Compassion, empathy and sympathy are all vital when dealing with complaints from patients. Dr Daniel Cohen, international medical director for patient safety and risk management software specialist Datix, outlines how the rules of a Just Culture can help.
Over the past decade the concept of a ‘Just Culture’ has become firmly entrenched in the vernacular of patient safety. The recognition that human error is multi-factorial, and that everyone will make mistakes, has led to the creation of a paradigm where harmful incidents are thoroughly evaluated. If human errors are acknowledged, then the administrative or disciplinary actions are appropriate to the cause of the human error.
In the complexity of what we call modern healthcare, clinician-patient communication may often fail to satisfy the needs and wants of individuals who deserve understanding and compassion.
I have written extensively about this and readers are referred to my recent compendium, Improving Patient Safety: What does Just Culture have to do with it? posted at www.datixusa.com.
What has been lacking in our application of the Just Culture paradigm is an appreciation that those on the frontlines include both healthcare professionals and patients. In order to achieve safe outcomes and to reduce risk of liability, we must consider patients as crucial components and partners within the healthcare system. They are, after all, the experts in ‘patienthood’.
Failure to comprehend this is a causal factor in preventable readmissions and other harmful incidents, some resulting in disruptive behavior and malpractice claims.
Failure to listen
When patients complain, we need to listen because if we don’t we may fail to learn about weaknesses in our processes of care. When we do not listen, or are perceived as not listening, some patients may elevate their behavior progressively to belligerence and disruption.
We need to be compassionate, to empathize and sympathize, and we need to listen and learn and keep our impatience under control.
Our goal of achieving best clinical outcomes requires that we understand the basis for patients’ complaints and treat the patients accordingly in a Just Culture framework. There are certainly very aggressive patients who are unrealistic and disruptive despite our best efforts to accommodate them, but most patients just want to feel better and get better.
We can do much to understand their concerns and modulate the risk of disruption. We need to take deep breaths and engage compassionately, and importantly we need to understand what matters most to patients.
I was invited to make ward rounds with a colleague on a very busy internal medicine service. Two patients’ stories are worth examining.
Ms A was a 78-year-old woman admitted after a stroke with resultant moderate left hemiparesis. She suffered from hypertension, arteriosclerosis and had experienced several TIAs over many years. She was awaiting discharge and placement in a rehabilitation facility and was told her discharge would be in three days. She was sharing a two-bed room with an 80-year-old woman with dementia, disorientation and a urinary tract infection.
When we were speaking to Ms A, she begged my colleague to transfer or discharge her immediately. Ms A broke down, crying: “I can’t get any sleep. My roommate is shouting and trying to get out of bed all day and night. How am I supposed to heal and get better? I have pleaded to be transferred several times, but the nurses just pat my hand and assure me that everything will be better soon. No-one really seems to care about me. Please help me.”
Would anyone blame this patient if she became belligerent or even disruptive? Are we not responsible for listening? Is not what matters most to her, what should matter most to us? If her blood pressure elevates while she is upset and she has a stroke while in our hospital, are we not culpable and responsible?
The second patient, Mr B, was a 65-year-old man admitted with a history of chronic regional enteritis admitted after an acute myocardial infarction, now several days post-admission.
He had some cardiac rhythm issues so was undergoing stabilization before discharge. He was steaming mad when we approached his bed, and before we could even say hello, he tore into us: “I want out of here, now!”
When we asked what the matter was he told us that he had been transferred to different wards in the hospital four times in the past 48 hours, most recently in the middle of the night. He had just had two loose bowel movements with mucous and had been told he was to be transferred once again to an isolation unit because of the risk of C. difficile.
My colleague was at a loss to understand why the patient had been transferred so frequently, except that there was a bed shortage problem, but his explanation did little to comfort this man who was red-faced and very angry.
Would anyone blame this patient for being belligerent or even disruptive? Are we not responsible for listening? Is not what matters most to him, what should matter most to us? If he acts on his intention to leave the hospital before his cardiac rhythm problem is stabilized, are we not responsible for his unhappiness and his potential adverse outcome? Are we not culpable in his complaint?
Clinician and patient communication
Patient complaints may, or may not, be well-grounded, but what really matters is why the complaint has been made. In the complexity of what we call modern healthcare, clinician-patient communication may often fail to satisfy the needs and wants of individuals who deserve understanding and compassion.
This is particularly the case when sharing uncomfortable or troubling news with patients and caregivers. Admittedly, some patients, especially those with more limited capacity to understand the multifaceted issues relating to their illnesses, may harbor unrealistic expectations.
Unrealistic expectations can, and will, trump accurately shared information and explanations again and again. But more often than not, patients simply want to get better, and when complaints, belligerence and disruption arise it is likely because of an imbalance among explanation, expectations and comprehension.
Unfortunately, some clinicians do not communicate effectively. We may not use language appropriate to patients’ levels of understanding or take into account the social and cultural surroundings in which patients live. We may be patronizing. We may not understand the belief systems that our patients incorporate into their thinking.
In the worst case, we may let our own biases interfere with communication. In circumstances where the stage is set for miscommunication, and most of us can get a sense of this before the conversation actually begins, it may be useful to have a professional patient advocate participate in potentially difficult conversations to smooth the edges of communication.
Medicine is complicated enough without miscommunication serving as an independent variable affecting safety and quality outcomes; and that is why it matters. Just treatment of, and for, patients is part of the Just Culture. N
Datix is a leading supplier of software risk management, incident and adverse event reporting. Dedicated to patient safety since 1986, their solutions are used widely within private and public healthcare organizations around the world. Their US operation supports both US clients ( including the US Department of Defense Health Services System ) and Datix’s strategic partner UHC, an alliance of 116 academic medical centers with 283 affiliated hospitals. For more information please visit www.datixusa.com
Daniel Cohen, Datix, US