Unhealthy Cultures of Care

Midwifery Practice in Zones of Danger

Many Certified Nurse-Midwives and Certified Midwives will seek employment with hospital corporate systems that may be new to them. During the hiring process, prospective new-hire midwives are introduced to most aspects of the hospital regime that it is particularly proud of. During this quasi-courtship, the midwife is not likely to discover the dark underbelly of the institution until much later in his/her employment.

One of the brighter spots, which might be presented during hospital hiring is the concept of teamwork which the hospital will tout, shamelessly, without revealing any substance underlying the concept. New clinicians are unlikely to experience a hospital's actual rendition of teamwork during the early stages of orientation.

Ideally, healthcare teams function on platforms designed for interspecialty cooperation and open communication among providers with diverse backgrounds and training. The differing scopes of practice among participating team members are recognized as essential in patient emergencies. The expectation is to function smoothly without hierarchical drama or competition. It is, however, crucial for all essential providers to take part in team training. In hospitals truly dedicated to team training, patients benefit when provider egos do not compete, and the team maintains a horizontal structure. This can facilitate true coordination of members' talents, experience, and backgound.

So, what do well-functioning care teams have to do with avoiding malpractice and other legal mayhem? Just about everything. In order to be a functioning healthcare team, the following must be incorporated: trust, patience, empathy, and regular drills specific to potential emergencies and the talents of a team of providers. Practice scenarios for emergency situations must be managed and debriefed on a regular basis. Everyone must know their role and scope in each situation and understand how every other team member will function.

Some hospital systems understand and respect the concept. Others are without a clue. Or they don't care. In hospital litigation, almost every inch of the medical record will be requested as potential evidence. Even if the hospital is not diligent with documentation of team training, the lawyers prosecuting an injury case will be. They will search for evidence of team training that could be related to a patient injury and will obtain it through requests for production of documents. The absence of team drills in vulnerable environments, like OB, will bolster a plainitff's case against the hospital and discovery efforts will be made to determine whether this lack of evidence can be developed for consideration by a jury.

If you have never had the experience, it might be informative and enlightening for you to contemplate how truly unhealthy cultures of care and dysfunctional care teams operate:

During one unfortunate period of hospital employment, I participated, for the first time, in an OB Unit's fever dream of Critical Events Team Training (CETT). Right away, the process was suspicious because the only "team participants" were the labor and delivery nurses and the certified nurse-midwives. No doctors, no residents, no NICU, no unit secretaries, etc. Just the already warring factions of RNs and CNMs. In her questionable wisdom, the "OB Women's Services Director (RN)" considered this to be a legitimate team training for CNMs experiencing OB emergencies. Adding insult to injury, the RNs from the unit were assigned to run the training scenarios, impersonating patients that we would encounter. (The hospital did have a sophisticated “learning lab” with stations to practice appropriate shoulder dystocia pressures and other competencies, but the facilities were available for the residents, only.)

Unknown to me, my scenario involved the dramatic appearance of a 28 week G1P0 with no prenatal care who presented to the triage unit in active labor. My "assignment" was to perform in this situation, alone (unrealistic scenario #1). I was directed to the triage room to await my fate, when suddenly the door burst open. One of the more demonstrative OB RN's was wheeled into the room crouched on hands and feet, riding the gurney like it was a surfboard (unrealistic scenario # 2). To add to this drama, she was shrieking at the top of her lungs. Her "family" (two other RNs from the unit), accompanied the gurney, struggling to maintain straight faces.

As the concerned midwife, my first reaction was to calm the "patient" and re-position her to supine for an examination. I began to ask the pertinent triage questions but the "patient" would not stop yelling long enough to answer. Fetal monitoring was not going to happen. Her pretend family, in the meantime, were opening all the cupboards and rumaging through drawers in the room (unrealistic scenario # 3).

By this time, according to my taped and failed performance, I should have examined the patient, pulled out a precip tray, turned on the warmer, and called NICU, in that order. Yeah, but what if the patient was crowning? Or the feet were presenting? Certainly, in my years as a hospital CNM, I have never witnessed quite this type of behavior from a patient or family. My first instinct was to laugh because the entire training was such a farce. It was later that I realized it was a not-so-subtle effort to shame and humiliate. It was filmed and I was, seriously, informed that I had failed.

In retrospect, I should have pressed the emergency button and, actually, called for security, grinding this “critical event” to a halt. Although, I hate to admit it, I did learn something from the experience. Obviously, team training is not a joke. Nor should it present an opportunity to make a fool of someone. It certainly was not a proper opportunity to learn anything useful in regard to emergency patient care.

In the wrong hands, poorly conducted training exercises can be a traumatic experience. Institutions that refuse to take these exercises seriously, or allow only one provider group to run them, can ruin the experience for someone who is there to learn. If there is a preexisting unhealthy dynamic between provider groups, it can become ridiculous. Training fiascos, like this one, might also allow individuals with negative agendas to inflict abuse and waste everyone's time.

"The clinician operating in isolation is now seen as undesireable in health care - a lone ranger, a cowboy, an individual who works long and hard to provide the care needed, but whose dependence on solitary resources and perspective may put the patient at risk".1 Given the uncoordinated state of care by groups of people who have not devevloped team skills, it is not surprising that some clinicians report that team care may actually increase medical errors. High performing teams are now widely recognized as essential for creating patient-centered, coordinated and effective delivery of health care.2

Finally, team members must learn to accept the talents of other members of the team and accept that one type of training or perspective is not superior to the training of others. Fellow team members can be taught to rely on each other in order to recogize and avert failures, regardless of where they are in a medical care hierarchy.3

In a healthy culture of care, legitimate training is useful and thought-provoking, potentially encouraging bonding among different providers. If an entire group of providers are there to support one another with a common goal to prepare for something useful, the exercise can become what it is intended for: preparation for disaster, not creation of one. Unfortunately, my "training exercise" did not enhance cooperation, expertise, or excellence in patient care, it merely embedded resentments.

In litigation, legal professionals are adept at revealing hospital department dysfunction through simple discovery, taking into account the tendencies toward negligence that reside in unhealthy cultures of care. Absence of hospital team training may, also, bolster a medical injury case and attorneys can pursue this approach in order to convince a jury of hospital negligence.

As midwives, if you find yourself in this type of environment, run-don't-walk to your next professional opportunity. Ugly cultures of care become embedded over time and rarely rehabilitate, in spite of recruitment and hiring campaigns for "best talent". If you cannot vacate such an environment, self-preservation and maintaining legal integrity may come with "rising above the stress" with self care, enhanced focus and dedication to your calling, change agency, and meticulous documentation of training shenanigans on and off the record.

P.S. I am humiliated to admit that I still don't know how to properly prepare a warmer. . .

1 Mitchell, P., Wynia, M., Golden, R., et.al. Core Principles & Values of Effective Team-Based Healthcare. Institute of Medicine OF THE NATIONAL ACADEMIES. October 2012.

2 Ibid. p. 2,3

3 Ibid. p. 5

http://www.midwivesontrial.com

Frivolous Lawsuits

Electronic Fetal Monitoring: Management and Standard of Care Part 3