I have a patient in the ward in respiratory distress. I ask the nurse to please change the patient from nasal prong to face mask oxygen. She simply doesn't budge. When I ask her again for the mask, she replies that they don't have any. (No face mask oxygen!?!) The patient's saturation has now dropped to 73% and he is very tachypnoiec. I ask her to kindly find a mask. Then she says to me she's not going to because she doesn't think the patient needs oxygen.
This little scene has made me consider the concept of conflict resolution in the workplace. Numerous variables play a role in complicating the issue: The nursing staff are often older than the doctors in South African hospitals as junior doctors have to serve a number of years in state hospitals before being able to move to private practice. This introduces the awkward situation of giving instructions to a lady who may be your aunt or mother.
Secondly, strong cultural divides still exist in South Africa. The indigenous tribes still afford their leaders and nobility a high level of respect. If you happen to be a descendant of a rival tribe or a commoner, you can surely not be taken seriously if you aim to give instructions to a person of a higher social or cultural ranking than yourself. Unfortunately and despite more females now qualifying than males, the male doctor is much more respected than the female. Remarkably enough that divide is most severely enforced by the older female (patient and nurse alike).
There is also the unfortunate age-old conflict between nursing staff and doctors. The two professions run alongside each other and are meant to compliment each other in different and specific ways. When the one encroaches upon the other, either side has to back down and accept leadership from the other. This does not sit well with human nature. Unfortunately I have to acquiesce that doctors have in the past era of paternalistic medicine forced instructions upon the nursing staff with a certain unattractive bossiness. As a result there is a feeling amongst certain nurses, perhaps the ones previously disrespected by an egoistic doctor, to suppress the young doctors' sense of self-importance before it can impact on the nurse.
With that we return to the common goal of treating patients, ensuring their comfort and healing them as far as is possible within our human limits. From my training it is quite clear to me that my patient is in serious need of oxygen. This is not the time for pussy-footing or shying away from a conflict situation. The patient's well-being is the top priority. Before revealing the outcome of this little scene, I'd like to invite you, my reader, to contribute your own tested methods for dealing with workplace-related conflict and suggestions to resolving my patient's dilemma.
In an emergency situation, diplomacy and leadership do not always go hand-in-hand...
ReplyDeleteAs a female doctor, I have found that diplomacy or kindness is sometimes mistaken for weakness. It is not until one raises one's voice and perhaps even threaten before a sense of urgency is instilled into the subject matter. Keeping one's professionalism can be trying.
I do not necessarily have the same tribal and cultural problems in the UK as you describe in your blog but the general scenario is not unfamiliar.
In my experience there are three conflict situations on the ward (luckily they are few and far between):
1. Nurses that do not realise the urgency of the situation and go for their tea break because they are entitled to it by work-law.
2. Nurses that claim they cannot administer anti-biotics/fluids because they haven't had the appropriate training.
3. Older more senior doctors that do not practice evidence based medicine. As a young doctor is sometimes difficult to go against their decision.
How have I resolved these situations?
I try to avoid conflict wherever I can. On a day-to day basis, I am friendly and reasonable towards the nurses. I have installed a system on the ward by which they can put all the jobs, they want me to do, on a list. I periodically check it throughout the day and complete it. This saves my bleep going off constantly and instils a sense of trust and consistency. I try to be as approachable as possible and focus to win the senior nurse in charge's approval. This recipe usually avoids conflicts. There have been the odd time where I had to try out my diplomacy skills...
When it is time critical, I usually end up doing things myself or get another nurse/assistant to help me if one is being obstructive.
On one occasion I have called a nurse into the office after an incidence. With the support of my boss we discussed the incidence and filed it as a serious incident and I placed a formal complaint. She did make my life hell afterwards but I knew I was right and I had that to stand on.
Another time I had to go against the decision of the senior medical registrar on-call.
I simply went behind his back after repeatedly suggesting that we need to administer anti-biotics ASAP in a patient with overwhelming sepsis that ended up in ICU (he wanted to wait for the WCC!).
I really don't know how else I could have dealt with the situation as I even quoted a paper that clearly describes the timeline of anti-biotic administration and mortality figures in sepsis.
Each situation has been different and with experience I believe I am getting better at conflict resolution in time critical situations. Although I imagine there is still a lot to learn. I will therefore be interested to hear other people's experiences.
Thanx for your insightful comments, dear colleague. I was surprised to learn that you struggle with much the same issues in the UK. The nurses going on tea at the oddest times is exactly what happens here. I have actually found myself knees and all on a patients bed, doing chest compressions in a resus with the nurse just disappearing to tea because its her time slot. I have done calls where there is no time to get wet or dry past my lips before 3am because it is simply too busy. I assumed that if one chooses to be in the health care profession, your patients' welfare comes before your own comforts!
ReplyDeleteI wholeheartedly relate with your comment about diplomacy or kindness being confused with weakness. I find this line very difficult to tread. It is not in my nature to be a hard ass dictator but my orders are often ignored. Once one starts threatening and constantly fighting the system, your personality also takes on harder, unattractive edges.
Here is an incident just to illustrate the obstructive attitude of the nurses in my hospital: When one is scrubbed up in theater and on call the anaesthetist, his intern or the floor nurse would by convention answer your phone. The calls would come from other doctors wishing to refer patients or from nurses in the ward reporting an emergency. In my hospital the nurses usually say its not in their job description to answer the phone so even the student nurses would stand right next to it, letting in ring. On this particular occasion though, one of our phones started ringing and the nurse asked who's phone it is. I replied, "Mine, thank you sister." Now, I'd been working at the hospital for a substantial time period and they all knew who I was. The nurse answered the phone saying, "This is mine's phone."
I wonder if her attitude would be any different if the doctor on the line trying to reach me were in fact looking out for the well being of a family member of hers.
Your method of getting the nurses to keep a jimmy-list for you thereby reducing constant beeps or phone calls is brilliant.
Please send in your comments again!
Seems to be a common problem in our country. Maybe elsewhere as well, would be interesting to get comments from other parts of the world.
ReplyDeleteI suspect the attitude is a cover-up for incompetence, laziness and/or stupidity. No-one with a scrap of insight can overlook the priorities so carelessly.
Sad,isn't it?