Physicians rarely spend a night in the hospital as a patient. We are there to work. But last year I unexpectedly spent a few nights in a row as an in-patient. I had elected to stay in a quad room, which placed me with two roommates on the orthopedic surgery floor. I was horrified by what happened during the nights I was there. I shared that quad with two women about twice my own age. Both were recovering from implants after hip fractures. As such, they required moderate to maximal assistance for toileting. Daytime staff were getting one patient up to the washroom on a regular schedule, and this seemed to prevent incontinence. This 98-year-old patient spoke only Russian and German and was lucky enough to have a family member at the bedside as an advocate throughout the daylight hours. There was a drastic night and day difference, however. Night nursing staff spoke to her very disparagingly in English. This may have been because they didn't think she could understand what they were saying, but the tone of voice was unmistakable as disdainful, bothered, irritated, and frankly disrespectful. There were expletives and, "Geez! Come on, will ya!?"
The other patient was better able to advocate for herself, although she had a tendency to get confused at 9 p.m. and to hold forth in loud conversation with make-believe party planners until midnight. When she cried out in pain during the changing of her soiled Depends, she would admonish, "You don't have to be so rough!" and the retort would be, "I've got a lot of other people to take care of, you know!" Night shift nurses' anger at this patient pulling on her full diaper, which caused further soiling of the bed linens, was expressed in a way to shame the patient. There was a "look at the mess you made" attitude that showed no assumption of responsibility for the bed-bound patient.
As horrifying as this was, I felt worst about not speaking out from behind my own curtain to let my roommates and the nurses know that this was not acceptable treatment. While the nurses assigned to those beds were not also assigned to me, I wasn't in great shape myself and worried that giving negative feedback might affect my own evenings. I required assistance getting to the bathroom from my bed, and I imagined that being blacklisted might lengthen the wait after I hit the call button or when I requested pain medication. This is a terrible type of tyranny, although the patient relations team told me later that there would not have been repercussions. In 40 more years, would I be one of the patients lying across from me, with no one speaking up to protect me?
I finally met with the patient relations team at that major Toronto hospital this month. To their credit, they were quite concerned with my report once they received it, and they were willing to discuss what might be done to minimize or even eradicate these incidents. Common assumptions start off with an expectation that we don't have enough nurses to provide care, but they informed me that the staff on that unit have not been reduced or cut. Some might imagine that the nurses on the night shift haven't been able to attend education on compassionate bedside manner when it is offered during regular bankers' hours, but that hospital has committed itself to professional development, and each of the nurses involved in my story had been relieved for an appropriate amount of time to attend the course on Service with Heart. So what else can be done to assure that client-centered care is offered more of the time?
Some hospitals have created surveillance methods that alert patient relations offices when something like my evenings at the hospital occur. One way to do this is to encourage patients and their visitors to complete surveys or to feel free to contact patient relations. One deterrent to participating in this system would be worries like mine about repercussions while we're still in the hospital. Another way to watch out is to plant various undercover observers who conduct spot checks at random times, but in our conversation, we found this beside the point, because our resources are better spent on supporting staff so that they can perform well, as opposed to lying in wait to bust them and then punish or fine them.
Further reflection revealed that health care workers don't need more lessons on how to be compassionate -- that would be preaching to the choir, on borrowed time. They likely won't be motivated by negative reinforcement either. At this point in our dialogue, the only new idea we have developed is that snippy behavior with our patients likely arises in the same way as road rage or other interpersonal conflicts do outside the hospital. The sense of needing to rush until we're feeling off balance can lead away from the more compassionate approach. One of the teaching materials used in nurse training shows that taking a moment to slow down one's approach to someone in need can make all the difference between, "Come on, will ya?" and "How can I make you more comfortable?" How long does that moment take? All of 13 seconds. They timed it.
Harried family members who are caring for patients with dementia have also reported to me that taking the time to take three really deep breaths can allow them enough mental space to be more patient, just in time to avoid conflict. I timed myself: On average, this series of breaths took 14 seconds. This is a moment. This is the moment that it takes for kindness to arise.
The question yet to answer is how we can remind our nursing staff (and ourselves) to take these moments when we need them most. This would amount to reinforcing the practice of taking a moment. Again, we all agree it's the right thing to do, but we fall down on operationalizing it. The patient relations team and I floated ideas about auditory reminders, but if those occur too frequently or too regularly, they fade into meaningless background noise. A similar concern relates to visual stimuli, such as flashing lights. The more complex solution may require a shift in the workaday culture. My work with high school students to understand what influences their behaviors has indicated that they are most likely to adopt the behaviors of those with whom they spend the most time. It may be the case that our team leaders showing that they are taking a moment and inquiring after others' practice of the same will be more effective than sounding a bell or flashing the lights. What will it take to make hospitals more hospitable? It might just take one well-placed moment at a time.
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