Interview of Theresa Brown, RN on Her New Book "Healing" (Part 2)

Subscribe:

To make sure you don't miss an episode, be sure to subscribe today! Please rate and review the podcast.

Automated Transcript:

Mark Graban (2s):
Welcome to Habitual Excellence, presented by Value Capture. This podcast. And our firm is all about helping you and your organization achieve Habitual Excellence via one unifying focus, one value-based structure, and one performance system. In other words, it's about helping you capture dramatically more value through achieving perfect care and perfect safety for patients and staff. To learn more about Value Capture and our services visit www.valuecapturellc.com. Hi, this is Mark Graban. Welcome to episode 65 of Habitual Excellence. Today is part two of the discussion that we started last week in episode 64 with Theresa Brown author of books, including her most recent healing.

Mark Graban (51s):
So I hope you enjoyed part one of the episode. Here is again, Theresa Brown, part two...

And the case you referenced RaDonda Vaught is, is the name of, of the nurse. And I wasn't there, I'm not an expert on the case, but my, from my reading of it, I mean, I've, I've seen commentary a lot, especially online, even in nurse forums. Some nurses say, well, if you just read the label on the medication, like the there's this hard line that says, you know, it was egregious, then you know, you, you raise different levels of punishment, losing your job, losing your license. Then there's the whole prosecution and conviction layer and like reading what happened there.

Mark Graban (1m 35s):
I mean, it seemed like there were many, many systemic factors she was working in and she was helping out by working in an area she was unfamiliar with. I think it was in re I believe radiology, and it was somewhat unusual to have to sedate a patient for that. There were time pressures from the doctor and others. And then there was this culture of just kind of ignoring the need for overrides and the factor, like you said about the couple of letters, like there could have been, there were maybe there were cultural factors that could have been better error proofing in place to not set her up to fail.

Mark Graban (2m 16s):
And I'm not a lawyer, but it seems like there's often like, you know, kinda mitigate relative legal liability where I don't think anyone is saying she's blamed less, but it seems like the system and society is punishing her. And I don't know where, where, where the, where the hospital is. And it assume like they're, they're blaming the nurse when the, it begs questions of, so what are you doing to prevent this from happening again?

Theresa Brown (2m 48s):
Right, right. And too right. Two points that you brought up one again, there's that very hard line culture, you know, it's clearly marked as a paralytic her mistake. I would never make that mistake. No one, no one, except someone who's really stupid and doesn't care would make that mistake. And that's it. And there is that strain in nursing. I know that. And it's PR it's probably there among physicians also, and it's just, it's so problematic. And like you just said, we can admit this was a very, very serious error.

Theresa Brown (3m 32s):
And she knows that like she never denied that she reported it and that's the other issue. And that actually, I just got my, my COVID booster last night and the pharmacist was talking to me about this just totally off the cuff about, we do not want a system that encourages people to lie and hide things.

Mark Graban (3m 57s):
And it sounds like from, from my reading of the reports and everything that happened there, that this error could have been covered up. And I'm not saying people should cover it up, but I think that fear factor now will prevent people from speaking up in ways that would prevent future errors. That's why I think, you know, this, this, this transparency and this focus on learning and improvement more so than retribution and punishment is something people talk about in the patient safety movement. A lot of groups, the Institute for safe medication practices and the Institute for healthcare improvement and, and, and, and some bleeding voices in the healthcare quality movement has spoken up very loudly about how this conviction is a big setback for future patient safety.

Theresa Brown (4m 48s):
Yeah, definitely because if you think, wow, if I make a mistake and I report this, okay, it's one thing to lose your job, to lose your license, to go to jail. Right. And I read the da said, well, it, that the DA went out of his way to say, this is not about nurses. This is about this nurse, but also said, it's like she was driving drunk. And I thought, it's absolutely not like she was driving drunk. She was at work. Like, I mean, if she was drunk at work, okay, that's different. But she was working. She made a mistake, a very bad mistake within an incredibly chaotic system.

Theresa Brown (5m 34s):
And to get back to you saying, if she could have said, I have a concern, this looks very different from when I've given this drug before I have to reconstitute it. It says, you know, but it is very familiar to feel like, even though everyone says, oh, you know, ask if you have a question ask, but then it can be, you don't know that, like what, what are you thinking?

Mark Graban (6m 3s):
Sure. The, the, the shaming that comes from speaking up and you, you, you write a lot Theresa about maybe the word pride applies. You wrote in "Healing" how it, wasn't easy to write about a mistake that you disclose you wrote about in your book, "The Shift" giving an injection of a steroid. Can you tell that story briefly? And like some of the, your reflection of why it was difficult to even put that into writing?

Theresa Brown (6m 37s):
Yeah. So very quickly that I was working outpatient oncology at that point, and someone had been ordered, I'll just make this up. Let's say 45 milligrams of, let's say 60 milligrams of dexamethasone. And so I don't remember the exact details and it comes in 20 milligram vials. So I went and pulled up three 20 milligram vials into a syringe and gave it slowly to the patient.

Mark Graban (7m 5s):
And I think you said it was like three times what the normal injection might be, might normally be a viral,

Theresa Brown (7m 12s):
Right? Yes. And so I thought this is really weird. I've never done this before, but we were working with a bunch of different doctors and, you know, that's the other thing that the problem of lack of standardization. So you just kind of felt like, well, this is weird, but we do a lot of weird. So, and then I was looking at the order, which I think had been faxed in and written over on the side. Very, very pale was to put the dexamethasone in a small bag and run it over 15 minutes. So I literally, when I saw that one, I literally wanted the ground to open up and swallow me.

Theresa Brown (7m 58s):
I felt so terrible and told the supervisor, and she said, go call the doctor. And the doctor was fabulous. It's like he said, oh yeah, I don't think that's going to, you know, my cause her pressure to drop. So monitor that. Yeah, fine. Very reassuring. Just really wonderful because I felt so, so bad. And that's the other problem in nursing. At least there's this culture of, you can never make a mistake.

Theresa Brown (8m 38s):
And the reality is we're human. We're gonna make mistakes. And so then you need to create a system that makes mistakes a lot less likely. So like I say, why can't we have a standardized order form? Why does every doctor use own for...

Mark Graban (8m 58s):
Well, and why are we relying? I mean, it seems like such a vivid illustration of a system problem that faint handwriting, which might not have looked faint originally. But however, it came through the fax didn't come through well. And like you said, if it, if that's not a standardized form in some way, I would make the case, you weren't set up for success there.

Theresa Brown (9m 22s):
Yes. And, and that gets me to another thought I often had as a nurse, that healthcare is still such an oral culture. And it's as if we haven't adapted to the complexity of so many more drugs than they had 50 years ago, you know, so many more technologies. And as a patient, I really felt that I, I didn't understand why can't they just give me a piece of paper that says here's an algorithm of what might happen. Here's the order. We would like things to go in for you. And then on the other side could be a list of physicians, right?

Theresa Brown (10m 6s):
I mean, they gave me the names of some surgeons. And again, I asked my friend for a recommendation, very, you know, it's the rare person, right? Who has a breast surgeon, who's a good friend, but the lack of anything in writing, like we know that people go into appointments and they don't hear what is said well, and my husband would come with me. So between the two of us, you know, it was like, we would have one brain. Cause he, he had his own feelings about his wife having breast cancer. And I felt like every time I should leave with a piece of paper that tells me something,

Mark Graban (10m 48s):
I, I mean, I've heard patients who want to record those visits and sometimes doctors don't want them doing that. It's for their own reference. So I could go back when I'm maybe in a different state of mind or clear-headed to go back and make sure I heard it correctly. Cause even notes could be incomplete or inaccurate.

Theresa Brown (11m 8s):
Right. And yeah, it's, that is really, really a puzzle to me for why there isn't, I mean, every hospital could do it or we could have a national database, but of course, then everybody would argue about what goes in it, but sort of, you know, here's the, here's the 10-minute video you can watch about having breast cancer. And there was a video they made about exercises to do after lumpectomy, which, which I did, but you know that there's, there's at like where's the breast cancer app, you know?

Mark Graban (11m 48s):
I mean, I think there are online communities. I have friends who have been cancer patients where they really rely on kind of a peer group network of other patients. There's a society for empowered patients. I forget the, I, I think I have the name slightly wrong, but people are trying to fill in those gaps in different ways.

Theresa Brown (12m 11s):
Yeah. And I, and that's where I found help with Tamoxifen. I, I, as I talk about in the book, I made a decision to try and not spend a lot of time online because I'd seen so many patients and family members look online and end up being terrified by what they saw there. But I did find some chat groups talking about Tamoxifen and how hard it was to be on it. And that made me feel a lot less alone. That was very helpful.

Mark Graban (12m 45s):
One of the things I wanted to ask you about, and this is something you wrote about in "The Shift" and you did use the phrase too proud. You wrote about being too proud to speak up, to share a concern with a manager that a shift's assignment was as you called it potentially overwhelming. I'm curious to hear, you know, your, your thoughts on that. And then there's kind of a follow-up question when it comes to nurses being overburdened and nurse/patient ratios, your, your thoughts about different efforts to sort of try to mandate limits on patient/nurse ratios.

Theresa Brown (13m 20s):
Yeah. Again, the question you asked is where at another one of these situations where whatever gets thrown at you, you're supposed to be able to take it and to say, this is just, this is too much, you know, why, why am I the person who has five patients or, you know, why do I have the person who needs chemo every two hours? I mean, one day at work I had, we had a protocol that basically was chemo almost every two hours. That's one of the pre-transplant protocols where we're sort of just wiping out their immune system. And I had two patients on that protocol that day.

Theresa Brown (14m 3s):
Right. But there's this feeling of, and it's probably my personality, probably the culture of, I don't want to be that person who's "whining. This is too much for me. I can't do this. You know, instead of, instead of like an adult saying, this is not a safe apportionment of patients, which yeah, that's a problem. But I, I do agree with staffing ratios because unfortunately it seems like that's the only way to get enough nurses on staff. And I've said this so many times and I'm sure that people listening to this podcast, most of them are aware of this issue, but because nurses don't bring in income, we're seen as an area of labor costs only.

Theresa Brown (14m 53s):
And so, oh, we want to cut labor costs. Let's cut nurses. I'm sure it's never quite that cut and dry, but that's how it feels when you're working on the floor. And then there are these situations where you're always working a little bit harder than you should be. You have too much to do, then you can really get done. And it's, it's not a question of laziness or not wanting to work hard. It's about not being able to give patients the attention they absolutely need. And, you know, I worked with very sick patients who were often getting blood transfusions, who were getting chemotherapy, who were getting experimental drugs, who are at risk of systemic side effects, you know, neurological problems that would onset because of some of the infections that could come with the stem cell transplant, they were on immune suppression.

Theresa Brown (15m 54s):
You know, they were really, really complicated patients and a nurse needs to have time to have eyes on those patients as we call it. So I wish I didn't feel like ratios were necessary, but it seems like nothing else is maybe gonna make that happen. And the one thing I wish people would think about also is there is data coming out now that shows the cost of not having enough nurses. So, you know, urinary tract infections go up falls, go up. I'm imagining that civil suits sometimes go up or malpractice suits go up.

Theresa Brown (16m 39s):
But I feel like the people who deal with that pot of money, don't talk to the people who are looking at the labor pot of money. And I really would like for those two people to talk to each other and the, you know, there could be a sense of we're investing in the overall good environment for our patients. I just read this book called, oh, I'll holds right here. Patients come second.

Mark Graban (17m 9s):
Oh yes. I've interviewed Paul Spiegelman. He's one of the authors. Yeah.

Theresa Brown (17m 17s):
Yeah. And wrote about it for the American Journal of Nursing about invest in your staff and you're going to get good results, which just makes sense to me from an experiential perspective, I wish they had had more data in this book about money, but the argument is great and it, it makes sense to me. And now this, all these issues so important because we're coming off, COVID a lot of nurses have quit nurses have left regular jobs to become travel nurses.

Theresa Brown (17m 58s):
So we have ended up with this healthcare environment that is fragmented, even if it's well-staffed and maybe well staffed by people who have no loyalty to that particular institution, which I don't mean they're disloyal. I just mean they don't know who the people are. They're not there for the long haul. You know, they're there to show up, do their job and then leave. And they may be fantastic at doing their job, but this whole relational piece is going to be missing. And you need that.

Mark Graban (18m 31s):
Yeah. Well, I could see where if, if the nurses aren't feeling properly taken care of, for lack of a better word properly supported in, in their work environment in different ways, the temptation would be say, well, if it's, if it's gonna be lousy, I might as well get paid more to put up with the lousy. And that's, that's unfortunate that it even gets to that. You know, you're talking about staffing levels. You also write a lot in "The Shift" about like under your theme of just, you're supposed to just take it, like nurses not getting breaks or time to eat that has a direct impact on fatigue and errors and the health of staff members.

Mark Graban (19m 16s):
That sounds like a systemic issue. You, you write about some of the trade-offs of like, you know, the 12-hour shifts are shown to increase the risk of errors because of fatigue, but then say, people will say, well, but now we get better continuity of care. I'm like, well, do you want, like, how can we have both? Can we improve "The Shift" handoff process in a way that reduces fatigue without creating other problems? I threw a lot at you there, but I'm just curious about your thoughts around the issues of fatigue from shift lens, then breaks and lunches. What can or should we do about that?

Theresa Brown (19m 51s):
Those are such great questions. And I'm thinking we would often say on the job, you know, I wish I wish I could get a break where I could leave. Y you know, I need to get something from the drug store. And there was one that was about us. Seven minute walk away. I wouldn't on my lunch break. I could walk to the drug store, pick up what I need and come back. But you can't because who's going to take your phone. And it's, I think it's really hard for people to understand what it, it almost feels like being a servant in a way that, you know, you can't leave the hospital because there's no one to take your phone for you.

Theresa Brown (20m 33s):
And your phone is your connection to everything that's going on with your patients. And there are hospitals where they have lunch nurses come in and then there are, cause I know when I went to MD Anderson a few ago to give a talk, they said, then the problem they had was nurses single. I can't leave my patients know this sort of, no one can take care of my patients as well as I can, like yeah. For half an hour, someone else can take care of patients. So it can become a kind of, again, that sort of, I would call it a maladaptation to the work environment is no one can do this as well as I can. So that is definitely a problem.

Theresa Brown (21m 16s):
You know, that walking across the street to go to Starbucks, felt like a huge treat because you actually got to get outside and breathe some fresh air and just leave that environment. And everyone needs breaks. Wait, there was another really important thing you're asking me. Can you remind me what the,

Mark Graban (21m 39s):
So tell me about the 12 hour shifts and the dynamic of fatigue versus handoffs

Theresa Brown (21m 45s):
Shifts. So this was fascinating to me when "The Shift" came out, I did a whole bunch of interviews similar to this one. And these were just interviewed by all kinds of people, right? Like mostly radio people, not healthcare people, the point being and to a person, pretty much, they all asked me about 12 hour shifts and they didn't ask me like, huh, they asked me like, isn't that a really bad idea? And it stunned me because I thought in a good way though, because I had no idea the public thought about that or cared about that. And I would say, yeah, you're right.

Theresa Brown (22m 26s):
There's clear evidence that after 10 hours errors go up and it was clear that people would feel better if nurses did not work 12 hour shifts. So yes, you, you get to the sticking point though, which is I w and I've sent this five of my patients for 12 hours. I don't have to worry that any balls are going to get dropped. You know, again, it's like kind of, I'm looking out for them and, you know, w which, which we are, but yes, couldn't, we do handoffs better. Couldn't we have an electronic record system that was actually helpful rather than just being sort of a mass of data.

Theresa Brown (23m 9s):
That seems like it does nothing for the people actually using it. I mean, just, just imagine if you actually really had a task list that was real tasks that you had to get done. And, and I would just add to that during the day. So the person coming to take over for me would have that it would just already be there. You know, these are the really important things you're going to need to think about. Cause we, we do handoffs, but to think of it could be into the electronic record would be one. I mean, that's a whole nother piece.

Theresa Brown (23m 50s):
Like why do we have these electronic health records that don't do anything for the actual clinicians, but yet it's interesting too. When, when interns had their hours restricted, there was a lot of complaining, right? That we'll, we're not, we're not getting that continuity of care. And then it turned when you people start talking about it, it turns out that their handoffs are terrible, that they were so bad at handoffs. And I said, so improve the handoffs.

Mark Graban (24m 20s):
Yeah.

Theresa Brown (24m 21s):
Right, right. But, and that gets to another problem of, yeah, but we've always done it this way. And we're all these really smart, educated people. Right. And this is, I love telling this story on the bone marrow transplant unit, we had one of the drug rooms where the Pyxis was, and there was the Pyxis and then a refrigerator and the refrigerator door opened out. So if someone was getting medications out of the refrigerator, nobody else could use the Pixus. Right. It's not, not well done. And I was in there one day and one of the facilities, people wasn't there and he said, you know what? I can move that door.

Theresa Brown (25m 2s):
So it would open the other way. And I, and I was in a hurry and I said, you know what, when I first started working here, I would have really cared about that. Now I don't even think about it.

Theresa Brown (25m 13s):
Yeah. And it's like, I've gotten conditioned to think of everything being harder than it needs to be.

Mark Graban (25m 20s):
And, and, and so that point, before we wrap up, I wanted to ask you there's, there's overwork, there's fatigue. And then unfortunately, there's burnout. You, you said in, in "The Shift", this is another thing I highlighted here. One of the key factors in burnout is employees feeling like they have very little control over their work environment. That's pretty much status quo in hospitals for nurses and doctors. That's one thing that at valley capture, we really try to help change that culture where it's not even feeling like it's actually having control over elements of the work environment. And, and it's sad to hear you, you know, to, to, to see, right.

Mark Graban (26m 3s):
I, I probably wouldn't disagree with it from my observations of, of that being the status quo of having little control over the work environment, if just fighting through things, working around tolerate and getting used to, instead of improving, it's a big, heavy question, but have you, have you seen, or do you have thoughts on how we can start shifting some control of that environment to the caregivers?

Theresa Brown (26m 32s):
Yeah. That is a great question. And for me, and I've written about this, and I know this is a multi-million dollar problem, but how the, the electronic health records we use now are mostly set up for billing. They take a huge amount of time. Things are always being added on to them. So we have to do more. And I found that just enormous in terms of taking me away from the bedside, this incredible amount of pressure I fought to get the charting done every day.

Theresa Brown (27m 14s):
And then it's not useful to me. Like so much of the information was not useful, which gets back to no, why would I go in for a mammogram? Do I have to write down all that information? Well, because they can't print it out easily in a way that's useful. So why do we have record systems like that? I know the answer to that question. So that's one thing, because it just eats up a huge amount of time. And then it's this weird thing where we get judged on our charting know in nursing school, you're taught, if it isn't charted it isn't done.

Theresa Brown (28m 1s):
And the presumption is, if it's not charted, you didn't do it. There's never a presumption that, well, you just didn't get it charted. And I, for whatever reason, found that just incredibly difficult. I know I'm not alone in that though. That's a pretty common feeling. And, and the other thing would be yeah. To, to get rid of that toxic culture. That's so suspicious of people saying, I have a concern, or I'm not really sure I'm supposed to handle this patient. I mean, this, this did happen to me. Once someone getting continuous bladder irrigation and on the floor for patients was standard.

Theresa Brown (28m 49s):
And then we were getting an admission of family that was notoriously difficult to handle. And my manager gave me that couple. And so here, I've got someone continuous bladder irrigation means they have to constantly be getting fluid going through their bladder and you can't let it run dry. And then all of a sudden I'm getting an admission, the family that when they show up, the wife wants this and this and this and this and this and this and this and this and this. And my manager knew that. And I didn't feel like I can say, how exactly am I supposed to be doing continuous flood irrigation when Mrs. Acts is going to want me to be in their room for an hour when they first get here.

Theresa Brown (29m 33s):
So instead of having a sense of assignments or sort of punishments or challenges, there just needs to be so much more of a sense of what is good care. And for me, that really comes down to professionalism and, you know, the, the letting people be nasty to each other, you know, criticizing someone because they called a code and maybe they shouldn't have all this. You can call it all different things. But to me, it's a lack of professionalism. And if someone says, I have a concern, the first response should be, I have to listen to that.

Theresa Brown (30m 17s):
So those are two things I can think of right off the top of my head. And if there was more help available, I mean, it, in nursing, it drove me nuts to have the charge nurse be someone who would just walk around with a clipboard would never help. And it was, I gave a talk at Intermountain. Actually, they, they have a book club and they read this shift. They had me come out to talk about this shift. And, and I was talking about how you have some charge nurses. Like some charge nurses will take every admission and get that person settled. And then they, they hand them off to a nurse and some walk around with a clipboard and they don't do anything.

Theresa Brown (31m 2s):
I don't know what they're doing with the clipboard. And they said an Intermountain that they had just standardized the role of the charge nurse. And there were people who said they didn't want to do it anymore.

Mark Graban (31m 13s):
Well, there's something else that could do. Maybe them as if they're not supporting the nurses in the patient care. I mean, yeah. Sometimes redefining that leadership role means other people are going to select out her select in maybe that's for the best.

Theresa Brown (31m 31s):
Yeah, no, I agree with you. It's I mean, and as a new nurse, our, we had a nurse practitioner who was supposed to help on the floor and she would say, well, you're feeling stuck ask the clinicians. And that was the clinicians who have the worst bullies. That was my first job. And I remember once going to want, you know, this is not work because of this person. This is what I was told to do. So I'm going to do it. And I said, can you help me with this? And she just looked at me like I was an idiot and said, no. So to feel like, ah, I feel like I'm drowning. Can someone come help me? Well, the water is still here instead of, you know, here, that would, that would be huge.

Mark Graban (32m 17s):
Well, so as, as we wrap up Theresa and thank you for spending so much time with me here today, again, our guest has been Theresa Brown author of books, including "The Shift". Again, that was a New York times bestseller. Her, her new book are very personal journey. As, as a patient, the book is called "Healing: when a nurse becomes a patient" and, and, and at the end here, I just wanted to share, I mean, in the epilogue, you said as a nurse, I told myself that if the system failed patients, I could make up for it by working harder, better and longer. Sometimes that was true. But then, you know, you say, you have to admit any one person giving 120% to the job just to paraphrase camp can't balance out the problems in the system.

Mark Graban (33m 6s):
It leads to fatigue. It leads to burnout from people having to do too much. So, you know, that's something I, you know, we're, we're, we're inspired to try to help change those circumstances. Those systems, that culture is you described so vividly and your books and as he did here today. So I'll, I'll, I'll leave you with, with the final word, if there's anything else that you want to add on that or anything else that you want to say to wrap up?

Theresa Brown (33m 34s):
Oh, thanks, Mark. Well, this has been really fun. And I think the strength of this and the, the work you do is the thoughtfulness that goes into it. And I think most people in healthcare are good people. They want the best results. And I think that goes all up the chain of command, and we need more thoughtfulness about what people are going through and what the people who take care of them are also going through.

Mark Graban (34m 6s):
Well, thank you for sharing. I'm sorry.

Theresa Brown (34m 8s):
Oh, just I'm hoping for a reset after COVID. That's my wish.

Mark Graban (34m 13s):
I hope I hope we get that. And I want to thank you Theresa for sharing, you know, all of your stories and your experiences and your efforts to help open people's eyes and do things to help drive improvement to the systems for, for patients, for caregivers, for everybody involved. So thank you. Thank you again for joining us today.

Theresa Brown (34m 32s):
You're welcome. My pleasure.

Mark Graban (34m 35s):
So again, we've been joined by Theresa Brown. Her website is TheresaBrownRN.com. Please look in the show notes to look for links to her books and the website. Thanks again.

Theresa Brown (34m 46s):
You're welcome.

Mark Graban (34m 47s):
Thanks for listening to Habitual Excellence presented by Value Capture. We hope you'll subscribe to the podcast and please also rate and review it in your favorite podcast, directory or app to learn more about Value Capture and how we can help your organization on this journey to Habitual Excellence. Visit our website www.valuecapturellc.com.