What happened:
- A routine operation – a patient story
- Prioritisation
- Graded assertiveness – breaking the hierarchy
- Communication methods, techniques
- Projects (cqi quality improvement projects)
- Tools
- Situational awareness
So what?
1. I will not retell the patient story, as it will not do justice to the event. You need to hear it for yourself. I will tell you this. The patient story of a routine operation alarms and horrifies me. It outlines a breakdown of basic communication yet highlights the impact of a hierarchical regime. The nurses did not question or were assertive however were able to in an instant identify the core of the issues at present. The failure: to intubate and ventilate resulting in catastrophic patient death. The nurses were able to identify a crisis yet felt restrained or were not assertive enough to to act. Despite regulations and procedures in place for this type of catastrophic event, they were not followed and the patient died. If communication methods (discussed later) were utilised, the outcome may have been different. “If the policy is not active and living it is not useful.”
2. Prioritisation is so important that the processes of training are to be called back upon in a time of crisis. There was an identified issue with the airway, fix this and then continue to assess. There was a failure to do this for the patient. The nurses were able to identify that the tracheostomy kit was required and delivered to the room however, and this relates to communication, the anaesthetist may not have been made aware of this in an assertive or graded manner. Although prioritisation and delegation are essential skills in healthcare in times of crisis we sometimes need to take a step back, breathe, and look at the whole picture. Our priority is the decreasing oxygen saturation, to fix this they have failed to utilise a LMA and failed to intubate, however they failed to utilise an appropriate airway for this complex case. I remember a discussion with an anaesthetist post an difficult airway when I was a student in theatres observing the clinicians and it ended up being a nurse with advanced airway training to intubate with the utilisation of a scope. They were focused on the airway however they never lost sight of the patient as a whole. On discussion I identified that although there was difficulty intubating they were able to ventilate this patient. This was such a simple concept however this anaesthetist stressed the difficulty with explaining this to his medical students. They would always focus on the inability to intubate and forget that ventilation is the more important of the two. If you cannot ventilate the patient is dead.
3. Graded assertiveness
The concept of this is still difficult to grasp. However this may be due to my nature to consider myself an advocate for the patient and will often follow different segments of this scale. This concept to break down the hierarchical structure is an essential topic which needs to come to the forefront in health. Probing questions to determine and establish a baseline is an excellent starting point with graded escalation. I was taught another method which consisted of saying I disagree. I disagree with …. And then walk away if unable to confront. Graded to in disagree with you because…. And engage in conversation. To I disagree and this is why… The assertiveness of the language was thought to break down different “stirrers of the discontent”.
However the application of PACE would be far more relevant we already have that acronym in our system as pre-arrest criteria for escalation. It is unwise to utilise the same acronym for multiple meanings in the same healthcare industry as this would generate confusion. I’m calling a pace call…. Are you becoming more assertive with me or is there patient deterioration? I intend to use this system however I will utilise it with caution as graded assertiveness most definitely has a place in my healthcare delivery and the arena of patient safety. There is a long way to go to have this type of communication as a standard in healthcare however it should be taught as an undergraduate level to train our staff of the future. “It is our profound professional duty to act if you recognise a patient in danger”.
4. Communication
As touched on before and building on yesterday’s discussion, communication and utilisation of appropriate communication is vital for patient safety. The repeat back, read back, teach back, methods of communication provide us with direction to not only identify that communication has occurred but that communication was effective. With a low percentage of the verbal message actually heard and understood it is vital that we as clinicans and as advocates do this right. It is our moral and professional duty. Keep the communication short, brief and to the point. Don’t sugar coat it. If there is a larger or underlying message to be delivered utilise some of the other techniques being utilised extensively here, listen to the patient and the story. Communication is our only method of delivering information so use it well.
5. Quality projects.
How is change generated? Through structured identification, stakeholder engagement, intervention, and evaluation. These projects, however, need to be structured to be sustainable and follow SMART principles. Cyclic approaches often miss both the smart principles and sustainability. Although there are many barriers, there are actually many opportunities. But it cannot be forgotten that these projects require structure, leadership and direction. What are the aims, what are the goals, were they achieved?
6. Tools.
There are many models and tools to aid in basically every aspect of human interaction.
PACE. Squire guidelines, communication styles, methods and processes. Tools to guide writing and development of statements .
- To increase/decrease….
- By…. ( method/process)
- In…(target)
- By… Timeframe.
Don’t forget smart and the cycle processes in policy development and change management.
Learn and utilise. If you can think of a process, someone has a tool to Aid you. Ask for help.
7. Situational awareness.
This is the most important lesson I have learnt today. Although I could pride myself on good situational awareness it is vital to act upon the identification. In reflection I already do this in practice. This is evidenced by observing and assessing a junior nurse give PO medications. She took the medications to the bedside and was giving the medications to the patient. She had half a cup of water and had started taking her tablets. I had walked out without a word and returned with a jug of water. On discussion with the patient she realised she needed more water and there I was with a jug in hand to refill her glass. I had acted without conscious thought but had fulfilled a recognised need before the patient and the junior nurse had realised there was a need for more water. This is only minor but it resonates in my memory as the point where I could identify as an expert on Benners novice to expert theory. I had subconsciously identified and acted without having conscious thought, it was practice. On further reflection I do this frequently. A patient is deteriorating and we are waiting for a doctor to review, and I have deemed it safe for me to leave the bedside. however I have identified the need and called for an X-ray, had an abg syringe and needle on hand, an ecg and a printout of the latest blood results. If the patient is febrile I will have the culture bottles and relevant blood sampling equipment ready for the dr to collect. The message is, don’t just identify an issue, do something, within your scope to safely and competently resolve the issue.
What now?
I will continue to practice in an excellent manner however I am becoming far more aware of my failings and lackings. This is important as I am becoming more aware of who I am. I am progressing to what some may consider as the peak of the nursing profession in regards to clinical practice however I still don’t know who I really am and what or where I can achieve. Is this where I am meant to be? Is this what I am meant to do? What impact will I have and what can I achieve? I will continue to strive for excellence in patient safety and I will utilise whatever means on hand to achieve our primary goal. A safe and highly satisfactory patient journey. We cannot perform without our patients and they should be central to what we do. This I feel we as a cohort of professions fail to achieve. I am a professional. I am an expert. These excuses create barriers which have become ingrained in our culture. I hope that as evidenced by this conference with the Australians bucking the trend we can continue to do so and continue to strive towards excellence and truly take place as advocates and global leaders in healthcare.