Several years ago I was remodeling my home. I was removing old plaster from the ceiling at the top of the steps that connected the first and second floor. I had positioned the stepladder so that the ladder rungs were directly in front of the top step of the stairwell. After knocking down a section of ceiling plaster, I started backing down the ladder so I could reposition it. My right foot slipped off the bottom rung of the ladder.
I remember trying to grab the stairway handrail as I started to fall. I missed. I remember laying on the floor at the bottom of the stairs trying to assess how much damage I had done to myself. Everything seemed to be intact except for the sharp pain in my right shoulder whenever I tried to move my arm. The pain and limited arm mobility convinced me that I needed to seek medical help.
I was alone when I fell. I lived in a small rural community and decided that I could drive myself to the nearest medical care 15 miles away instead of calling 911. My rationalization for that decision was that I could be more than halfway to town by the time our small volunteer ambulance service could mobilize and arrive at my house. Never mind that I would be driving a manual transmission pickup truck with an injured right shoulder that I could barely move without severe pain. I also decided that I would not go to the ED at the hospital where I worked.
I knew that I would receive excellent clinical care at the ED where I worked. I also knew that I would have to expect some good natured teasing from co-workers long after the ED visit was over. I was okay with that. The motivation for seeking medical care from a different provider was based on my concern that I would be scolded or reprimanded for the careless behavior that led to my injury if certain ED nurses would be assigned to my care. I was already painfully aware that I had made a mistake. I didn't want to be verbally punished for it.
Blaming the Victim?
The ability to make a mistake, an error, is a universal characteristic of all people. Yet, healthcare professionals working in the ED can be some of the quickest to assess blame and shame on patients who present themselves with injuries or conditions precipitated by simple human error events. Like my fall, for example.
Some of the phrases I wanted to avoid hearing as a patient were phrases I had heard colleagues use with patients during a work shift. Phrases like: "You did what? Really!" Or: "What were you thinking? Well, obviously not much." Or this one: "If you had been more careful, you wouldn't be here right now taking up space needed for really sick people."
Part of this attitude can be attributed to the stress and strain every emergency nurse feels when faced with a waiting room stuffed full of patients with non-emergent complaints. Blaming the overcrowded conditions on the patients, however, is delivering mail to the wrong inbox. A root cause of ED overcrowding is a fractured healthcare delivery system that funnels patients to the ED for primary care and the accompanying failure of healthcare leaders to reasonably and safely address the situation. Patients aren't the enemy here.
An empathetic response to a human error incident provides the foundation for a healing conversation instead of a blame-based conversation. Being empathetic does not mean the nurse agrees with the circumstances of what happened to the patient. We can't control the messages that come at us but we have total control of how we respond. An empathetic response acknowledges that a human error occurred without attaching a right/wrong or good/bad value judgment to the event. As such, empathy is a learned behavior that requires commitment, practice and repetition to be of value when communicating with patients. An empathetic response to a patient situation is a sign of professional integrity and emotional maturity. Use it often.
The nursing director of the ED where I worked asked me why I didn't come to our ED for evaluation of my injury. I told her the reasons behind my decision. She thought all staff members were being professional, empathetic and positive when communicating with patients. My comments disappointed her. At the same time, she was empathetic to my concerns. I appreciated that because it was a difficult conversation to have with her.
There are patients who participate in risky behavior. Risky behavior is basically a safety issue. People engage in risky behavior for one of two reasons: the person knows the risk associated with a certain behavior and chooses to engage in the behavior anyway or the person does not perceive the risk of a behavior before engaging in it. All of us participate in risky behavior at times. Do you check, read, or respond to text messages while you drive? Do you always obey the posted speed limit? Enough said.
Many patients who have something happen to them that should not have happened due participating in risky behavior will modify their behavior in response to supportive coaching, age appropriate education and positive reinforcement provided by the emergency nurse. Give these patients the benefit of the doubt. They are usually smarter than you think they are.
The nurse who cared for me during the evaluation of my shoulder injury never criticized me for injuring myself by creating a safety risk with the stepladder at the top of the stairs. As she was reviewing my discharge instructions with me, she asked me if I had thought about how I was going to create a safer working environment for myself so that I didn't tear up any other body parts while tearing down the rest of the plaster ceiling. She grinned at me. I responded in kind. I knew I wasn't going to make that ladder location mistake again. So did she.
Choose Your Words Wisely
There are different groups of patients who participate in repetitive risky behavior that bring them back to the ED on a regular basis: the diabetic who refuses to follow care instructions that help maintain safe blood sugar levels or the addict who travels from ED to ED searching for prescription narcotics to support a drug habit. The patient every nurse wants some other nurse to care for during the ED visit.
It is easy to slip into a judgmental, even confrontational, relationship with patients whose behavior causes harm to themselves and creates care situations that should not be happening. I know these patients well. Having said that, what value is added to the clinical care relationship between nurse and patient by the nurse being critical, judgmental or spiteful? Isn't that type of nursing behavior creating a situation where something is happening to a patient that should not be happening? The answer is yes.
The distance between healing words and harmful words is as thin as the edge of a razor. Human mistakes and risky behaviors are not going away anytime soon, so lean toward the side of healing. Learn and use empathetic communication techniques. Practice choosing words that help heal instead of harm. Practice being a more patient nurse today than you were yesterday. Choose to set aside personal biases and ingrained prejudices when interacting with patients so that you have the opportunity to learn something new. Realize that not every patient is going to value or appreciate the care you are trying to provide to them. Most importantly, take comfort in the knowledge that you are making a positive difference in someone's life every shift you work, whether you know it or not. At some point during that shift, a patient listened to you, trusted you and decided to change behaviors to reduce the chances of something happening to them that should not happen. And in the end, that is why we do what we do. So be good at it.
Richard Watts is principle manager, senior ED consultant for Alpha Consulting Group. He has over 20 years of experience in Emergency and Trauma Services.