Is Perception Everything When Caregivers Lack Clinical Skills?

Not long ago, there was a patient at the hospital who was admitted for pneumonia. During the course of hospitalization this patient attempted to get to the bathroom without assistance. She fell. The fall resulted in a hip fracture. She was taken to surgery two days later for the repair. The surgery was successful and the patient was returned to the original floor. Everything seemed to be going well when suddenly she became unresponsive. She coded and was resuscitated but it was unsuccessful. The patient died. A root cause analysis was done over this incident pointing to the fall as the problem and the decision was made to mandate the hourly patient round. Nurses or patient care technicians (PCTs) are to enter the patient room, go over a scripted checklist with the patient that includes pain, elimination needs, and position changes, indicate when they will return, document the round and leave the room. The hourly round is supposed to reduce patient falls, prevent skin breakdown, and cut down on the patient calls between rounds. Most nurses are very busy during their day. They do not have adequate time to round on all their patients and get the rest of their jobs done. This results in skipping hourly rounding while documenting creatively at the end of the day. Managers, in an effort to make sure that all patients are seen, then mandated that PCTs round hourly instead of alternating hours between nurse and PCT as was originally intended. According to our Studer coaches, patients will believe because of the hourly round that we are giving them excellent care if we appear in the room every hour and go over this checklist with them. Do they really?

I saw a TED talk the other evening about perception. “Perception is everything” was the theme. In my field, health care, we apparently agree. Perception is very important. A patient’s perception can mean the difference between getting well and going home or dying in the hospital. According to research done by someone, patients who perceive they are getting excellent care, regardless of the actual quality of the care, are more likely to have a positive outcome than patients who perceive their care is bad (again, despite the actual quality of the care). Do you believe this? I have trouble with it. I have known some nurses who spent hours in the room with the patient, talking, counseling, bathing and documenting but when it came to recognizing clinical deterioration, they were completely clueless. I remember when I first started in this business, nurses could be absolute holy terrors and nothing would ever be said because they were excellent clinicians. They might have the bedside personality of pit vipers but they brought their patients back from the jaws of death and the patients were grateful for it. Usually these were the ICU or ER nurses. The hard core battle axes that stared death in the face and you just knew that death itself was a little intimidated. Was perception as important then as it is now? Or perhaps patients perceived that care would be above par when the nurse was no nonsense and a bit brusk. I don’t think so, however. I believe that at some point in the past 20 years things have changed drastically.

Now don’t get me wrong. I think that it’s important to offer quality and service to patients. Their caregivers should be empathetic and friendly. We see patients on the worst days of their lives. They don’t deserve to be treated like widgets moved through an assembly line. They don’t deserve harsh words or rough hands. They deserve to be taken care of, pampered a little, reassured and comforted when they are frightened. From what I gather, talking to people who’ve been in the patient position over the past sixty to eighty years, nurses were caring. They might have been no nonsense but you could tell that they cared through their actions. That does not seem to be the case anymore, according to these interviewees.

My point is that perception has not always been the be-all, end-all of reality. At least, I didn’t think so. I’ve always believed that intention was a valid element on which to base judgment. We have probably all seen the quote “the smallest act of kindness is worth more than the grandest intention” (Oscar Wilde).  However, I think that action without intention is careless. There is no act of kindness without the intention of kindness behind it. We hawk perception as the cure but is it really? Is it not much more likely that the real problem is that we are lacking caregivers with the clinical skills necessary to offer excellent patient care? This includes the softer clinical skills of empathy, compassion, communication, and the hard won character traits of accountability, integrity and contribution. So rather than focusing on perception as the way to fix a problem with clinical skill, why not address the intention behind the actions. If a nurse does not intend to give excellent care, then she shouldn’t be in the field. No amount of pretense is going to make her give excellent care. It may fool the patients but probably not for long. Someone who is pretending to care won’t be able to keep up the pretense in the face of patient demands where someone who actually cares will rise to the challenge. Conversely, the nurse who truly cares about the patient needs the opportunity to learn and grow in her craft.

I’m the first to admit, it’s not an easy fix. This demands a look into the way nursing is taught. Nursing is not a good job for everyone. It is tough. Not only is there a lot to learn about body systems and disease processes but there are ways of thinking about problems that are absolutely vital for the nurse. Critical thinking is the ability to use the body of knowledge we possess as nurses, along with the most current research, to approach a problem and develop a solution without becoming emotional or panicking. For the new nurse, it takes almost five years to begin to think critically about patient situations. Up until that time, the new nurse is just learning to take care of the tasks that consume her day. It takes that long for her to become comfortable enough with the everyday tasks that she can learn to see the bigger picture. Perhaps by incorporating more clinical time into the nursing program, new nurses would begin a faster transition to critical thinking proficiency.

I believe that instructors need to weed out nurses who do not have the necessary attitude or character. While this might take some specific parameters and attention to detail, I believe it is possible to do. In Medical School, students compete against each other, not only with grades but with procedures. Med schools weed out the students who do not have the grades or the resilience for the program. Nursing programs should do the same. If the student nurse is not at the top of her class she will not be offered a good internship program. If hospitals commit to recruiting only the best and offering nursing internships that would give the new graduate clinical practice and mentoring we might end up with a better quality nursing student and graduate nurse. Instructors could make nursing students compete for procedures. My experience with students on the floor is that they will do everything in their power to avoid work. If they have to be checked off on a number of procedures it stands to reason that they would know how to do some of these procedures when they graduate. If they don’t get the procedures then they don’t graduate and the school weeds outs yet another student who did not want it badly enough. We got away from the diploma schools but maybe that was a bad idea. Could we not combine the book work of the BSN program with the clinical labs of the diploma school? The hospitals that participated would have the added bonus of free student labor and a skilled labor pool from which to choose the best and brightest. It might be worth considering.

I believe there is an urgent need to fix these issues before it’s too late. When the last of my generation is retired, the only ones who will be left are the nurses who are graduating now. The nurses who don’t have the first clue about critical thinking will be in charge of the ICU. The nurses who consider Facebook a good place to complain about their patients will be taking care of you and me. The nurse who thought herself above giving her patient the bedpan, causing a little old lady to climb out of bed over the rails and fall, fracturing a hip, will possibly be a manager or director. In my opinion, that would be a damn shame.


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