Thousands of hospitalized patients die every year and the cause is directly attributed to nurses and their “failure to rescue” the patients within their care. We’ve all heard about that one patient that came in with one issue and died of another. Those of us who have reviewed charts for malpractice cases refer to it as the “snowball effect”—reading the progress notes of a patient who died due to failure to rescue will make you cringe at the glaring errors.
Patients may have one clinical issue, however minor, that if overlooked by the nurse, cascades into a huge mess of concurrent errors and oversights that often leads to the injury or needless death of a patient. Did you ever wonder why this occurs? Short staffing? Maybe. Nurse burnout? Could be. The main contributing factor, though, is that unfortunately there are many nurses who don’t think creatively or innovatively. They don’t act on their assessment findings nor do they follow up on a change in patient condition. They fail to act as advocates for their patient. Nurses who fail to rescue use “traditional thinking” rather than critical thinking.
Failure to rescue always includes four key elements: (1) Omission of care; (2) a failure to recognize a change in patient condition; (3) a failure to communicate a change in patient condition to medical or other staff; and (4) poor or lack of clinical decision making.
Preceptors and nursing instructors, no matter the level of nursing taught (RN, BSN, MSN, NP, or DNP), should review the below list. It contains elements of traditional thinking. Promoting traditional thinking stifles critical thinking.
Nurses
who don’t think critically:
Don’t learn from their mistakes or the
mistakes of other nurses.
Demand that nothing changes and have a
“but we’ve always done it this way” attitude.
Treat each patient interaction in
isolation.
Fail to “connect the dots” from one
interaction to another.
Fail to learn about cause and effect.
Do not connect new events with prior
knowledge.
Do not see what is possible in the future.
Solve problems in isolation.
Demand that all things be done their way
and not any other.
Allow personal dislikes and prejudices to
cloud judgement.
Lack self-confidence.
Have poor verbal and written communication
skills and do not interact well with others.
Do not further their education or promote education
for others.
Force others to make decisions quickly or
set time limits on when decisions can be made.
The behavior and clinical actions of nursing preceptors and instructors affect a student or new nurse long after their clinical rotation or orientation has ended. In fact, the actions of a preceptor or instructor will influence the new nurse far into their nursing careers.
The following statements, said by a preceptor or any nurse to another nurse, will stifle critical thinking:
“That’s a dumb idea.”
“I can’t believe your school didn’t teach
you __________.”
“Your idea is good, but it won’t work here.”
“It’s too complicated so I’ll just do it
and you can watch.”
“You spend too much time talking with your
patients.”
“We tried that here on our unit and it
didn’t work.”
How do you teach critical thinking to your preceptees and students? Let us know in the comments!
In 1944, Ingrid Bergman and Charles Boyer stared in the famous movie thriller “Gaslight.” If you like psychological drama, I encourage you to watch this film. If you want to learn what some bosses do to their employees, look up the verb “gaslight.” Just like in the film when Gregory (Boyer) purposefully manipulates information in such a way as to make his wife Paula (Bergman) question reality and her memory, a boss who gaslights you is manipulating and harassing you. If you have a boss who makes you doubt yourself and your reality, then you are the victim of bullying on a whole different level — gaslighting. The boss that uses this technique is fully aware that what they are doing is wrong.
Gaslighting is a subtle technique employed slowly and artfully. Your work life may have started out uneventful; with your boss complimenting you and your work. Your thought your opinion was valued and that you were appreciated. You felt respected.
Bosses who are bullies don’t want you to succeed because they will lose their power over you; they will do anything to impede your success, make you miserable, and block your momentum. But why does a boss gaslight? Because they want you to bend their will, to make you leahttp://minoritynurse.com/why-good-nurses-leave-the-profession/ve your job or to get you fired. If you challenge them, they will make the attacks worse. They employ their tactics to confuse and frustrate you. They want you to be discredited in the eyes of your fellow employees and supervisors. You are not “allowed” to have any ideas, thoughts, or actions different from theirs; your existence at your place of work is a problem for them.
A gaslighter will:
Pretend not to see you, acknowledge your existence or your work but will then be overgenerous with compliments and concern.
Change project guidelines, adding extra work and increasing the potential for failure.
State you are too emotional, your needs don’t matter to the bigger organization, that you are making a “big deal” of things, tells you to move on and forget the issues that concern you — by doing this they are trivializing you and your place in the facility. They do this because they want you to feel that what you are feeling is not reality.
Invade your privacy, listen in on your conversations, follow you, snoop within your office, monitor your location within the office, and watch who you speak to.
Withhold important information so that you cannot complete your work.
Share your private information with other employees.
Tell you one thing and then later deny it was said.
Allow work cliques to exist so that you are isolated.
Publicly humiliate or ridicule you using snide remarks, racist comments, and off-color jokes.
Micromanage.
Not be fair in the treatment of all — different rules for different employees.
Allow supervisors to mistreat and bully employees.
Gossip and lie to others regarding your appearance, health, personal life – in order to damage your reputation. The goal of this behavior is to make others believe you deserve the unfair treatment you’re given.
Attempt to give the appearance that they are listening to you when you speak, when in reality they do not care.
Take credit for your idea, telling you they had to “fine-tune” your original idea making it, no longer yours. Either this or they take an idea of yours that they had originally openly criticized.
What can you do?
Document! Trust your feelings that you are being harassed and abused and that you feel overwhelmed, depressed, and anxious. Documenting will be necessary should you choose to contact Human Resources.
Always have another coworker present when you meet with a gaslighter. If you are alone with a gaslighter, send a follow-up email to any conversation. Copy all employees that should have access to the information.
Limit your communication to emails and memos and make sure directives and instructions for projects are in writing and are clear and based on facts only.
Surround yourself with work friends who will reaffirm your talents and skills, because you will begin to doubt your self-worth.
Set boundaries that you will not let anyone cross, including your boss. If your react emotionally to them, they will merely point out that you are one with the emotional issues and that you are reacting inappropriately. They will make your emotional punishments worse than in the past.
If you decide to contact Human Resources, be sure that you speak to a representative who you trust and bring your documentation. Be prepared to request a department transfer or search for a new job.
Some employment specialists recommend that you confront the bully; however, the person who gaslights will not tolerate being confronted, in fact, the aggression will become worse.
I recently visited a friend while they were in the hospital and during my visit, I stopped by the coffee shop. As I sipped my coffee, I listened to the calls the nurses were receiving on their unit-specific mobile phones. While I can appreciate that a phone makes for better communication between the nurses and hospital staff, I can also appreciate that the same staff are unaware that the phones are inadvertently putting patients at risk.
During the hours I spent with my friend, I was inadvertently present for phone conversations, all on speaker, regarding what patients required pain medication and their room numbers, whose test results were received and their result, what patient was being combative and needed sedation, and who required pain medication. I heard patient names, room numbers, physician names, and patient conditions. And I learned that the wife of the gallbladder in 100B called. Needless to say, it was an interesting and enlightening time. Let me just say that when HIPAA became de rigueur, nurses would have been fired for less illicitly passed information than I learned that afternoon. You weren’t allowed to utter a patient name or room number anywhere where other patients or family members or the public in general were located. If overheard or reported by fellow staff, you were terminated.
The nurses carrying on these conversations were on a break from their units, attending a Nurses Week event, but I’m sure these conversations occur all day long, no matter where the nurse is… in report, at the bedside, at lunch, even in the bathroom. While I’m sure the latter is at most inconvenient and intrusive, the prior is downright dangerous. I’m sure if they even get a break off the unit, the phone goes with them and so does the stress.
We teach students and new nurses to prepare medications where they are not distracted, to check everything multiple times. We never tell them “OK, let’s see if you can titrate this medication while a disembodied voice is telling you about another patient who urgently needs you.” We also don’t teach them that while they are attempting to complete complex therapy requiring their undivided attention while keeping a field clean or sterile, that they will be called multiple times about multiple patients. Several studies have noted that these distracted nurses are at higher risk of committing a medication error or an error of omission.
Do they change gloves and wash their hands after handling the phone? Do they ignore the calls when they are in the middle of changing a dressing or toileting a patient? A 2009 study in Turkey found that 94.5% of health care workers’ cell phones tested positive for bacteria including the MRSA. Further, it was found that mobile phones were only cleaned per policy 10.5%. That leaves a staggering 89.5% that were NEVER cleaned! You don’t need to be an infection control nurse to figure out that the mobile phones carried by nurses and other staff are contaminated with nosocomial pathogens that place both the staff and their patients at risk. So along with the importance of hospital staff washing their hands after patient care, they must also be mindful of hand hygiene between patient care and handling of their mobile phones.
Although many hospital systems have implemented policies with regards to mobile phone use, hopefully to increase patient safety and confidentiality, they need to be reviewed and reinforced periodically. It is easy to become desensitized to our actions and those of others in the health care field and it is pretty glaring when violated. Policies should include when the phone should be in silent mode, when and how phones should be cleaned, and how calls to nurses should “roll over” to the nurse’s station—especially when staff are involved in patient care activities. The policy should also include enforcement and the consequences of policy violation.
I knew something was wrong when she was late for work. She hadn’t called out and hadn’t texted anyone where she was. I peeked into her office. I wasn’t looking for any clues about where she was or anything; I was looking for her in an empty room. What struck me was how neat the otherwise messy work place was. It was as if she was going on a trip and wanted to leave the office orderly in case anyone came in while she was gone. The loose ends were tied up. Thankfully, she was not successful in her suicide attempt.
Everyone claimed to not know anything, but we knew the whole story, pieced together from social media posts. We were all quiet and looking at each other like we were examining each other to see if anyone else was at risk for committing suicide. One nurse said, in typical off-color nursing humor: “We know what we are going through ourselves, but you never know if the person next to you is circling the drain.” We all nervously giggled. The comment hurt to hear…but it was accurate, stripped down to the basic cutting truth. We really don’t listen to the answer of a tossed out “how are you”? We are so concerned with ourselves and our own issues that we rarely take the time to reach out to someone else.
Prompted by what happened, the hospital presented education on suicide prevention. I didn’t want to attend. Why bother? I’d been depressed after my mother died, I’d been through treatment, and you couldn’t tell me anything I didn’t already know, but a friend of mine did attend and she was very moved by what she had heard. She shared with everyone on the unit what she felt was the most important takeaway: do not be afraid to ask someone if they want to harm themselves or commit suicide.
During a private conversation, this friend came right out and asked me if I ever thought of commiting suicide, if I’d ever been depressed. I didn’t look her in the eye when I said that in the past I had thought of what the world would be like without me in it, particularly after my mother had died. I told her that I had felt like I was surrounded by blackness, like I was sitting in the bottom of a well and I couldn’t get out. I had sought help and was diagnosed with depression. When I saw tears in her eyes I immediately regretted what I had said because I didn’t want anyone to know that I had been depressed—that there was a chink in my armor. She told me that she had learned that people who are depressed verbalize that they are in a very dark place, feeling like they are surrounded by nothingness and blackness with no way out. My friend kept looking at me like she was really seeing me and asked me to make her a promise. She made me promise that if I ever felt like that again, that I would tell her. My mental fingers were crossed. Strong people don’t reveal weaknesses and we certainly don’t share feelings—we just tamp them down, deny them, and keep going. I didn’t need help and besides, I was thinking, what could you do for me? But the concern and the tears in her eyes really stayed with me.
The truth was that I was sitting at the bottom of that well. Work and life and just the energy required for living were becoming too much again, but my friend had opened the door to the darkness and a little bit of light had shone in. Several weeks went by and we were talking on the unit about work related issues and I causally asked my friend if she remembered making me promise to tell her if I ever felt like I was sitting in the blackness. Tears filled her eyes again when I told her that I was back in the well again. I watched as she went to the computer, made an entry, and handed me on a piece of paper: the link to the employee assistance program at our hospital. She stayed with me while I contacted them and I was seen by a counselor the next day.
I
am aware that we all do not know someone we feel comfortable talking to, but in
our busy days of being a nurse and caring for patients and caring for ourselves
and our families, we need to be able to recognize when one of our colleagues is
reaching out, however silently, for our help.
Not since the last time some celebrity or politician said something uneducated about the profession of nursing has there been such a furious backlash. Fellow angry nurses have spent valuable time spewing our collective anger about what Senator Maureen Walsh said, venting about how we feel, creating memes, posting on Facebook, gathering signatures, debating in groups and demanding that action be taken and repercussions suffered. But what exactly was accomplished? Aside from the fact that everyone ran to their neutral corners, patting each other on the back and congratulating ourselves for insulting someone 2,000 miles from our home?
Of the main things I remember being taught during one of my clinical rotations is that when a patient feels a loss of control, they attempt to overcome that loss by controlling their caregivers and their immediate environment. They micromanage their situation, attempting to control their surroundings even while the larger picture of the potential of painful testing, a debilitating illness, or death is being denied and not dealt with.
I think of the patient in this situation as the nurse…we are buffeted by hurtful words and feeling that no one outside of nursing understands our professional lives, we feel as if we have lost control…we HAVE to make the person understand that what they have said is wrong, that what THEY have done is unimaginable. They MUST understand what a nurse goes through, has gone through, and what we are willing to go through in the future for our patients. We become angry and think of how to prove ourselves and explain our position for all to understand. We lash out and why we lash out is because we often times feel powerless to deal with our situation just like our patients. It is easier to scream over Facebook and write emails and letters to a person we will never meet, than to tackle the immediate problem of our own employment circumstances. Half the time we can’t make our immediate supervisors understand what our working conditions are like, so how do we expect to change the mindset of anyone else?
So, by mailing decks of cards did we change anything? With all our emails and letters, did working conditions on our units improve? Did our staffing levels get better? Did our pay increase? Did our benefits change? Did we make anyone finally understand? In a word…nope. What we did do is spend a lot of time, money, energy, and emotion on something we had no control over, much like one of our patients trying to control the uncontrollable.
Imagine what would happen if the time and energy that was expended in writing emails and letters, gathering signatures, and making phone calls to a state senator in a state where we probably don’t live and therefore cannot vote for or against, was spent in improving the working conditions of OUR units, OUR hospitals, OUR health care system?
Imagine if we worked together as professionals with a clear understanding of both sides of a situation, not screaming in reaction to headlines or snippets of information, but the true situation. In this most recent instance, the political person we were attempting to fight against was actually fighting FOR nurses, not against them and said something that while not the most enlightened, was taken out of context. For that, she and her family are receiving death threats…is this really how we want to be perceived—ill-informed and angry? Or as the professionals that we are…in control, educated, and mindful of the big picture?
I put to you that some of what we have done in the past to correct how the public understand nursing is obviously not working if we still have television shows that portray us incorrectly, so-called celebrities that have no idea what we do, and politicians that must constantly be reminded of how valuable we are. So yes, continue to fight the good fight, but be mindful that there will be people that remain ill-informed or say stupid things.
In honor of National Nurses Week, I invite you to take a look at your surroundings and ask yourself “What can be done to change them?” To better the circumstances of the profession as a whole, start with your unit, office or facility because unless that is changed, the rest of the health care system will not be.
