Alice shared her recent experience of visiting her friend, Mary following a major surgery to treat a life-threatening cancer. When alice arrived, Mary had the call light on because she was extremely nauseous. Alice sat with her and tried to comfort her.
Ten minutes went by. Ten minutes can seem like a lifetime when you are nauseous, in pain or having trouble breathing.
Fifteen minutes later there was still no sign of help. Alice went out to find a nurse. The halls were empty, but eventually Alice ran into someone in scrubs.
Alice: (Worriedly) “My friend has been ringing for a nurse. She is suffering and no one is coming”.
Staff: (After looking at her watch) “Ah it’s change of shift. Someone should be there soon”
Alice went back to be with Mary. She told Mary that ‘someone would be there soon’. She didn’t the mention the shift change part. Her friend looked and sounded so sick, the supposed justification didn’t feel right. Five more minutes went by. A grueling five minutes for Mary and on top of circumstances that are already so troubling. Again, Alice went out into an empty hall. Walking around a corner she found a group of nurses at the nurses’ station talking. She interrupted them.
Alice: (More worriedly) “My friend has been ringing for a nurse. She is suffering and no one is coming”.
Nurse: (After looking at her watch) “Ah it’s change of shift”.
Alice: (Worried and angry) “I hear it is change of shift, AND my friend is suffering! Please make sure someone sees her right away”
This event took place in metropolitan hospital. As my friend, Alice was telling me this story, she wondered how this could happen. Frankly, I can envision it happening in any facility that is chronically understaffed. Nurses and other staff may be fighting to ensure time is available for change of shift dialogues and no doubt this is very expensive time for an organization. But we shouldn’t shut down the business of healthcare in the process, right? And understanding how this could happen does not justify it.Ten minutes can seem like a lifetime when you are nauseous, in pain or having trouble breathing. Click To Tweet
Change of shift was tragically in the news earlier this month when a NYC Emergency Response System failed to notice an emergency call for four minutes. In this case, 4-year-old Ann Russo, a victim of a hit and run in the Upper West Side of Manhatten died and we know, don’t we, that the first few minutes of emergency care are crucial to survival?
How would you answer Alice’s question?
It is hard to defend, yet with enough staff, cohesive teamwork, and progressive leadership this type of situation can be avoided altogether or readily addressed in the moment. Adequate staffing (at least most of the time) would help prevent this problem because ensuring patient’s needs were met before shift change would have been more likely. In addition, adequate staffing would have fostered teamwork and co-creative problem-solving to ensure that someone was available during shift change to triage calls and either solve the problem or get someone who can. Progressive leadership in this situation includes advocating for staff, role-modeling healthy limit-setting, creating an environment for collaborative problem-solving, and discipline for instances or patterns of neglect.
The top three root causes of sentinel events are; Leadership, Human Factors, and Communication!