Nurses Often Silent About Physician Mistakes

March 25, 2011

March 25, 2011 — Medical software can alert a nurse to a harmful drug interaction, but such a high-tech tool goes to waste if the nurse feels unsafe telling a physician or cannot make anyone listen.

Almost 60% of nurses report they have experienced this kind of scenario, and 17% say it happens several times a month, according to a new study by the American Association of Critical Care Nurses (AACCN), the Association of periOperative Registered Nurses (AORN), and a training company called VitalSmarts. The study, aptly titled "The Silent Treatment," describes a hospital universe where more than 80% of nurses observe physicians and other clinicians taking shortcuts, such as not washing their hands long enough, exhibiting incompetence, and demonstrating disrespect that shuts down lines of communication.

At the same time, the study highlights ways in which nurses can bring up and resolve such knotty issues — dubbed "undiscussables" — with the help of physicians who create a climate of openness.

Corrections Don't Have to Sound Accusatory

Several experts on patient safety interviewed by Medscape Medical News agree that the study identifies a communications problem in healthcare, but they caution against boiling it down to a tagline of bad doctor/good nurse. James Conway, a senior fellow at the Institute for Healthcare Improvement (IHI), said silent nurses have more to do with the wider issue of organizational culture.

"In some cultures, honesty and transparency is rewarded — in others, it’s not," said Conway, a former chief operating officer at the Dana-Farber Cancer Institute in Boston. "It’s determined by what is important to the boss."

Amy Halverson, MD, director of the Nora Institute for Surgical Patient Safety of the American College of Surgeons and a colorectal surgeon in Chicago, stresses the importance of nurses airing their minds. The reluctance of nurses to point out clinical errors, said Dr. Halverson, does not necessarily mean physicians are not receptive to correction.

"If you'd ask more doctors, they'd say they would like nurses to speak up," she said. "We all come to work wanting to do a good job. If I've made a mistake, I'd rather have someone speak up in the moment as opposed to having the consequences of the mistake."

One key for success, Dr. Halverson said, is "escalating the importance of the situation without escalating emotions." That can be done coolly and calmly with the traditional SBAR formula: describe the situation, supply the background, and then give an assessment and recommendation.

"It doesn’t have to sound accusatory," said Dr. Halverson.

Many physicians appreciate nurses who go beyond ringing an alarm bell about a clinical problem and offer up a solution as well, she said. This kind of empowered nursing should occur on an everyday basis, not just during crises, and it stands to become more valuable as restrictions on resident hours at teaching hospitals shifts more responsibility from physicians-in-training to nurses.

The notion of physicians listening to nurses is not exactly a revolutionary concept. "I was told this when I was a resident, and I passed it on to medical students," said Jim Fasules, MD, senior vice president of advocacy at the American College of Cardiology (ACC). "If a nurse came up to you and had a concern, and you didn't listen to her, you were nuts."

Dr. Fasules said the physician-nurse partnership is a given in his specialty, so much so that the ACC includes roughly 3300 nurses as members. "They’re part of our team," he said. "We can’t function without them."

"The Vast Majority of Clinicians Want to Do the Right Thing"

The study by AORN, AACCN, and VitalSmarts cites several anecdotes in which physicians blow off patient-safety protocols, such as donning a full sterile barrier during arterial line placement. To the IHI's James Conway, such behavior suggests more than physicians running amok. Rather, it suggests that hospitals have crashed up against a truism in organizational science: most efforts to institute major change do not succeed.

One reason why is the failure to engage those closest to the desired change in the nitty-gritty details and secure their buy-in, said Conway.

"The vast majority of clinicians want to do the right thing," he said. "They don’t want their patients to get an infection or stay in the hospital longer. But does the hospital give them time to wash their hands or put the soap dispenser in easy reach?"

Another failure factor is leadership that pays only lip service to new rules and procedures. In the hospital world, said Conway, that means rank-and-file physicians are not rewarded for following patient-safety protocols or held accountable if they do not.

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