Assertiveness in Healthcare – Standing up to Authority, For All the Right Reasons
Clinics are a key learning medium for medical and nursing students. As a nursing student in my third year clinical rotation at a maternity center, I encounter many clients daily, some of whom are faced with gynecological problems. We are expected to interview clients and identify their problems, prepare a care plan and identify some teaching needs on a regular basis.
One morning, as usual I went to interview and assess my client. During assessment and detailed history taking, I realized that my questions to her for e.g. family history, dietary habits and previous antenatal complications, had already been addressed by other health care providers during prior patient interactions. With my clinical assessment, it soon became obvious, from the patient’s gestures and facial expressions, that she was getting irritated by the repeated questioning. Despite the discouraging signals, I tried my best to be friendly and polite, to reinforce her to continue with her story and reassess her condition at regular intervals to identify any abnormality, and to fill any communication gaps to ensure a better treatment plan.
Receiving these sorts of red signals from a patient can be very demoralizing for a young nurse. But I decided not to dwell on this negativity and rather turn this into a source of motivation to learn. Soon after wrapping up my conversation with the client I went through the confidential file; I realized that some components of documentation had errors regarding family history and previous abortions.
According to an article, family history is very important in identifying risk factors, not only genetic diseases but also multi-factorial diseases such as hypertension and diabetes (Daeleman et al, 2013). Hence in my case, the aforementioned patient reported a family history of hypertension, diabetes and stroke, whereas only diabetes was marked positive on the file. I was shocked that even at an esteemed secondary hospital, we either neglect asking common questions or pay less attention while documenting, which causes errors.
I also felt proud of myself that despite facing discouraging patient gestures, I decided to press on with my questioning, for the patient’s sake. After a brief discussion with the registered nurse assigned, she, despite correcting the file, told me that it’s not our mandate; and that as nurses we cannot make any corrections in doctor’s component so just let it be and left. I was expecting a sort of appreciation for identifying an error but it went the other way around, which made my heart heavier.
A day at a new setting had already been sour for me, furthermore, this incident added fuel to the fire. My self-confidence plummeted. After the discussion, I didn’t talk to any other health care professional present in the hospital. Neither did I discuss the incident with my mentor, as I was not sure of how she would react to it. When doctors were on their round, I tried to gather courage to discuss the documentation error, but failed.
In one paper, it was mentioned that when a patient himself, due to some barriers can’t communicate issues and even when nurse herself feel that there is any potential harm to patient then she must advocate for her patient in a professional manner to develop a trusting relationship with patients and their families (Ronnebaum & Schmer, 2015). This thought added to my burden, as I had failed to advocate for my patient.
Later, while I was lost in my personal conflicts, I barely noticed that registered nurse I discussed the patient’s documentation errors with, was discussing something with the doctor in-charge. All I could make out was that the doctor was praising that nurse. I got closer to them and got a little shaky. The reason behind that appreciation was that the registered nurse had pointed out the error, which was at first identified by me, and the doctor was glad seeing this. He acknowledged her in front of the whole staff and stated that her actions showed that she not only cared for the patient but also kept herself busy by reviewing all the files, and we all should take her as an example. I was numbed that moment. I thought I should go straight to them and tell the whole story assertively.
Expressing positive and negative feelings straightforwardly, without any intimidation, can empower assertiveness. It can improve quality of care to their clients, peers, and even themselves (Amicone & Miller, 2015). But I stopped, because I knew this is one skill that I lacked. Well, I was at least happy for the patient that her file is now free of documentation errors and now there is less chance of harm due to medical negligence.
An article entitled ‘Clinical documentation in the 21st century’ (Khun et al, 2015), the importance of documentation in patient health was emphasized, as mistakes can cause physical harm to patient. It is also said that the reason for error is overloading the files with non-pertinent issues. Therefore, physicians must learn to use modern EHR (electronic health records) to eliminate irrelevant things and to avoid misinterpretation of handwritten notes.
The incident I encountered had the same issue – there being so many unnecessary details in the file but important family components were not recorded adequately in the file. And if we talk about EHR, at Aga Khan University, we still go for hand written documentation of patient progress and nurses’ notes, which might posses’ patient at potential risk in near future.
After my clinical posting that day, I gave thought to the whole day spent and tried to identify all the learning points, upon deep reflection, I concluded that firstly, I must not hesitate in taking history from the patient. Secondly, if I find any error in anything which may harm patient in anyway, I must learn to speak it out to the authorities myself. Moreover, I learned to advocate better for the patient. Assertiveness is one skill; I must work on it. I will re-consider all my mistakes as learning points in order to work efficiently as a nurse in the future; for both my patients and myself.
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