Abstract
Most nurses were taught in nursing school to avoid talking over a patient as if the patient were not there. This manuscript describes the author's experience of being talked over as a patient—what it meant to her as a nurse relating to the ethics of the situation and as an educator of future nurses. The American Nurses Association's Code of Ethics for Nurses with Interpretive Statements (2015) addresses the responsibility of nurses at all levels within an organization to sustain a work environment that ensures quality, safe patient care. Nurses who embody this responsibility are knowledgeable, skilled, and mindful of what they say and how they act and interact around, with, and over patients and toward each other.
As a hospital nurse of 30 years and an academic nurse educator for 8 years who studies hurtful peer conduct such as incivility among hospital nurses, I recently got a view of nursing that I have never had before—as a hospitalized patient. While I walked away from the experience with a renewed appreciation of the integral part that nurses play in sustaining the delivery of quality, safe, patient-centered care in health care institutions, I am moved to write about a distressing interaction between two nurses who were directly involved in my care (I will call them Molly and Pam). The situation stirred my thoughts and feelings about something I learned, and I imagine most nurses were taught, in nursing school: Don't talk over a patient as if the patient weren't there. In this article, I explore my experience as a patient of being talked over: what it meant to me as a nurse relating to the ethics of the situation and as an educator of future nurses.
The Situation
I arrived at the hospital early in the morning for a procedure. Molly admitted me to the pre-procedure holding area and placed an intravenous (IV) catheter in my left antecubital vein. When I was transferred to the procedure room, Pam greeted me. When she pushed some fluid through my IV catheter, I grimaced as I reacted to the intense pain, and blurted out “Wow! That burns!” Not saying anything to me, she immediately focused on my IV site. She told me, “You need a new IV.” As she removed the nonfunctioning catheter and then quickly rotated my left forearm from its anterior to the posterior surface, tapping my skin with her fingers in search of a new vein, she mumbled something. I don't know what she said, but I sensed from her body language that she was upset.
I didn't speak up to Pam about how her conduct was affecting me because I was afraid that doing so might make the situation worse.
While Pam worked on my left side, Molly appeared on my right; as she approached, she smiled and reached out for my hand, held it, and looked at my left arm where Pam was working, alternating her attention between Pam's face and my left arm. Pam stopped working, looked at Molly, and scolded her: “Don't use the antecubital.” Neither nurse looked at me nor spoke to me as I lay on the table between them. Instead, they glared at each other while I became the audience to Pam's apparent discontent and Molly's possible embarrassment. Molly squeezed my hand and let go. When she left the room moments later, Pam moved to my right side to look for a vein. After a while, I had a new IV site, and before I knew it, my case was under way. The outcome of my procedure was good.
Talked Over: The Patient's Experience
I saw both nurses as knowledgeable and skilled. However, their ability to care for me physically is not what has stayed with me the most. I did not care that I needed a new IV because the first one no longer worked. Instead, I felt uncomfortable from the cold in the room and scared about my looming procedure. Pam's body language and brisk touch bothered me. Her subsequent interaction with Molly distressed me further. I could not understand whether she was irritated with Molly or me or the two of us. She seemed unable to control the flow of nonverbal communication of her feelings in front of me, and all I could think of was that she was about to insert a needle into my arm. Pam's outward expression of her feelings did not make sense to me, and I wanted her to stop showing her emotion to me. I didn't speak up to her about how her conduct was affecting me because I was afraid that doing so might make the situation worse.
Molly's nonverbal communication transmitted something different. Her touch acknowledged that I was there between the two of them, and the simple act of holding and squeezing my cold hand comforted and reassured me. In contrast, her abrupt departure from my bedside confused me. I wanted her to come back because, unlike Pam's demeanor, Molly's presence was soothing.
Talked Over: Its Meaning to Me as a Nurse
I could relate, as many nurses likely can, to what Pam may have felt in this intense situation. The health care work environment is often extremely stressful. I sensed that Pam acted out her feelings in reaction to the pressure to get my procedure started, an all-too-familiar scenario in which institutional priorities can compete with patient care despite all the bedside nurse's efforts. The only thing slowing the progress of my case was the lack of a working IV; as was typical for me, my veins were hard to find, and I was cold, which did not make the task any easier. Perhaps warming my cold hands and arms would have helped, but that step could have felt too time-consuming to Pam. Maybe her focus on what she was doing and the pressure she felt to get the IV inserted took away from her awareness of how she was acting.
Talked Over: The Code of Ethics for Nurses
While Pam's feelings in this stressful situation may be easy for nurses to relate to and understand, the way in which she communicated them toward Molly and over me is incongruent with some of the provisions in the American Nurses Association's (ANA) Code of Ethics for Nurses with Interpretive Statements (the Code; 2015). The Code describes the ethical obligations of all registered nurses (RNs). Each of the Code's nine provisions articulates the responsibilities of RNs, while the respective interpretive statements provide direction for their application (ANA, 2015). Provision 1 of the Code states, “The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of each person” (ANA, 2015, p. 1). Interpretive statement 1.2 speaks to nurses’ relationships with patients and the significance of trust in establishing these relationships. Pam's knowledge and psychomotor skills were undeniable, but her demeanor functioned as a barrier to her ability to gain my trust.
Pam's conduct stood in contrast to Molly's. It is not clear to me whether Molly felt as much stress as Pam when she came into the procedure room. If she did, she did not show it. Instead, she used touch to communicate respect and compassion and to acknowledge that I was present between the two of them. Because of this, I felt I could trust Molly.
Interpretive statement 1.5 focuses on the nurse's relationships with colleagues and others. Nurses must create “an ethical environment” and “a culture of civility and kindness”; they have “… an affirmative duty to act to prevent harm” (ANA, 2015, p. 4). Pam failed to interact with Molly in a respectful way when she chose to reprimand her in front of me for her choice of IV site. Her admonishment of Molly was uncivil, exemplifying words and actions that violate the respectful interactions colleagues should expect from each other in the workplace (Pearson & Porath, 2009). Pam's uncivil approach violated the nurse's commitment to resolving conflict in the best possible way. As a consequence, her conduct may have harmed her working relationship with Molly. Relationships between nurses may suffer when a nurse experiences hurtful conduct, such as incivility, from a nurse peer (Purpora & Blegen, 2015).
Respectful interactions, civil exchanges, and the best resolution of conflict are some of the hallmarks of relationships that nurses have a duty to construct (ANA, 2015).
In contrast, Molly's conduct was congruent with interpretive statement 1.5 (ANA, 2015). She calmly controlled the contentious situation she found herself in with Pam, likely making the best choice to end the conflict at the moment; she walked away from it, a recommended response in the face of a public display of incivility (Griffin, 2004).
Provision 6 states, “The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe quality health care” (ANA, 2015, p. 23). Interpretive statement 6.3 addresses the responsibility of nurses at all levels within an organization, from first-line staff to executive RNs, to sustain a work environment that ensures quality, safe patient care. This statement underscores that nurses must “… demand respectful interactions among colleagues, mutual peer support, and open identification of difficult issues …” (p. 24). Further, “Nurses should address concerns about the health care environment through appropriate channels” (p. 24). I do not know whether Molly and Pam discussed what happened between them the morning of my procedure, but they had a responsibility to have this potentially difficult conversation. Once I recovered, I felt responsible as a nurse to provide feedback about my experience individually to my colleagues, Pam and Molly. I wrote to them using a feedback sandwich to respectfully describe what went well, what could be better, and what would have helped in their care of me (Milan, 2003). Further, I used a patient survey to describe the pressured environment I saw nurses endure as they tried to care for me in a system that is often unforgiving of any deviation from the schedule.
I use my story as a case study to spark discussion about how to practice with compassion and respect to build trust in relationships with patients, create ethical work environments, and engender civil relationships with colleagues.
Talked Over: Its Meaning for Me as a Nurse Educator
My experience as a patient has informed my teaching of future nurses in two ways. First, I talk with them about why the concept I learned in nursing school—don't talk over a patient as if the patient weren't there—is incomplete. I use my story to illustrate a new version: Don't talk, act, or interact around or over a patient as if the patient weren't there. Second, I use my story as a case study to spark discussion about how to practice with compassion and respect to build trust in relationships with patients, create ethical work environments, and engender civil relationships with colleagues.
Final Thoughts
For most of my life, my view of nursing was from a nurse's point of view. From this perspective, I am a provider of care in a familiar environment. As a patient, I experienced nursing in a new way. As the receiver of care in an environment that was not my own, I felt vulnerable. I saw and heard things from nurses that were confusing and upsetting, adding to an already trying circumstance: being sick and hospitalized. I was reluctant to tell my nurses what I thought and felt about what I saw them do and heard them say. The ANA Code of Ethics for Nurses addresses the responsibility of nurses at all levels in an organization to sustain a work environment that ensures quality, safe patient care. Nurses who embody this responsibility are knowledgeable, skilled, and mindful of what they say and how they act and interact around, with, and over patients and toward each other.
Footnotes
Disclosure. The author has no relevant financial interest or affiliations with any commercial interests related to the subjects discussed within this article.
Christina Purpora, PhD, RN, is an associate professor in the School of Nursing and Health Professions at the University of San Francisco in San Francisco, California.