There's a Hole in the Sky

Nursing education dedicates a great deal of time to scaring nurses to death.   There are two ways that this is accomplished.  The first is to show innumerable films, provide massive amounts of literature and invite endless speakers to discuss the endemic problem of medical error.  The Josie King story was presented to my graduate cohort twice and it was presented once again when I began my current job. Rightfully so.  Medical errors kill 44 thousand people every year in the U.S. alone. Consider, by comparison, that 347 people died last year from drowning, 10,000 in drunk driving accidents, and 23,000 from drug overdose.  Add those up and it still doesn't number those lives lost to preventable medical error.  

The second scare tactic in nursing education is to "prepare" student nurses for inevitable hazing by doctors and senior nurses in the workplace.   This horizontal and lateral violence is described very matter-of-factly, as a sort of ritual for becoming a good and seasoned nurse, as if we were about to rush a fraternity, but without any choice in the matter - or a sweatshirt to wear after its all over. Perhaps that is because it isn't ever over.  

After having experienced this abuse first hand, and having witnessed a fair number of medical errors in my seven short years as a nurse, how is it, I wonder, that these two issues have never been discussed in tandem, as directly correlated, one to the other?   

This all came to me just last week when I was working with a particularly difficult provider.  She not only undermined my skill as a nurse, but resorted to nuanced, but embarrassing, condescending and personal attacks.  This was in the room of a patient and her family.  Because it went on for the good part of an hour during a particularly long procedure, I had the time to reflect on how I would deal with the situation out of the company of the patient, in a forward but politic manner.  My decision, in the end, was not to address it at all.  This is what we are taught:  ignore this unnecessary and inappropriate exercise of power, or lash out to "gain respect" from those providers who are notoriously abusive.  The latter is a widely accepted social mechanism within the culture of medicine that is, to my eye, sophomoric.  It would be ludicrous in any profession to retaliate, but particularly shameful in medicine where peoples' lives are at stake and promoting anything but cooperation among caregivers is an utter absurdity.  

During my own recent incident, I became acutely aware of the effect that the shaming - or to call it out as what it truly is, the bullying - was having on my physical and emotional state and my critical mental processes. I pride myself in being pretty cool, calm and collected in medical emergencies and being a critical thinker under virtually all circumstances.  Both of those assets seemed to totally dissipate with each abusive remark and, instead of  thinking about the work at hand, I became aware of a number of physical and mental changes: 

• I felt hot and sweaty.  I felt flushed. My skin was prickly and my heart was beating hard and fast. That is to say, I was aware of my heartbeat and breathing which any healthcare provider will tell you is not normal. 
• I was having trouble making decisions and responding to requests, directions and questions from other people in the room.   I didn't feel that I was "tracking" well and found it difficult to make decisions and to move as quickly as I typically do while performing tasks that require full concentration: administering medications, changing IVs, attending to the patient, using the EMR, setting up instruments, lights, taking/transcribing verbal orders, etc. for the provider, supporting my patient and her family.  I was basically finding it impossible to multi-task because I was so focused on not responding to the bullying.  The single task to which I was attuned was my dynamic with the provider.  

This is essentially the worst position to find yourself in as a nurse, because you are running an extraordinarily high risk of making a mistake.  Had I not been in my then-current-but-atypical self-possessed state-of-mind, I would have reacted and responded without much self reflection, almost immediately, which is a terrible approach.  It is the absolute wrong thing to do because the patient then has two providers operating in the same reactionary way toward one another and their actions and thought processes are totally unrelated to patient care. 

According to an American Nurses Association study, 56.9% of nurses report having been threatened or experienced verbal abuse at work.  48% report "strong verbal abuse" on a regular basis. Physiologically, the reaction to stress is embodied in such a way as to make goal-directed decision making impossible. Studies have shown that plasma levels of glucocorticoids and catecholamines increase, causing "increased cardiac output, skeletal muscle blood flow, sodium retention, reduced intestinal motility, cutaneous vasoconstriction, broncho-dilation and behavioral activation" while insulin drops, leading to stress related hypogylcemia, which essentially explains all of the physiological symptoms I had in the interaction with my provider.  Furthermore, when this happens there is an imbalance in hormone levels that can also produce functional neurological changes causing us to resort to habitual coping mechanisms rather than higher level decision-making strategies.  If I were a patient or family member, I would never want a nurse or doctor with inhibited decision-making processes providing care. 

The last thing healthcare providers need in our already chronically stressful work environment is a social and communicative structure that normalizes institutionalized abuse leading to even more stress. The question is how to go about breaking the cycle of power and the incessant bullying that goes on in these work environments.

For once, I think I have nothing to say on this matter: no solutions, no recommendations, no ideas. And the reason being is that the bad interactions that I have had in the last few weeks have been so demeaning and demoralizing that all I can do is replay them.  This does not mediate the unhealthy dynamic nor diminish the power of the shame.  In order to dedicate oneself to the mindful intention of living a good, meaningful and quiet life - and being an effective healthcare provider -  it seems impossible to carry these incidents long enough to come up with a logical solution.

Basically, in penning this post, I have demonstrated that this kind of abuse immobilizes us all - even those, like myself, who virtually always have something to say.  It paralyzes those trying to do right by others as much of the time as possible, those seeking peace in their everyday lives, and those who we inherently expect to protect and preserve the lives of others.  

How can that be? How can we let it be?