Looking back at our first day, I’m again overwhelmed with emotion thinking about the Lewis Blackman story. In the video we are able to see each and every breakdown in the system that eventually led to this tragedy. My heart breaks for the family. My heart breaks for the nurses and the doctors and all the members of the healthcare team, who I am sure felt ultimately responsible. Yet it is the system that is at fault, not any single action or single person. A system that should be there to serve and protect the most vulnerable, our sick patients, has actually been the what has fostered one of the biggest obstacles to providing safe, quality care: a lack of communication.
As a nurse, I can imagine how that night shift nurse felt when she was concerned about Lewis and attempted to call for help. She was likely considered an “outsider,” being an agency nurse, and probably did not know the physicians she was working with. In my experience, if a physician did not know me well, they were less likely to really listen to my concerns or value my opinion. The nurse, like every nurse I know, has probably had previous negative encounters communicating with some physicians that has left its mark, deterring her from being more assertive, and serving as a barrier to future effective communication.
Nurses need to feel empowered to speak up when something isn’t right and feel that their opinion and concern over their patients is valued. This educational experience this week is one valuable step in beginning to improve the communication barriers we as healthcare providers face. Until we can truly work as a team, with open, honest, and effective communication, we will continue to hear tragic stories, like Lewis Blackman’s. Patient safety and high-quality care will come when the system transforms to prioritize those and fosters an environment that supports the healthcare team in providing the care they have been educated and trained to give.