The Q Word Podcast
“The 3.5 Biggest Lies of Nursing”
Nyssa: Today we are discussing the three and a half biggest lies in nursing.
Lisa: So what do you mean by “the biggest lies in nursing?” I don't understand.
Nyssa: Well, this is my opinion only. But these are three lies that nurses tell one another. It's just a warning episode that when you hear these words come out of someone's mouth, it should be a red flag to you. And I will be arguing why you should not believe these lies.
Lisa: Okay. So this isn't what patients believe about nurses, but what nurses believe about nurses?
Nyssa: Yes. This is lies nurses tell other nurses.
Lisa: Kind of like me teaching a child that the sky is green?
Nyssa: Yeah… yeah, like that.
Lisa: Okay. Alright. Well, hit me with it. Let's see...Oh, is this like truth or dare? Or like truth or lies? Is this one of those mixer games where you put on your name tag, you know, three statements? Two are the truth and one is a lie. Do I get to pick?
Nyssa: You can... but here's the spoiler: they’re all going to be lies!
Lisa: Dang it! That's not how you play the game, Nyssa!
Nyssa: Sorry, I didn't know!
Lisa: Alright, alright. Well go ahead and start lying to me. I know how much you love doing that.
Nyssa: This is the first lie. If you have been a nurse for even a short amount of time, I guarantee you have heard someone tell you this and try to convince you of this. They will make an excuse for the bad behavior of a fellow nurse, and they will end the excuse by saying, “… but she's a really good nurse!” So let me give you some examples. You have a co worker who cannot seem to show up to work on time. They are chronically late. People put up with their bad habit and say, “Well, I know that they're always late... but they're a good nurse! It’s okay, they're a good nurse!” Similar for the ones who call in all the time. Call in to work, and don't show up to do the job. So in nursing, when you show up late, nurses can't just clock out and go home at 7:08- when the shift ends- if there's not someone to receive the patients. You can't leave patients unattended. So by you showing up late, it causes a domino effect that impacts me- after I've done my 8 hour, or 12 hour, or 24 hour shift. It impacts the patients and it impacts the entire flow of the department. This is a big deal. What happens is people will defend nurses who have experience and have strong clinical skills and defend this bad behavior by saying that they're a good nurse.
Lisa: Is that in order to not be called out on your own behavior if you ever show up late? What's the purpose of it?
Nyssa: So this is where the lie comes in. The lie is that being a good nurse is just your clinical or just your experience. My argument is that in order to be a good nurse, you have to be solid clinically, you have to have some level of experience- even if it's a novice level of experience- and you got to show up on time and you got to come to work. There's a worse version of this, and this is the version that you hear it most often in. You have someone who's very gruff, you have someone who's jaded, you have someone whose bedside manner leaves something to be desired. And someone will say, “Well, yeah, she's a little crusty and she's a little jaded, but she's a really good nurse! Yeah, I know she seems pretty abrupt and I know she's kind of short with people, but she's a really good nurse!”
Lisa: You know, I worked in the elementary school system for a while and we had a fifth grade teacher who hated kids. She just hated kids. And I was like, “What are you a teacher for? These kids can tell you hate them.” And everybody would say, “Yeah, she's really gruff. The kids don't like her. But you know, she's a great educator.” But I didn't think she was actually educating the students at all because they hated her. Like, she was horrible. They didn't want to go to class, they felt depressed, wasn't a good situation.
Nyssa: And the thing is, my argument about why this is a lie is that you have to have the total package. You have to have the bedside manner, you have to have the teamwork attitude, you definitely have to have strong clinical skills, you've got to have the attendance record. In order to be considered a good nurse, you've got to have the whole picture. So a red flag should go up when someone is defending someone's bad behavior, and then wraps it up with, “But she's a good nurse!” It can also be a he, by the way... “But he's a good nurse!” No, they're not. They're not. It's a lie.
Lisa: So what do you do to correct that behavior? Audience, the face that she is making right now shows that she was not prepared for this question.
Nyssa: Well, no, I think that you do a podcast where you're trying to argue that good nurses are the total package. I remember the person who taught me this, it was the chief nursing officer. I'd heard this lie over and over again and I believed the lie. And she was the one who said, “No, wait a minute now. That's not true. In order to be considered a good nurse, you've got to have more than just one or two elements. It's got to be the whole thing.” And it was a light bulb to me. I think that this lie is sort of woven into our nursing culture, and it needs to be unraveled.
Lisa: So you can flip the script and say, “Yeah, she's great clinical and she's great with her patients, but she's never on time and that makes her not the best nurse.” Would that be an accurate assessment?
Nyssa: Yeah, that's right. That leads us to our second lie. And it's actually the one and a half lie. So the second one is: when we talk in medical terms- and this is going to seem a little like an oxymoron- but in medical terms, we never say always or never.
Lisa: Fair enough. I see how that works.
Nyssa: Right? Right?
Lisa: Never say never... was a good Bond movie.
Nyssa: Yes, never always say never. The examples that we mainly use are when you say something like, “Asthmatics will always (fill in the blank)...” or “Diabetic patients never (fill in the blank).” You're always going to have an exception. Always going to have an exception to the rule.
Lisa: You’re really undoing yourself here.
Nyssa: There are always going to be outliers and so it's a blanket statement to say, “Most asthmatics will…” But be cautious when someone tells you, “Asthmatics will always…” So when we're applying that to the behavior of nurses, I would really caution you when you are being taught by someone or when you're asking a question about something and someone tells you, “Well, the reason we do it that way is because everybody does it that way. Everybody's doing it.” It sounds like eighth grade peer pressure, and kind of, in some ways, that's what it is. If the only rationale for doing something a certain way is because that's that's how everybody does it, you should probably dig a little deeper. That should be a red flag for you. Particularly if that rationale is not following the written process or the written policy. So, wait, why are we doing it like this? “Well, that's how everybody does it.” That's not true. So be skeptical. It's probably a lie.
Lisa: Okay, so culturally, again- I'm sorry, I'm going to throw these back at you- but
as a novice nurse, when you're faced with a preceptor, let's say, who says, “Well, this is the way we've always done it. This is how we always do this, how everybody does it.” How do you push back on that?
Nyssa: Well, what I would say is you need to find out for yourself is this, in fact, the proper way it's being done. And if it is, they should be able to say, “Well, we're doing it this way, because the policy says blah, blah, blah…” or “the evidence says x, y, z…” or they should be able to give you a rationale that's not just, “Everybody's doing it this way.” If you're saying, “Why does the policy say this, but we're actually doing it this way?” That's when you're going to hear, in all likelihood, “Well, that's just how everybody does it.” So the converse of this lie is also kind of closely linked to it, and that is why it counts as the half of a lie. It's so closely related to the other one. And that is when you hear them say, “Well, no one does it that way. I know the policy says that…” or “I know the procedure says that, but no one really does that.” Then you should be equally skeptical and it is probably a lie. There is sort of a footnote to this. Let me explain it by giving you an example. In the last 5 to 10 years, we have realized that putting foley catheters in patients can be a detrimental thing. So we’ve always known that the minute that you put a urinary catheter into someone's bladder, you've just created a superhighway for bacteria. It's a very, very high likelihood that they're going to get a urinary tract infection on top of whatever illness or injury they came in for. It used to be the culture that we put foley catheters in just about everybody. Well, in the last 5 to 10 years, we have realized that that was a mistake and that we should be very careful and very choosy as to which patients need an indwelling catheter and that the majority of patients, in fact, do not. One of the ways that a department that I worked for decided to monitor this, or manage this, was by saying that anybody who's putting a catheter into a patient had to get the approval of the charge nurse. So even if a physician has written an order for this patient to get a catheter, you had to get the approval of the charge nurse. Now, when they set this process up, you can understand the reason why they wanted to do this. You have a second set of eyes to look at a patient and see that yes, in fact, the benefits outweigh the risks in this patient. However, the charge nurses received no additional training as to how to decide which patients warrant it and which patients don't. There was no way to document this conversation that you've had with your charge nurse. So if I go to the charge nurse and say, “Hey, Dr. Jones wants to put a foley in Miss Susie Q in bed 12.” The charge nurse is like, “Okay!” and that's that's the end of it. There's no log to document it, there's no place in the computer to chart it, here's no roll to sign in, and there's no, therefore, accountability.
Lisa: Okay.
Nyssa: So as a nurse, what you've just taught me is that you've put very low priority on this process. Because whether I do it or not, there's no record of it. Whether we had a conversation or not, no one's following up. So nurses quickly realize, “I mean, this is a waste of my time. It's a waste of my charge nurse’s time.” And they triage it down off their to do list.
Lisa: You mean, the asking for permission from the charge nurse?
Nyssa: Right.
Lisa: So if the charge nurse just automatically says, “Yeah, fine, go for it”, it becomes less important than taking somebody's temperature? I mean, you at least write that down, right?
Nyssa: That's right.
Lisa: But you don't write down whether or not you checked with the nurses to whether the foley catheter should have been inserted?
Nyssa: Well, there was no process for it, so where do I write it down? Do I write it down at the charge nurse's station? Do I write it in the patient's chart? Really doesn't belong in the patient's chart... Is there some third place where it needs to go? Is there an email that needs to be sent? The process was never clearly defined. So nurses abandoned it because it just seemed like it didn't have a high priority for the people who made the policy. So therefore, why are we going to waste a few minutes of precious time to follow this policy? So, in the end, the fact was, nurses tried to do this, they tried to follow the rules, they tried to follow the policy, but quickly abandoned it because it was inherently going to fail by design. And therefore, really, truly no one was doing it. No one really was doing it. But it requires a deeper dig to find out, wow, this process was ill-defined from the beginning and needs to be tweaked if we're going to make it work. So months later, when management looks at it, says “Gosh, no one's doing this! Why is no one doing it?” Well, people were trying to do it, but you just have no record of them trying to. And so yeah, in the end, no one really was doing it.
Lisa: How did these miscommunications start? Is it some bureaucrat that makes the decision that this new policy needs to be implemented, but then it isn't rolled down the proper channels so that it's implemented effectively?
Nyssa: Right. And my recommendation for things like that, because new information that impacts patient care and nursing care comes out all the time. So one of the best ways that I have seen that these kinds of changes successfully work, is when you do what's called rapid cycling. So for the next week, any foley that you put in, you're going to get approval from the charge nurse, and he or she is going to write it down on this log. And in a week, we'll come back and say, “You know what? That was a huge pain to have it in writing. Let's do an email instead.” And you just kind of rapid cycle. Alright, for this following week, let's try it again but let's do an email instead. So rapid cycle trial, including the people who are the end users, is how you make something succeed like that.. Nurses want to follow policy. Nurses want to do the right thing for their patients. So you have to build it so that they can. And then they will!
Lisa: It’s like the Field of Dreams! “Build a policy, they will insert the catheter!”
Nyssa” So, Lisa, when you think of professions who have the lowest morals or the lowest trustworthiness- what kind of professionals do you think of? What kind of professions, generalized professions, do you think of?
Lisa: I don't know any personally, but I believe that that assumption is generally made about lawyers.
Nyssa: Lawyers, okay. There any others come to mind?
Lisa: Goodness, how many people am I going to get into trouble with if I say college professors? No, I can't say that. That's not accurate.
Nyssa: What about the people in Washington, D.C.?
Lisa: Oh, politicians!
Nyssa: Yeahhh. What about when you go to buy a new vehicle?
Lisa: Oh, goodness! Look at me. I'm so trusting. You’re right! Used car salesman definitely have that reputation.
Nyssa: Right. So there's a Gallup poll that is conducted every year where they asked around 800 adults about the most trusted and the least trusted professions in the United States. And the ones who consistently rank at the bottom are: politicians, car salesman, lawyers- as you mentioned- and people who are in advertising... because obviously their job is to make something seem better than it is.
Lisa: Yeah, those madmen.
Nyssa: Those are the professions who are at the bottom end of this Gallup poll. Since 1990, nurses have ranked number one on this poll every single year. That's 28 years, except for one.
Lisa: Number one in terms of most trustworthy?
Nyssa: Most trustworthy.
Lisa: Okay, good.
Nyssa: The most trustworthy profession since 1990. The one year that was the exception was 2001- when 911 happened- and firefighters, because of their heroic acts, that were so, so very public, were rightfully ranked number one in the year 2001. So all the other years it has been nursing, the nursing profession.
Lisa: I venture to guess that nurses were pretty high up there still, though.
Nyssa: Yes, absolutely. So nursing is consistently ranked number one; and not only is it consistently ranked number one, but it's kicking the butts of number two, three, and four. So when these callers are asked to give nursing a percentage, 80 of the 100 are going to give it high or very high on trustworthiness and ethics. The number two profession is a tie between pharmacists and physicians- so both medical professionals. About 65% of people rank them very high or high. So nurses are getting 80, while physicians and pharmacists- who are tied for number two- are getting 65. So we're way above even number two or number three. So this is a really important thing to understand when you are a nurse. When you are stepping into this profession at the get go. What impresses me is that you have been handed the trust of the public. Nothing that you have done yet has earned that. It's what the people in the last 28 years have been doing that has us consistently ranking high that you are inheriting. One of the reasons why nurses are consistently ranked high is because of all the health care professionals- when people are at their most vulnerable- nurses are the only ones that are at the bedside 24/7. So your physician bee bops in once, maybe twice a day if you're lucky. The pharmacist you may or may not even see. The other ancillary people are in and out. But the nurse is 24/7 in and out of your room, at your bedside. The only ones doing that. The other reason- which this is kind of a newer development- why nurses have gained popularity or retained popularity, is because of the popularity and the boom of the nurse practitioner role. So most physician’s offices and physicians that are in the hospital have really expanded the role of nurse practitioner. And what that has done is that has decompressed waiting rooms and that has increased the amount of time that patients get to spend with their practitioner. Physicians are less hurried because nurse practitioners are offloading their caseload. Nurse practitioners are also less hurried, so people feel like they are getting better care because they are sharing that care between a nurse practitioner and a physician. And the role is very, very popular among patients. So that has aided to nurses remaining at the top of the trustworthiness and ethics polls. So we've talked about how nurses inherit this by nothing that you have done. Now, you step into your nursing practice... how do you keep it? How do you keep that trustworthiness? How do you keep that integrity? So here's where the lie comes in.
Lisa: Okay... Lie number three!
Nyssa: There's going to come a point in your career where you have made a mistake. It will likely come very early in your career. My first big mistake happened when I was still in orientation. That's another story for another time. It's a doozy!
Lisa: Making a note. We’ll be recording that soon. Let's not keep our listeners waiting to find out how Nurse Nyssa fucked the pooch early on.
Nyssa: So when you make your mistake, and every subsequent mistake that you make after that, you are at a crossroads in your nursing practice where you have to decide how you're going to handle it. A majority of mistakes are going to be unseen by anybody but you. So you have to decide which path you're going to take. So let me give you an example. There was a new nurse who had just gotten off precepting, she had just gotten off orientation. She was in the department and she was caring for a patient and she made a mistake; she made a medication error. And she recognized her error and she didn't know what the process was to do next. So she went to a nurse who was working in the same zone as her and she said, “I've made this med error, what do I do?” And the nurse told her, “No one will ever know. Just chart it the correct way. No one will ever know.”
Lisa: That doesn't sound like the right approach.
Nyssa: Right. So that's the third biggest lie in nursing. And the nurse, the new grad nurse, recognized that. Did not sit well with her. And so she went and found her preceptor. She was off orientation, so her preceptor was no longer looking over her shoulder, but she went and found her preceptor who had taught her and who she trusted. And it's a nurse named Amanda, that I work with in the department, who is the exact nurse that we described earlier. Everyone loves her. She's a clinically gifted nurse. She shows up to work on time. Patients love her. Preceptees love her. She's great, you wish you had a department full of Amandas. So this young lady sought her out and said, “Here's my issue. I've made this error, and this is what I was told: That no one will ever know.” And so Amanda brought her to me. So the two of them are now explaining to me this situation. And this is when we have a talk about integrity. And now this little girl is upset and tears are welling up in her eyes and you can tell that this is not the position that she wants to be in for many, many reasons.
Lisa: Can we roll it back a second? What is your official role in this dynamic?
Nyssa: So I was the educator in the department.
Lisa: Okay, thanks.
Nyssa: So we have this moment where we get to talk about your options. The advice that you got, in my opinion, is bad advice. But if you had chosen to follow it, no one really would know. You could have charted it the correct way, that wasn't the way that you did it and no one would ever know. Except for you. Now you have just made a decision about which path your nursing career is going to take. If you decide to do it the correct way, these are the following things that are going to happen. And so we outline those things and work through those processes. Now let's flip the story on its head and rewind to when I was that girl. So when I had just gotten off of orientation- remember on orientation, I already made my first med error. Now I'm off orientation, and I just made my second med error and I recognized it. I went to the charge nurse, who was the night charge nurse, her name is Michelle. And I explained to her, “Michelle, I've made this med error. What do I do?” And I was upset and I was questioning my ability as a nurse. This is now my second error. And she said, “Alright Nyssa, this is what I want you to do: I want you to go and assess your patient. Make sure that this did not have any kind of harm to your patient from what happened. And then I need you to call the physician and see if they want to make any orders to adjust what has happened. It's likely that they won't, but you need to let them know as a courtesy anyway. And then we have an occurrence form that we have to fill out. And I will help you fill that form out since you've never done it before. We will sit together and we will fill this form out.” And then Michelle gave me a gift. And the gift that she gave me was, she said, “Nyssa, you are a good nurse.” She knew I was questioning myself at that point. Then she put the cherry on top of the gift, and she said, “I would let you take care of my momma or my children.” What a great charge nurse, what a smart thing to say to someone who has made a decision that was hard. I'm gonna have to have a hard conversation with a physician. I'm gonna have to have a hard conversation with my patient when I tell them I made this mistake. I'm already beating myself up. And she just salvaged my integrity by saying, “You did the right thing. And I trust you and I would let you take care of my closest loved ones.” What a smart thing. What a great charge nurse. I had an assistant director who taught me that the only people who are not making mistakes are the people who are not doing any work.
Lisa: That's a really interesting way of looking at it. Probably makes sense.
Nyssa: So we are human as nurses. The idea is to be vigilant enough and be careful enough that the mistakes that you make are small ones and can be reversed or rewound. But there's a lot of reasons why it's important to report these things and to go about it the right way. The top one being your integrity. But the next thing is: what if there's a systematic issue that we need to investigate? What if there are other nurses making this mistake because of the way the medication is labeled or because of the place that it's in in the med room or some other systematic issue that has set a nurse up for failure? That needs to be investigated. And you need to make sure that the institution that you are working in has an attitude of what's called “just culture.” “Just culture” means that when you report these things, there's not a punitive action. There should not be punitive action if you didn't willfully and neglectfully make this mistake. It should be a place where you can learn from it and not repeat it and that it can be investigated to find out how to prevent it in the future.
Lisa: Is there a three strikes you're out, sort of, dealio? If the mistake is made multiple times in a row, the same mistake? I would think that if a nurse hasn't learned from those mistakes, that's got to be a red flag of some sort.
Nyssa: I would agree that that needs some investigation. And so you know, one of the important things that we learn in this, I know from my own practices, that mistake that I made on orientation, whenever I give that medication now, I still get a butterfly in my stomach which makes me hypervigilant about giving it. I check, I double check, I triple check. I'm going to do everything I can to mitigate that ever happening to me again. Does that mean I won't make a mistake with that medicine again? No, it's not a guarantee. But I sure am doing my very best to make sure it doesn't happen. And so it is a learning opportunity for all of those who are involved.
Lisa: Right.
Nyssa: So ultimately, it might be true that no one will ever know... but you. And then the choice becomes yours.
Lisa: And the choice is: fess up, go straight to whoever's in charge, let them know what happened and deal with it right on the spot.
Nyssa: Fix it and learn from it. That's right.
Lisa: The culture that we live in now is so much more special snowflake than it was 10 years ago, 15 years ago, 5 years ago, that there's this fear of confrontation or this fear that you're going to lose everything if you fess up to any mistakes. I see that in a lot of the students that I see coming through right now at the undergraduate level. And I I do worry about them- that they're not prepared to own up to, “Okay, wait, I stepped in it and I made this mistake. How do we fix it?” They're not prepared to do that. Not all of them. Some are, of course, but I see more and more that aren't and I worry about what the consequences of their actions will be down the line. Sure, you can lie on somebody's chart, but then if there's a contraindication of that medicine that you gave them wrong, or if you gave them something that specifically doesn't work because of something wrong with their physiology, that sounds like a really serious problem.
Nyssa: Absolutely. So in other professions where you make an error, it might cost someone hundreds of dollars, or it might waste hours of someone's time. In our profession when you make a mistake the consequences can be…
Lisa: Literally life and death.
Nyssa: Literally life and death. That’s right.
Lisa: So what's your advice? What is the best way for a nurse to fess up to this mistake? Immediately go straight to, who? The charge nurse?
Nyssa: I would say, if this is the first time that this is happening to you, absolutely get your mentor to walk you through what to do with this process. If you've made a mistake that's with your patient, assess your patient and make sure that your patient is stable, the thing that you did has not caused them to need more interventions. After that, get your mentor to go through it with you- your educator, your manager, your charge nurse- and let them walk you through this process. Hopefully you will have someone like I did who will make it a non punitive thing, who will help to restore your confidence, will help you learn from it and understand that this is something that happens. It happens.
Lisa: Alright! So that's three lies there.
Nyssa: It’s three and a half.
Lisa: Okay. Be the whole package. Don't be a lemming.
Nyssa: That's right.
Lisa: And…
Nyssa: Preserve your integrity.
Lisa: Preserve your integrity. I like that. I was gonna say, “Someone will always know...” But that sounds a little ominous.
Nyssa: So we would love to hear your stories of, “But she's a good nurse!”, “Everybody's doing it.”, “Nobody's doing it.”, and, “No one will ever know!” Share them with us on theqwordpodcast.com or on social media. On Facebook you can find us at: The Q Word podcast. On Instagram: The Q Word podcast, and on Twitter we are The Q Word podcast.
Lisa: You can also email us at- guess what- theqwordpodcast@gmail.com. And we would love it if you would rate us on iTunes, Stitcher, Podbean… those are the only three that I know. I'm sure there are a lot more. Give us a five star review if you like the podcast. You don't have to write a review, nobody cares about those. But we would love to see your five stars because those make us happy. We like to pluck them off the internet and weave them into our hair and then we sing happy songs about how popular we are. So thanks for all the information Nyssa. I will try to keep an ear out for those lies and hopefully know what to do if I hear them.
Nyssa: Okay! Good job, Lisa!
Lisa: Good job, Nyssa! Bye!
Bibliography
Brenan, M. (2019). Nurses Again Outpace Other Professions for Honesty, Ethics. Gallup. Retrieved from https://news.gallup.com/poll/245597/nurses-again-outpace-professions-honesty-ethics.aspx
HealthIT.gov. (2019). How Do I Use A Rapid-Cycle Improvement Strategy? HealthIT.gov. Retrieved from https://www.healthit.gov/faq/how-do-i-use-rapid-cycle-improvement-strategy
Keywords
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