"I don't trust nurses."

At a recent training program in quality and safety improvement, one focusing on the topic of communication in clinical settings, a second year resident said firmly, "I don't trust nurses. I don't pay attention to what they say."

Now, this might be a case of extrapolation from something that residents are often told, "Don't trust anybody." In that context, "trust" is not used the way commonly understood. No, in that case, it means, "Do your own analysis of the patient's condition and don't assume that what you heard from someone else is still correct." That's fine.

But that wasn't the context of this young doctor's remark. Here, rather, was an affirmative statement about the value of nurses and about their judgment.

We could consider this an isolated case of an arrogant person and let it go at that, but I fear what we saw here is a more commonly occurring disrespect for those "underneath us" in many clinical settings, manufacturing industries, and service organizations.

Here's a story about a young, wise doctor named Michael Howell, excerpted from my book Goal Play!

Michael had some intuition about how to solve the problem of decompensating patients based on his literature review of articles from Australia. Early in 2005, he led a six-week pilot program on two medical wards and one surgical ward to test out his version of rapid response teams. Under this program, if a nurse notices that a patient has developed a certain condition, based on a standardized set of criteria (“triggers”), the nurse is required to call the doctor, the senior nurse in charge, and the respiratory therapist—and they all come to see the patient. They collaborate on a plan of care for the patient going forward. Regardless of the time of day or night, the intern/resident then calls the attending doctor in charge of the patient to let him/her know that the patient has “triggered."

Under Michael’s plan, the standard set of triggers is based on changes in heart rate, blood pressure, oxygen saturation, urine output, an acute change in the patient’s conscious state, or a marked nursing concern. The last one, “marked nursing concern,” means that if the nurse has any concern whatsoever about the patient, based on observation or instinct, s/he is authorized to call a trigger.

Well, it turned out that Howell’s program was incredibly effective. 

Over the course of the first year, the hospital observed significant reductions in “code blue” cardiac arrest events and a significant reduction (a 47% decrease) in relative risk of non-ICU death for our patients. Residents now needed to practice emergency resuscitation mainly in the simulation center because so few actual patients needed it. What a lovely problem to have. We also learned a lot about teamwork, communication, and systems of care as a result of closely reviewing our responses to called triggers.

Here's something else we learned over time. There were many objections at the start of this program from attending physicians and residents that certain "lazy" or "inexperienced" or "uninformed" nurses would use the RRT "marked nursing concern" trigger as an excuse to pass the buck on certain patients.

Well, we learned instead that triggers based on "marked nursing concern" (amounting over several years to 38% in total and 18% in the absence of other vital sign criteria) were as or more likely than the other categories to accurately reflect the fact that a patient was in trouble. Putting it another way, if we had not recognized the unique ability of nurses to be especially attentive to patients' conditions, a number of people at our hospital would have decompensated, perhaps leading to their death. (The 18% figure amounts to over a thousand patients during the five-year study period.)

When you think about it, then, the attitude reflected in the resident's statement--"I don't trust nurses. I don't pay attention to what they say."--is not just arrogant. It is negligent. Research of malpractice claims shows that a failure in communication is often a contributing cause to the error leading to a lawsuit.

As Kathleen Bartholomew notes: "When nurses and physician don't communicate, it's the patient who loses every time." A person who has decided that he or she will habitually ignore the information provided by another member of the team invites error and harm.

I surely never want to be cared for by this young doctor!  Who is more likely to have an accurate sense of the patient's condition than the nurse? After all, nurses are at the patient's bedside for much of the day, while doctors drop by from time to time. Attentiveness to a patient's needs cannot be measured by whether an "MD" follows a clinician's name instead of an "RN."