TMI? How Transparent Should Nurses Be With Patients?

by jparadisi

cartoon by jparadisi

While on vacation, my husband and I waited patiently in a restaurant for our food.  In contrast with our leisurely pace, the wait staff swarmed almost cartoony in the effort to serve the endless crowd of customers. Clearly, they were short staffed, but not a single server complained.

Since we work in healthcare, my husband and I were sympathetic. Our server earned every bit of his tip.

Likewise, most nurses feel badly when patients wait too long for their care. Delays occur for many reasons: orders that haven’t arrived, lab results that aren’t back, unexpected admissions, critical changes in a patient, short staffing, unavailability of a medication, clerical errors, the list goes on. Because nurses are at the bedside we take on the brunt of the problem, whether or not the patient complains.

Hospitals competing for healthcare dollars compound a nurse’s frustration by intertwining messages of customer service with expectations for patient safety. In the worst cases, under duress, nurses and patients also confuse the two.

Most patients admitted for treatments are already aware of the potential risks: medication errors, hospital-acquired infections, or enduring the wrong procedure.They come to us for treatment because their options are otherwise limited. So, where is the line between giving patients honest answers about their treatment delays, and disclosing that you are short-staffed on the day of this patient’s very first chemotherapy infusion? Do you tell a patient that their treatment is delayed because there’s a mistake on the orders? If so, how do you do so without intensifying their anxiety?

Putting this conundrum into another context, I’m imagining how I’d feel if a flight attendant announced that our flight is delayed because “The captain heard a funny noise during the landing gear check,” instead of simply saying, “Please remain patient. We’ll take off shortly.” Would you want to know, and perhaps exit the plane? Or would you rather not know, trusting the plane wouldn’t take-off if there is an unresolved problem? How much transparency is too much?

Do you feel patients need to know everything happening behind the scenes about their care? If so, how do you engage in this disclosure? Does consideration for colleagues come into play? For example, has a colleague ever blamed you for a delay or mistake in front of a patient?

Just Because You’re Big Enough to Hold Still (patients, pain & procedures)

    I still experience culture shock, since my transfer from pediatric intensive care to outpatient adult oncology nursing , over the difference in sedation use during procedures for pediatric and adult patients. What allowed me to tolerate 15 years of pediatric intensive care nursing (yes, it is as emotionally challenging as you think it is) was the routine sedation of the child going through procedures. 

   Adult patients know that when their healthcare provider says, “You may experience some discomfort during the procedure”, what we mean is  “This is gonna hurt.” Remember, this is an industry that accepts anal leakage as a reasonable side effect of some medications.  Adult patients are expected to lie still.

   Like during a bone marrow aspiration. My patient cried before the oncologist arrived, but the doctor didn’t see that. She cried during the injection of the local anesthetic too. Her family looked concerned, but no one spoke up.  Nurses, because of our extended contact with patients, are the emotional thermometer in the room. It is my practice to request from the physician a small dose of sublingual lorazepam to offer the patient before such a procedure, just to take the edge off, but it’s rarely ordered, unless the patient demonstrates high anxiety levels in front of the physician, which indicates the patient might not hold still. The procedure lasted only minutes (the oncologist was skilled), but I winced to see my patient hurt. This patient made it through bravely. The physical pain was quick, then over, but the pain of the procedure was potentiated by the fear of a blood cancer diagnosis. Lorazepam does not control pain. It does ease anxiety.  She was big enough to hold still.

   Perhaps I’m sensitized to this issue because I have been a patient needing a biopsy for a cancer diagnosis too. I remember the white noise of anxiety drowning out my ability to hear all of the information presented to me during the early weeks that my treatment plan unfolded.  The surgeon, who was very good, wanted to do a biopsy of my lump in his office. It’s done all the time. I wanted the lump removed, under conscious sedation. That required an OR, and an anesthesiologist, the surgeon informed me. “That’s what I have insurance for,”  was my reply. I know too much about procedures.  I trusted my surgeon, and I wanted to be out while he did what he needed to do.  A member of  his office staff chided me about the request: “You’re a baby, I’ve had several lumps removed in this office myself, and went back to work afterwards.” I complained to the surgeon about the inappropriate comment.

   Like a frightened child, I didn’t want to lie still.