Sunday, September 13, 2015

"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."

31 comments:

  1. Great piece Paul, and totally agree. Hopefully this "young" physician will gain experience and understand the error of his ways. In other words, perhaps it is just inexperience talking, rather than a firm conviction.

    -NS

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  2. Sadly, over my long career in nursing, I worked with several doctors with this attitude. I never understood how it is helpful in any situation to feel you are superior to another person. I remember taking the time to teach new residents different tips, tricks, or techniques that one can only learn through experience. Some were extremely grateful, others treated me as if it was their due that I take my time to teach them - with no word of thanks after.

    The best residents I ever worked with were graduates of a medical school where they had to shadow a nurse for several shifts at some point in their medical school time.

    As for that resident - I feel sorry for him. It must be a miserable life to be so negative.

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  3. We did our best during the class to help in that regard! BTW, you'll note I was careful not to include the gender of the student....

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  4. Touche! I assumed the student was male, but to be honest, I often had a more difficult time with some female students, particularly in my earlier years (80s), as they felt they had to prove themselves.

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  5. Christine Olson OwensSeptember 13, 2015 10:34 PM

    From Facebook:

    Sadly, Paul, my nurse colleagues and I have fought this attitude for much of our careers. The best residents always understand and value nurses, especially the clinical assessment skills they bring to the table, while those that exhibit the arrogance you describe, likely never will.

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  6. From Facebook:

    Definitely negligent - & unfortunately very common. Some residents are wonderful - they understand that nurses might have more experience & knowledge - & truly partner in the care of their patients. Others, do not. I think part of the problem is a lack of knowledge about the nurses role, education, & training. Collaborative forums (like the Telluride Patient Safety Camp) help bridge those gaps. Thank you for your part in that.

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  7. From Facebook:

    Less than half of a residency is about learning science. The majority of it is learning how to work with people. That doctor will get it, eventually, one way or another.

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  8. I wonder how doctors who work in hospitals are evaluated whether they are hospital employees or independent contractors with practice and admitting privileges. A lot of companies in the rest of the economy use something called the 360 degree review to evaluate employees which means that subordinates get to weigh in about their bosses regarding how well they do their jobs, including communication skills and how they treat and work with their subordinates. There could be a similar mechanism for nurses to provide feedback to hospital management about the doctors they work with.

    Of course, if there is persistent behavior of the type described in this post, there needs to be corrective action or adverse consequences for the arrogant doctor up to and including dismissal or removal of practice and admitting privileges. Maybe then they will start to get the message that this sort of behavior is unacceptable.

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  9. From Facebook:

    That resident is way off base. I learned quickly as a resident that nurses have an excellent "spidey sense" about when a patient is in trouble, and you if you ignore it, it's at your, and the patient's, peril

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  10. From Facebook:

    I don't trust doctors who don't trust nurses.

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  11. From Facebook:

    Unfortunately I have seen this over the years too often.

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  12. Paul DeChant, MD/MBA @PaulDeChantMDSeptember 14, 2015 8:54 AM

    From Twitter:

    Thanks, Paul, for a great post showing importance of #lean principle of #respectforpeople in #patientsafety

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  13. Nurses soon realize which doctors do not listen and stop giving them information.

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  14. The best residents who rotated through my ICU were the ones who listened to the nursing staff. Two of them are now @ the very prestigious MGH EPS lab.

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  15. As a onetime OB doc, I learned very quickly to trust my nurses. They were my eyes, ears and hands with the patients. My motto was the only call I will be unhappy with is the one I don’t get. They saved my butt much more often than I would like to admit. That resident best grow up, or find a place where he is a lone wolf. Hard to do today and a lousy way to live.

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  16. The funny thing is, I don't trust residents.

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  17. Paul - good post, thanks for sharing. Anyone who doesn't trust another human being on the care team, regardless of role, education or title, needs to be afforded an opportunity to take their talents (or severe lack thereof) elsewhere...

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  18. From Facebook:

    I hope this resident learns, and SOON, how arrogant, bigoted, and irresponsible this attitude is. "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." There are good nurses and not good, good doctors and not good, and this resident is well on his or her way to becoming a bad, bad doctor. THANK YOU to all the amazing nurses I've worked with at Brigham & Women's, Leominster, Norwood Hospitals.

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  19. From Facebook:

    This is an extremely uninformed, and probably quite arrogant MD. The worst ones I've worked with had this attitude, and usually think of us as servants, rather than what we are: their eyes/ears at the bedside and in worst case scenario, a last line of defense against THEIR or pharmacy) mistakes. I've caught more than my fair share. When they make a mistake, it's that they're busy; when we do, it's our whole intellect called into question--it's getting better, but some hospitals are worse than others.

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  20. From Facebook:

    Arrogant doctors are the bane of good nurses everywhere. I don't trust a doctor who doesn't trust nurses.

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  21. From Facebook:

    Funny, I don't trust anything a SECOND year resident says... He's only 2 months out of the year where he probably killed 50% of his patients. (Eye roll).

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  22. From Facebook:

    Not just because my wife's a nurse but more than anything what gets me to a patient's bedside right away is when the nurse says he or she is worried.

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  23. Where were those observant, intuitive nurses in the Lewis Blackman case?

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    Replies
    1. Perhaps they were beat down by attitudes such as that of the resident mentioned in the original post, in addition to that of your reply.

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  24. The Blackman case displayed a massive failure of communication and numerous other problems on the part of all the caregivers involved, those in the room and those who should have been in the room.

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  25. In spite of a very devastating emergency dept. (negligence) experience that lead to the loss of a family member,
    I know and choose to believe that we can trust, rely and depend on our experienced, knowledgable and loving nurses. "Minus a few"
    What I find bothersome and concerning is a resident that can't, and question if other residents feel the same?
    I personally know nurses who do not necessarily trust the very doctors they assist or work around either, guess it works both ways !

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  26. The attitude displayed by the resident has been considered unacceptable pretty much every place I have been in the last 20 years. I'm a bit surprised that it still occurs often enough to warrant this posting. In keeping with what I have gotten from the authors other posts I would assume that he finds the fault to be with the medical school or hospital leadership. Interesting that so many commenters have called for punishment or dismissal of this physician. Indeed I have worked at one very well known institution where the physicians would never criticize a nurse for anything due to their well founded fear of being labeled "disruptive" with sure and swift retaliation. That place could only dream of actually being as good as its PR.

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  27. Perhaps. But I think this post has touched on but mostly missed addressing a very basic issue. When I was a resident at a well known teaching hospital we had people (staff, nurses, techs, admins, etc) who were drug addicts, bribe takers, incompetants, lazys, as well as wonderful awesome employees. One of the fundamental failures of our residencies is that we were tought nothing about how to address team members whose performance was a complete failure without being accused of bias or disruptiveness and potentially being punished for it. As a consequence my classmates instead were trained in "Learned helplessness". Do your job and all is "Ok". Exposé a problem and expect to be cut down by people who don't like being exposed. It's a real problem.

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  28. Thank you Richard for being completely honest, your valid points are understood and agreed with plus greatly appreciated. I sincerely believe if honesty was encouraged and rewarded in the medical field rather than frowned upon or punished for, the majority of the problems we have wouldn't exist.
    when you succeed your professionals, which I for one respect and admire!!!
    When you fail yourself, each other, and others your " just human beings". That excuse I do not respect or admire, and that's me being completely honest.

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  29. Excellent! I thankfully work in a teaching facility where my attending physicians have the utmost respect and friendship with the nurses, and that attitude really trickles down to the residents. I work in the ICU so I ordinarily deal with second-years and up, but even then they tell me that they're always informing their first years and interns that befriending the nurses is top priority. It takes everyone to keep the machine moving, and it's a much nicer workplace when there's a high level of mutual respect. Plus, we feed them . . .

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