would add quite a bit more. In fact, I believe we have to get rid of the traditional and very outdated and dysfunctional “secrets” or “secret of managing” doctors, aides, or anyone else mentality. Nurses as well as any other staff that have been in a traditionally deferential or subordinate relationship to higher status players have to take advantage of the opportunities presented by the movement to enhance patient safety and encourage interprofessional practice and develop the capacity and skills to deal with people in a direct, respectful but assertive manner. Rather than being so obsessed with leadership, nurses have to develop a concept of assertive team membership and learn the skills that have been utilized in aviation and other high reliability industries so that they can become true and full members of the health care team. The way to do this is to mobilize IAA — Inquiry, Advocacy and Assertion.
So here are my Seven Non-Secrets to more Effective Team Relationships, particularly when nurses or others are dealing with traditional high status players like physicians.
Step One — Never Apologize!!! Ever. As RN Paulina Bleah has written in an essay in a soon to be published book I have written with physician patient safety advocates David L. Feldman and Michael Leonard called Collaborative Caring: Stories and Reflections on Teamwork in Healthcare, nurses typically apologize to physicians when they ask them to do their jobs. A nurse calls a doc in the middle of the night, or anytime and begins with an abject apology (i.e. “oh Dr. Smith, I am so sorry to bother you), asks a question and then ends with an abject apology as if Dr. Smith has amnesia and didn’t get it the first time. Don’t apologize to anyone for asking them to do their job. Would you apologize to your lawyer for calling them and giving them a case or asking for advice? I wouldn’t since those nine of ten words and seconds of the apology would have cost me $20 bucks or more.
Step Two — Enter the Circle of Care. Don’t Position Yourself in the Outfield!! How many times have you seen the following? A group of physicians is talking together, or there is a supposedly interprofessional rounds going on. The physicians are standing in a circle. An RN comes up to them to talk about a serious clinical issue. She/he positions herself/himself outside the circle. No one invites her/him in. She/he does not move in. Or consider this “interprofessional rounds” that I described in my essays on Teams and Team Intelligence in First Do Less Harm. The “team” included an attending physician, a pharmacist, and two nurses – the bedside RNs caring for the patient the group would be discussing. As Dr. S discussed a series of patients, she stood with her back to the two nurses and addressed the residents and med students. For the next 15 minutes her stance never altered. She never turned to include them in the conversation. The two bedside nurses stood on tiptoe or craned their necks in an effort to hear what the doctor was saying to the residents and medical students. The two nurses never moved next to the wall even though there was plenty of room there. If you are in this situation, which many nurses confront every day, move into the circle, be part of the team. Do not place yourself on the outside.
Step Three – If You Are Invited to the Table Sit at the Table . In a previous blogpost I described a situation in which nurses and other non-MD professionals are attending interprofessional team meetings. Rather than sit at any seats at the conference table in the center of the room, nurses place themselves at the periphery, in the chairs on the outside of the room, even though there are empty chairs at the table. They do this, I am told, because those chairs are “reserved” for physicians and administrators. Who reserved them? No one really. So help create real interprofessional practice. Sit at the table.
Step Four – If You are Invited to the Table, Speak. How many times have I sat in a meeting to which nurses were invited and yet they said nothing. This is not just a phenomenon I have observed with bedside nurses. I have watched PhD RNs sit silently or speak only about narrow nursing issues when I know they have lots to say about broader systems issues. (Nurses claim after all that they are the ones who are holistic and have a broad understanding of health care system problems) I understand the nervousness people feel when they are in a mixed group, particularly one with high status players. So if you are going into such a meeting, role play it, practice, rehearse but speak up. If you don’t pretty soon people will wonder why they bothered inviting you and you will be either disinvited or further dis-regarded. Remember, silence speaks volumes.
Step Five – Insist on Equal Naming Practices. Nurses –even older nurses – constantly allow themselves to be called by their first name while they call physicians –even young ones – with title and last name. As in Dr. Smith, this is Suzy. This form of naming practice, unknown in the outside world where first names are now routine – delivers a very specific message about status. Nurses are not important, physicians are. Nurses not only allow this practice but reinforce it. Nurses who are on a first name basis with physicians typically change this practice when in front of patients. The physician they referred to by first name only suddenly becomes Dr. Smith when in the presence of a patient. When I ask nurses why they do this, they insist that it’s important for the patient to respect their physician. Like a mother in front of a child, they are telling the patient that they must respect their daddy. This not only serves to put the nurse in a one down position, it tells the patient that they must be deferential to the doctor. Don’t nurses deserve respect? And if respect resides in the last name and title, why don’t they insist on being called Nurse Smith? And how can they allow physicians to call patients by their first names if they insist the patient call the physician with last name and title? How can nurses claim to be patient advocates, if they are advocating for this paternalistic definition of the authority of the physician? This practice should end. To see how to do that please read what Bernice Buresh and I have to say about this in our book From Silence to Voice.
Step Six – Understand the Difference Between Respect and Reverence. Healthcare is totally confused about the difference between respect and reverence.
Webster’s Dictionary defines respect thusly, “a feeling or understanding that someone or something is important, serious, etc., and should be treated in an appropriate way.” http://www.merriam-webster.com/dictionary/respect?show=0&t=1405269538
Reverence on the other hand is defined as ”profound adoring awed respect.” Reverence is the attitude religious people feel toward God, or priests. Is this the way we want to view physicians? How can people intervene to appropriately challenge a physician, administrator, chief nurse, whomever, if we hold them in awe?”
Step Seven – Learn How to Speak Up. Nurses have been tutored in silence for centuries. This kind of tutoring still goes on. I recently wrote a blogpost about a student nurse who said he was “crippled by shame,” because his clinical instructors told him not to point out that attending physicians hadn’t washed their hands. “You don’t want to be considered to be a loud-mouth or know it all,” the instructor told the student. Nurses need to stop teaching each other how to shut up and need to help each other to learn how to constructively speak up.