[As written/circulated 2008-09 for the Barnes-Jewish Hospital Ethics Committee members]
Soon after beginning my position with Barnes-Jewish Hospital two years ago, I started rounding with Dr. Laureen Hill and her medical teams in the CT-ICU. One of our first collaborations was to identify vulnerable facets of patient care communication that, when they falter in some combination, result in a deterioration of trust and respect. As the following tool indicates, we eventually focused on three vulnerabilities -- i.e., (1) the information upon which patient care decisions are made, (2) the decision-making process, and (3) the goals/expectations that influence patient care decisions. This tool provides a construct for examining each vulnerability in two steps -- first with a description and then with a set of assessment questions.
The aim of this tool -- to aid in strengthening the ethical dimensions of patient care proactively and preventively by focusing attention on and raising accountability for the communication infrastructure upon which patient care depends. The hypothesis of this tool – If the overall assessment of these three facets of patient care communication in a given case is on the strong/reliable side of the threshold, it is safe to assume the ethical dimensions of the patient’s care are sound. If the overall assessment is on the weak/unreliable side of the threshold, it is safe to assume the ethical dimensions of the patient’s care need attention. If one of the three facets of patient care communication is assessed to be broken in a given case, the interconnectedness of the three facets of patient care communication makes it safe to assume the ethical dimensions of patient care associated with the other two facets are at significant risk.
In didactic sessions, I often introduce this tool by first showing the participants several photographs that illustrate various stages of bridge or building deterioration and asking them to explain the engineering concept of a bridge or a building having ‘structural integrity’ -- i.e., “the science and technology of the margin between safety and disaster” (e.g., fatigue/fracture of materials, crack initiation/growth, the capacity to handle unexpected/overloading stress). I then transition to the ethical dimensions of patient care by suggesting that bridges and buildings be considered metaphors for the delivery of a patient’s care from admission to discharge. Such visual aids are usually effective for preparing the participants to explore the link between the ‘structural integrity’ of the communication upon which patient care depends and the ethical dimensions of patient care. I close such discussions with the question – “Who is responsible for regularly assessing the communication upon which patient care depends?” The most common response – “We all are”. I remind them of the old adage/warning – “Something that is everyone’s responsibility often/easily becomes no one’s responsibility”. And I take advantage of the opportunity to reinforce recognition of nurses’ strategic position for assessing the communication upon which patient care depends.
“When does trust commonly break down in patient care?”When I ask caregivers this question, they invariably respond – “failed communication”. A proactive and preventive approach to the ethical dimensions of patient care encompasses ‘communication’ within its scope.
Soon after beginning my position with Barnes-Jewish Hospital two years ago, I started rounding with Dr. Laureen Hill and her medical teams in the CT-ICU. One of our first collaborations was to identify vulnerable facets of patient care communication that, when they falter in some combination, result in a deterioration of trust and respect. As the following tool indicates, we eventually focused on three vulnerabilities -- i.e., (1) the information upon which patient care decisions are made, (2) the decision-making process, and (3) the goals/expectations that influence patient care decisions. This tool provides a construct for examining each vulnerability in two steps -- first with a description and then with a set of assessment questions.
The aim of this tool -- to aid in strengthening the ethical dimensions of patient care proactively and preventively by focusing attention on and raising accountability for the communication infrastructure upon which patient care depends. The hypothesis of this tool – If the overall assessment of these three facets of patient care communication in a given case is on the strong/reliable side of the threshold, it is safe to assume the ethical dimensions of the patient’s care are sound. If the overall assessment is on the weak/unreliable side of the threshold, it is safe to assume the ethical dimensions of the patient’s care need attention. If one of the three facets of patient care communication is assessed to be broken in a given case, the interconnectedness of the three facets of patient care communication makes it safe to assume the ethical dimensions of patient care associated with the other two facets are at significant risk.
In didactic sessions, I often introduce this tool by first showing the participants several photographs that illustrate various stages of bridge or building deterioration and asking them to explain the engineering concept of a bridge or a building having ‘structural integrity’ -- i.e., “the science and technology of the margin between safety and disaster” (e.g., fatigue/fracture of materials, crack initiation/growth, the capacity to handle unexpected/overloading stress). I then transition to the ethical dimensions of patient care by suggesting that bridges and buildings be considered metaphors for the delivery of a patient’s care from admission to discharge. Such visual aids are usually effective for preparing the participants to explore the link between the ‘structural integrity’ of the communication upon which patient care depends and the ethical dimensions of patient care. I close such discussions with the question – “Who is responsible for regularly assessing the communication upon which patient care depends?” The most common response – “We all are”. I remind them of the old adage/warning – “Something that is everyone’s responsibility often/easily becomes no one’s responsibility”. And I take advantage of the opportunity to reinforce recognition of nurses’ strategic position for assessing the communication upon which patient care depends.
