It was 6:45 AM and I was preparing to receive a report from the night shift when the charge nurse asked me to rotate to 5-West (a neuro unit across the hall). I was a 22-year-old pediatric nurse working on 5-East, a respiratory and endocrine unit with cystic fibrosis and diabetic patients. It was not uncommon for nurses to rotate to unfamiliar units because of staffing shortages, but I didn’t expect it to happen to me – at least not yet. I was a new graduate and had only finished orientation two months earlier.
I had learned about external ventricular drains during nursing school, but I had never taken care of a patient who needed one. That morning, the needs of my young patients compelled me to learn very quickly how to monitor the intricacies of the device. While I distinctly remember feeling unprepared, uncomfortable, and nervous, I don’t recall everything that happened during that shift. I am certain I asked the nurses on the unit for help and was dependent on my pediatric patients’ parents to guide me – they were more comfortable around the device than I was. Everything turned out okay that day, and the next day I was back on 5-East monitoring breathing treatments for my cystic fibrosis patients and educating families on how to monitor blood sugars and deliver insulin – I was back in my comfort zone.
My memory of this experience was in the distant past until the other week when I facilitated a discussion at IHI’s Patient Safety Executive Development
program. Participants completed pre-work prior to attending the course, and one of the activities was to ask three frontline staff members the following questions: “Have you ever been unfamiliar with how to care for a patient assigned to you? If so, what did you do?”
The animated discussion in my group confirmed that this was a common experience and their staff’s reports on how they responded varied drastically, from reviewing guidelines on the hospital extranet to turning to Google for guidance. Some clinicians said they would speak up and ask for their assignment to be changed if they felt uncomfortable. Others replied that the nature of the relationship with the charge nurse or educator determined whether or not they felt comfortable raising a concern. One participant highlighted the importance of the issue when she described a root cause analysis she was currently reviewing that involved a nurse rotated to an unfamiliar unit and a patient in their care dying because of a medical error.
As the discussion evolved, the participants agreed that – whether you are a new graduate or an experienced clinician – the fear of appearing unhelpful or incompetent hinders raising concerns. Doctors in the group described how some units where they placed patients had a culture of following strict procedural guidelines, while other units had nurses who were close colleagues and felt comfortable asking each other for advice. Sometimes, though, even that type of comfort led to unintentionally ingraining unsafe norms on the unit, or “drift.” Ultimately, there were no right or wrong answers to the questions we were discussing – just a lot of candor and feelings of helplessness and sympathy regarding the situations hard-working clinicians are placed in every day.
The Patient Safety Executive Development participants really got me thinking: How do we deal with the reality that care providers face this situation all the time? Here are a few suggestions:
- Patient flow – The obvious answer is to address the problem of patient flow so that care providers are never assigned to unfamiliar units without proper preparation or training. If we address the problem upstream and ensure proper bed management, then care providers won’t be asked to “float” outside their regularly assigned units and patients won’t be placed in inappropriate beds in the first place. The science and complexities of patient flow are described in IHI’s White Paper, Optimizing Patient Flow: Moving Patients Smoothly Through Acute Care Settings
- Develop a culture of safety – In addition to addressing patient flow, we must create a culture of psychological safety where all caregivers, regardless of experience or discipline, feel comfortable speaking up when they have identified an issue that needs to be addressed. We must literally give providers dedicated time in their day to raise concerns, such as during unit huddles. We must also develop systems for educational opportunities that complement traditional in-services with in-time bedside training.
- Technology – Innovations in health care technology useable at the point of care appear promising, including smartphone applications that offer easy access to evidence-based recommendations. While technology will never be the sole solution, we should look for opportunities for caregivers to partner with and guide health care innovators.
Do you have other suggestions? Have you ever been responsible for a patient when you lacked adequate information, preparation, or training to care for them properly? Did you ask others what to do? Did you consult policies and procedures? Aren't there advantages and disadvantages to both responses? What would you want care providers to do?