Just Wrong: Three Simple Fallacies

RobbiRN, RN

Several articles have been published in past the few years listing various myths about nurses. Some are silly, like "all nurses marry doctors" or "all nurses are women." Some might be more believable by those on the outside, like "nurses follow doctor's orders." Yes, when it is reasonable to do so, but, no, when it isn't. Nobody mentioned the three myths at the top of my list:

"If you didn't chart it, you didn't do it."

The cliche is usually thrown out as a reminder that we will only have what we chart to defend ourselves if we ever end up in court. In the extremely rare cases we face a deposition, there are certain pertinent details we would want in the record, but the notion that our ongoing charting documents everything we do is ridiculous. A few bits of the history we enter will be helpful for other team members down the road, what medications were given, a trend in vital signs, or maybe even a few significant details from our narrative. The majority of what we enter- that we cleaned a patient up after BM, turned them to keep them off a pressure ulcer, various nuances of their pain scores, the character, intensity, frequency - falls into a digital trash basket, never to be seen again. A lot of the minuscule charting we do is arguably wasted, recorded "just in case." The truth is, no matter how meticulous we are in recording pertinent details, we never come anywhere close to charting everything we do.

For example, let's try the first ten seconds of a patient encounter: "The wooden door to room six is cracked open. I knock assertively at a level which can be clearly heard above the noise coming from the room while trying to avoid sounding demanding or overbearing. I also say, 'Knock knock, are you dressed?' before pulling aside the curtain, ceremoniously squirting sanitizer on my hands and overtly rubbing them together as I say, 'Hello, My name's Robbi. I'm your nurse here today.' As I speak, I make the following observations: The patient appears to be in her mid-thirties. She is moderately overweight, with good skin color, moves all extremities freely, and has no obvious injuries or signs of distress. A male visitor is leaning back in the chair working his cellphone with his feet up on the rails, soiling them with various pathogens from the bottoms of his shoes while obstructing access to the left side of the stretcher and the monitor. A toddler is spinning on the stool, using it for a miniature whirly bird, presenting an imminent risk for injury." Ten seconds of activity from the knock to the greeting takes nearly two minutes to write out at a 60-word-per-minute data entry speed. Extrapolated over a 12-hour shift, it would take about 144 hours to chart a remotely accurate approximation of everything that happens.

I've been deposed once in 25 years, in a case where the doctor settled because he didn't want the legal battle. The scant written record and my own standard of practice (I chart largely by exception) were enough for me to reconstruct the interaction to my satisfaction. We chart what is essential and cut corners when necessary. Even when we chart well, we barely hit the highlights. Ultimately, charting represents a scant, incomplete record of a very complex, fluid, psycho-social situation in which more than ninety percent of what we do will never be recorded.

"Patient satisfaction is a legitimate measure of appropriate care."

Let's start with the blatantly obvious: "Patient satisfaction" is what turns most people into patients in the first place. Assuaging one craving after another and poor lifestyle choices are the root causes of most illnesses. Our ER sees bizarre extremes of "satisfaction" daily: The COPD guy who signs out AMA, goes to the parking lot, chain smokes for thirty minutes, then gets the security guard to wheel him back in with an oxygen saturation of 74, respirations of 48 and dusky extremities; or, the IV drug user in with cellulitis in her foot because that's where she goes now that "all the veins in my arms are shot;" or, the 337-lb patient declaring that her stupid doctor can't get rid of her knee pain. "He tells me I needs to lose weight, but my friend weighs 457 pounds, and her knees don't hurt, so don't tell me it's the weight." In our evolving the-customer-is-always-right approach to healthcare, questioning lifestyle choices increases the risk of creating unhappy thoughts which may morph into a low satisfaction score.

Increasing service expectations by visitors present more distractions from our primary responsibility, patient care. Last week, I had a guy with an obvious ankle deformity. The minute I got him on the stretcher, the wife asked, "Could you get me something to drink, some snacks for the children, and some coloring books or something to write on?" I replied, "I'll be happy to. Would it be ok to finish covering his history and get him medicated first? I may be wrong, but it looks like he broke the ankle." I said it nicely, without sarcasm, like I was asking her permission. She consented but stopped short of withdrawing any of her requests.

The new nomenclature of calling patients guests, clients or customers misses some very significant differences. Customers pay, and they can buy what they want. Here, they often don't pay, and they can't have a narcotic just because they want it. Most business will call the police to have hostile or verbally abusive customers removed, but we are expected to absorb considerable aggression under the often-false assumption that there is a serious medical condition causing the abusive behavior. In the hospital, the customer needs to be satisfied, not trespassed or arrested. Even after lengthy explanations, many patients insist on poor choices for treatment or reject reasonable testing even in life-threatening situations. An AMA form protects their choice and limits our liability a bit, but they go home angry.

Yes, nurses should be professional, courteous, compassionate, and assertive when necessary. But, excellent, appropriate care will never guarantee patient satisfaction. ("I'm on five antidepressants and I'm still not happy.") Is patient satisfaction a legitimate measure of appropriate care or a valid basis for government incentives? No. Multiple studies have demonstrated that increased patient satisfaction leads to increased morbidity. The satisfaction goal is a pathetic, misdirected focus causing unwarranted anxiety and guilt among providers. This destructive fallacy needs to be exploited and removed from its lofty perch.

"No good deed goes unpunished."

You discharge a patient, get briefly caught up on your work, and spend several minutes helping a coworker. Your reward? A septic, 320-lb paraplegic with chronic bedsores and a full diaper lands in the room you just emptied. Your coworker shrugs. "No good deed goes unpunished." The prophesy rings true, again, or at least it feels that way.

Actually, every good deed is rewarded, but not always in ways that are clearly evident. A highly-regarded healer tells a simple story from a time and place where many worked as day laborers. Each day, men went to the market hoping to be hired so they could return home with food for their families that evening. There was nothing worse than going home empty handed if they couldn't find work. In the story, the owner of a vineyard goes to the market place three times to hire workers, first early in the morning, again in the middle of the day and once more late in the afternoon. At the end the day, he pays them all the same wage, beginning with the ones hired last. The ones who were hired first grumble because they were not paid more than those who worked only a short time late in the day. The master responds, "I paid you what I said I would pay you. Why do you begrudge my generosity?"

The story is well known, but it is often separated from the question that precedes it. It is told in answer to this question: "Master, we have worked with you from the beginning. What will be our reward?" When you put the two together, the meaning is clear and potent. The healer is essentially saying, "You're asking the wrong question. You should be asking, 'How was I so fortunate to be able to work with you as a healer all this time?'" His point is that the opportunity to heal is the reward. It's still true.

We often work understaffed and overrun, solving one crises after another as twelve hours dissolve into a blur of ER bedlam. Whether we are pulling a chronic drug abuser back from the brink of self-destruction, caring for a guy who got careless with a chainsaw, an anaphylactic reaction to a bee sting, or a sudden onset of SVT, that person's life is in our hands. Even when we are crippled by a cluttered system and flooded with demanding, ungrateful patients, we still get to look ourselves in the eye and know that we met real needs. Our reward goes beyond the paycheck or gratitude. The beauty of our profession is that healing is innately honorable and noble. The reward is inherent.

These three myths continue to dog our profession. They're just wrong. Take a deep breath, do a reality check, let go of unproductive, unwarranted guilt, and be proud of who you are.

Just Wrong: Three Simple Fallacies

"If you didn't chart it, you didn't do it."

"Patient satisfaction is a legitimate measure of appropriate care."

"No good deed goes unpunished."

About RobbiRN, RN

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