Patient Safety, Perception of Risk and Healing Presence
[Originally posted at the PPG blog on August 9. 2016 by Dr. KL Lagana]
You cannot open a medical or nursing journal, go to a staff meeting, or attend a professional conference without hearing about patient safety and the many strategies designed to improve outcomes and decrease liability. Patient safety and associated legal risks will be among the threads discussed during PPG’s Spring 2017 Conference (Save the Date - April 21, 2017), as we look at the impact of perinatal healthcare changes over the past decade.
Patient safety and the “Culture of Safety” have driven organizational focus since the Institute of Medicine (IOM) released the groundbreaking report: To Err is Human in (1999). Why? Because the report brought a shocking realization that we were perhaps seeing just the tip of the iceberg of preventable patient injury and death while in modern complex healthcare delivery systems. The World Health Organization and other national healthcare systems around the world were identifying similar errors. To Err is Human took great care to explain that flaws in the system of healthcare were to blame for many of the poor outcomes. Intensive effort has been expended by patient safety experts (Leappe, 2015). Still, it was just last month that the professional literature was full of critiques of a report in the British Medical Journal (BMJ). The study arguably found medical error to be the third most frequent cause of death in US hospitals (Makary & Daniel, 2016) and we are reminded that there is much work to be done in healthcare delivery.
Attention to risk reduction and promotion of optimal outcomes is very important. We support evidence-based practice because it gives power to changing practices that are not in the best interest of the patient, like excessive oxytocin use. But, ask yourself what motivates you as a perinatal care provider? What led to your entry into practice? Was it patient safety? There are of course many reasons, but a common denominator appears to be the desire to help people. There is usually a measurable degree of this, and to birth babies, and teach new parents to care for their babies, and importantly to decrease suffering. But few of us get up in to morning and say, “Today I am going to keep my patients free from harm.” However, if we manage to not harm our patients – are we fulfilling our duty to them? I would argue that patient safety is merely the bear-bones bottom line of clinical practice - a stripped down version of what healing is all about. Revisit the Hippocratic Oath (“first, do no harm”), the Nightingale Pledge (I will do all in my power to maintain and elevate the standard of my profession”), or the ANA Code of Ethics and you will find a multitude of duties for which we are responsible. It is a lot to do, truncating time for important provider-patient relationships, and sabotaging a sense of satisfaction with our chosen profession. Let me explain….
In facing the risk of medical error, we begin to lose confidence in our ability to independently protect the patient from falling through one of the many cracks in a complex healthcare delivery system. Anxiety – when trying to stay on top of patient’s needs on a busy day, or when working with an exhausted team, or the challenges of managing mothers with co-morbidities, or just getting charting done – anxiety is understandable. There is a growing body of knowledge that recognizes hypervigilance and anxiety as a symptom of trauma. According to Wikipedia (2016):
“Hypervigilance is an enhanced state of sensory sensitivity accompanied by an exaggerated intensity of behaviors whose purpose is to detect threats. Hypervigilance is also accompanied by a state of increased anxiety, which can cause exhaustion…. In hypervigilance, there is a perpetual scanning of the environment to search for sights, sounds, people, behaviors, smells, or anything else that is reminiscent of threat or trauma.”
Does any of this sound familiar?
I recently received an email from an old colleague who I had not heard from in a long time. She told me that she had not worked for several years and was being treated for PTSD. Apparently, somewhere in her 40-year career in nursing between Vietnam and working with an especially difficult team member, anxiety got the best of her and she had to take a break. Now, I am not suggesting that perinatal providers are all suffering from PTSD. But many of us do feel anxiety when we cannot be in two places at one time, like when technology is increasing risk to our patients and we must closely monitor it, instead of interacting meaningfully with the patient. We feel anxiety when our ability to sit down and really know the patient is replaced by the demands to be doing something else. Carper (1978) wrote about ‘the therapeutic use of self, which has been defined as the ability of a caregiver to use his or her personality "consciously and in full awareness in an attempt to establish relatedness and to structure nursing interventions" (NursingPlanet.com). Constant “scanning of the environment” as noted above for threat to patient safety, if not hypervigilance, certainly distracts the provider from connecting at that level with the patient. If over time we do not have signs and symptoms of PTSD, we certainly know exhaustion and perhaps waning job satisfaction.
Eric Cassell MD, in his 1991 classic, The Nature of Suffering and the Goals of Medicine stressed the importance of knowing the person, as well as the science of that patient’s disease or condition. The more a physician (or healthcare provider) knows his or her patient as a person, the greater the effectiveness of the relationship. This he stated is the basis of the doctor-patient relationship, in effect a collective collaborative relationship necessary for healing to occur. He cautions against patient stereotyping as this makes that patient two-dimensional and fails to recognize the evolving continuum of that patient’s experience.
So what is the solution to this modern day situation? There are strategies. A potentially under-appreciated strategy in healthcare systems for promotion of patient safety is to promote provider-patient relationships as primary, much the way we honor the chaplain-patient visit. One very low-tech strategy is to sit down for five minutes and meet the patient, the family, and the significant others. To maximize the therapeutic use of self, the healthcare provider must be quick to relate and prioritize the primary relationship of provider and patient, while providing care that also focuses on protection from harm. I believe that entering into a therapeutic relationship with the patient who may be for at least the time being, frustrated, angry, frightened, painful, or suffering is engaging and very challenging. But, seeing the stabilizing effect of therapeutic use of self is the reward of being a healthcare provider. Assisting with the passage of a new life into the world is of course the ultimate reward…. And as is human nature, we are more protective of those with whom we have relationships.
Meaningful healing relationships heal providers as well. Healthcare providers, while carrying a mega-dose of altruism, also need to be fed with the belief and understanding that we do good work – that we are in fact good people. It is a two-way interaction greater than the sum of its parts. We can then get up in the morning and say, “Today I am going to connect with the person who is my patient, even if just for the moment. And if necessary, I will protect her and baby too”. Our work has never been more important.
References
Carper, B (1978). The fundamental patterns of knowing in nursing. Advances in Nursing Science, 1. 1, 113-117.
Cassell, E. (1991). The Nature of Suffering and the Goals of Medicine. New York, NY: Oxford University Press.
Institute of Medicine (1999). To Error is Human: Building a Safer Health System. Washington, DC: National Academy Press.
Leappe, L. (2015). Patient safety in an era of healthcare reform. Symposium: Patient Safety: Collaboration, Communication, and Physician Leadership, 473:5, 1568-1573.
Makary, M & Daniel, M (2016). Medical error—the third leading cause of death in the US. BMJ, 353, i2139.
Wikipedia (2016). Hypervigilance. Downloaded from https://en.wikipedia.org/wiki/Hypervigilance on July 29, 2016.