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An earlier version of this presentation was presented as the keynote at the 2013 National Nursing Ethics Conference. Why Patient Advocacy is Hurting Patients
Sarah E. Shannon, PhD, RN
Associate Professor
Biobehavioral Nursing & Health Systems, School of Nursing
Adjunct, Bioethics & Humanities, School of Medicine
University of Washington
Clinical Ethicist, University of Washington Medical Center Acknowledgements
Thinking Exercise #1: Rheba deTornyay
“The Nurse as the Patient’s Advocate” 1.Take 1 minute. 2.On a blank piece of paper, write about a time from your own practice when you felt you exemplified being the patient’s advocate.
Patricia Benner
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Anna M. Shannon
Al
Jonsen
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What was the situation? Were other clinicians involved? In what ways?
What was the outcome?
NY Times 2013
March 16, 2013
Theresa Brown, RN
“This particular
doctor was known
for his explosive
impatience. On a
good day his temper
simmered just below
the surface. On a
bad day, he openly
seethed.”
Nursing Ethics: A Short History
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Nurse as the Virtuous Person (ie, Woman)
Nurse as the Loyal Soldier (with the Physican as Captain of the Ship)
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Nurse as the Patient Advocate Nurse as . . . ?????
408 comments
© University of Washington School of Nursing - uwcne.org
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Deluge! The Nurse as Patient Advocate Annas GJ, Healey J.
Journal of Nursing Administration 1974;4(3):25‐
31.
The nurse‐‐a patient advocate?
Donahue MP; Nursing Forum, 1978; 17 (2): 143‐51.
You and the law. Patient's advocate‐‐a new role for the nurse?
Sklar C. Can Nurse. 1979 Jun;75(6):39‐41.
The nurse as advocate.
Kohnke MF. Am J Nurs. 1980 Nov;80(11):2038‐40.
From loyalty to advocacy: a new metaphor for nursing.
Winslow GR. Hastings Cent Rep. 1984 Jun;14(3):32‐40.
IOM Report 1999: To Err is Human
1999 Institute of Medicine Report
 45,000 chart reviews done in 1997 – extrapolated to US
 44,000–98,000 annual deaths as a result of
medication errors - 8th leading cause of death
 Medical errors are the leading cause, followed by surgical
mistakes and complications
 More Americans die from medical errors than from breast
November, 1999
“approximately 100,000 patients die in
the hospital each year from medical
errors and 72 % resulted from
communication errors
cancer, AIDS, or car accidents
 7% of hospital patients experience a serious medication
error
Cost associated with medical
errors is $8–29 billion
annually
Report lays out a comprehensive strategy by which government, health care
providers, industry, and consumers can reduce preventable medical errors.
Concludes that the know-how already exists to prevent many of the mistakes, the
report sets a minimum goal of 50% reduction in errors over next five years.
JCAHO Sentinel Events
HealthGrades Quality Study 2004 
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© University of Washington School of Nursing - uwcne.org
Applied AHRQ (Agency for Healthcare Research & Quality) Patient Safety Indicator software to Medicare data
37 million Medicare discharges in 2000‐2002
Extrapolated to all discharges from every hospital in U.S. (excluding OB):  $6.3 billion annually in excess costs
 191,000 preventable deaths each year from patient safety incidents
2
ED Teamwork Failures
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Retrospective analysis of 54 large closed‐claims cases from emergency depts within 8 hospitals
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Communication / teamwork failures were major cause of adverse events in 80%
Communication Failures
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Risser DT, et al. (1999). The potential for improved teamwork to reduce medical errors in the emergency department. Annals of Emergency Medicine, 34(3), 373‐
383.
Communication Failures
Confidential interviews with 38 randomly selected surgeons in 3 teaching hospitals to elicit detailed reports on surgical adverse events resulting from errors in management Communication breakdowns among personnel were a major contributing factor in 43% of adverse surgical events
Gawande, et al. (2003). Analysis of errors reported by surgeons at three teaching hospitals. Surgery, 133(6), 614‐
621.
Errors by Type of Adverse Drug Event (ADE) and
Stage of Drug Ordering and Delivery
Leape, et al. JAMA 1995;274(1)
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Interviews with 26 randomly selected residents, stratified by medical specialty. Residents described being recently involved in 70 medical mishaps Communication failures were the most common contributing factor to adverse events in university teaching hospital
Sutcliffe K, et al. (2004). Communication failures: An insidious contributor to medical mishaps. Academic Medicine, 79(2).
MD
Ordering
ALL
41
(32%)
2
(5%)
4
(11%)
40
(32%)
87
(26%)
Potential ADEs,
nonintercepted
26
(20%)
25
(63%)
21
(55%)
84
(67%)
156
(47%)
Potential ADEs,
intercepted
63
(48%)
13
(33%)
13
(34%)
2
(2%)
91
(27%)
130
(100%)
40
(100%)
38
(100%)
126
(100%)
334
(100%)
39%
12%
11%
38%
100%
% by stage
 Cross‐sectional design
 82 adult ICUs in 9 European countries and Israel  1,953 ICU nurses and MDs
 Examined perceived inappropriateness of care = specific pt care situation in which clinician acts in a manner contrary to his or her personal or professional beliefs  27% reported perceived inappropriate care (usually “too much care”)  Perceptions of inappropriate ICU care were inversely associated with factors indicating good teamwork RN
Administration
Preventable
ADEs
Totals
Perceptions of Inappropriate ICU Care
Transcription Pharmacy
& Verification Dispensing
Perceptions of Inappropriate ICU Care
Factors OR (95% CI)
P Value
Symptom control decisions (MD only 1.73 (1.17‐2.56)
vs MD‐RN together)
.006
Involvement of RN in EOL decisions 0.76 (0.60‐0.96)
(agree vs not agree)
RN‐MD collaboration (good vs poor) 0.72 (0.56‐0.92)
.02
.009
Freedom to decide how to facilitate own work (agree vs not agree)
0.72 (0.59‐0.89)
.002
RN workload (high vs not) 1.49 (1.07‐2.06)
.02
MD workload (high vs not)
0.81 (0.56‐1.19)
.29
Piers RD, et al. JAMA 2011;306(24):2694‐2703.
Piers RD, et al. JAMA 2011;306(24):2694‐2703.
© University of Washington School of Nursing - uwcne.org
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Doctor and Nurse Ratings of Interdisciplinary Communication
Doctors
% rating 4 or 5 out of 5
70
Nurses
60
p<0.001
for all
50
40
30
20
10
% rating 4 or 5 out of 5
Trainee and Senior Physician Ratings of Communication Openness
0
Openness
Senior
Trainees
90
80
70
60
50
40
30
20
10
0
p<0.05
for all
Nurse-Doctor
Accuracy
Doctor-Doctor
Reader, Br J Anaesth, 2007; 98:347
Reader, Br J Anaesth, 2007; 98:347
Percent of Deaths with Physician‐Nurse Collaboration in Decision‐making
Regression path analysis15 showing open communication to mediate the relationship
between unit leadership and understanding patient care goals, with unit leadership being a
predictor of open communication in the ICU, and open communication in the ICU being a
predictor of understanding patient care goals. *The Sobel test statistic shows open
communication to be a significant partial mediator of the relationship between unit leadership
and understanding patient care goals (P < 0.001), with it accounting for approximately 52% of
the variance between the two variables.
Percent of Decisions
70
60
50
40
30
20
10
0
Physicians
Nurses
42% participation rate; 133 French ICUs
Ferrand, Am J Resp Crit Care Med, 2003; 167:1210
Reader T W et al. Br. J. Anaesth. 2007;98:347-352
© The Board of Management and Trustees of the British Journal of Anaesthesia 2007. All rights
reserved. For Permissions, please e-mail: [email protected]
Percent of Physicians Involving Nurses in Decisions about Withdrawal
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100
Percent of Physicians
Conflictus Study 80
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60
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40
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20
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0
UK
France
Turkey
Japan
Brazil
US
Azoulay, et al. AJRCCM 2009;180(9):853‐60. Cross‐sectional survey prevalence, characteristics, and risk factors for conflicts in 323 ICUs/24 countries (7,498 ICU staff members)
Intra‐team disputes = majority of conflicts (half EOL care)
Poor communication within the ICU team (in general or during EOL care) perceived as common. Conflicts were less likely to occur in ICUs that held regular interprofessional staff meetings
Respondents were asked to report conflicts that occurred within the last week. fewer than half reported the conflict was resolved at time of study
80% believed that the same type of conflict was likely to recur
20% indicated reported conflict was related to a previous conflict
Yaguchi, Arch Intern Med, 2005; 165:1970
© University of Washington School of Nursing - uwcne.org
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Conflictus Study: Sources of behavior related conflicts
Conflict in Health Care
TAXONOMY OF CONFLICT
Task‐Based
Conflict
Relationship‐based Conflict
Disruptive Behavior • Awareness of • Awareness of • Intimidating and differences in interpersonal disruptive behaviors
viewpoints and incompatibilities, • Verbal outbursts and opinions pertaining includes affective physical threats
to a group task.
components such as • Refusing to perform feeling tension and • Tends to not involve assigned tasks or friction. intense quietly exhibiting interpersonal • Involves personal uncooperative negative emotions issues such as dislike, attitudes
although may be annoyance, frustration, animated. irritation.
Conflict in Health Care
Conflict in Health Care
Task‐Based
Relationship‐Based
• Honest and inevitable
• Slips and Errors
FACTORS • Poor hand‐writing, confusing labels
• Competing tasks, language barriers, distractions (workload)
FACTORS SOLUTIONS
• Hand‐off protocols, checklists, CPOE, automated medication dispensing systems, alerts
• Team communication training (ie, TeamSTEPPS)
• Conflict skills: CUS, Two challenge rule, DESC SOLUTIONS
Fundamental Attribution Error
I’m stressed – you’re rude.
I’m overworked – you’re lazy.
I’m worried – you’re hypervigilant. 
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My behavior is best explained by situational factors and context.
Your behavior is best explained by a personality flaw or stable trait deficit. © University of Washington School of Nursing - uwcne.org
• People know of risks and do not speak up
• Wait for the train wreck vs stopping train
• Often presents as entrenched conflicts • Calculated decisions to avoid or back down from conversations
• Harsh language interpreted as disrespect • Top three problems: dangerous shortcuts, incompetence, disrespect
• Understanding the fundamental attribution error:
motivation for behavior attributed to context versus
personality (also called misattribution) • Conflict management training
Conflict in Health Care
Disruptive Behavior
FACTORS SOLUTIONS
• Culture of tolerance
• Power differential and high stakes, high tension environment • Fear of retaliation
• Revenue‐generating versus paid‐employee differences in status • Zero tolerance policies
• Codes of conduct
• Disciplinary actions 5
Issue 40: Behaviors that undermine a culture of safety | Joint Commission
2005 Study: Silence Kills Sentinel Event Alert
July 09, 2008
Issue 40, July 9, 2008
Behaviors that undermine a culture of safety
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Intimidating and disruptive behaviors can foster medical errors,( 1,2,3) contribute to poor patient satisfaction and to preventable
adverse outcomes,(1,4, 5) increase the cost of care,(4,5) and cause qualified clinicians, administrators and managers to seek
new positions in more professional environments. (1,6) Safety and quality of patient care is dependent on teamwork,
communication, and a collaborative work environment. To assure quality and to promote a culture of safety, health care
organizations must address the problem of behaviors that threaten the performance of the health care team.
Intimidating and disruptive behaviors include overt actions such as verbal outbursts and physical threats, as well as passive
activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities.
Intimidating and disruptive behaviors are often manifested by health care professionals in positions of power. Such behaviors
include reluctance or refusal to answer questions, return phone calls or pages; condescending language or voice intonation; and
impatience with questions.(2) Overt and passive behaviors undermine team effectiveness and can compromise the safety of
patients.(7, 8, 11) All intimidating and disruptive behaviors are unprofessional and should not be tolerated.
Intimidating and disruptive behaviors in health care organizations are not rare.(1,2,7,8,9) A survey on intimidation conducted
by the Institute for Safe Medication Practices found that 40 percent of clinicians have kept quiet or remained passive during
patient care events rather than question a known intimidator.(2,10) While most formal research centers on intimidating and
disruptive behaviors among physicians and nurses, there is evidence that these behaviors occur among other health care
professionals, such as pharmacists, therapists, and support staff, as well as among administrators. (1,2) Several surveys have
found that most care providers have experienced or witnessed intimidating or disruptive behaviors.(1,2,8,12,13) These
behaviors are not limited to one gender and occur during interactions within and across disciplines.(1,2,7) Nor are such
behaviors confined to the small number of individuals who habitually exhibit them.(2) It is likely that these individuals are not
involved in the large majority of episodes of intimidating or disruptive behaviors. It is important that organizations recognize
that it is the behaviors that threaten patient safety, irrespective of who engages in them.
The majority of health care professionals enter their chosen discipline for altruistic reasons and have a strong interest in caring
for and helping other human beings. The preponderance of these individuals carry out their duties in a manner consistent with
this idealism and maintain high levels of professionalism. The presence of intimidating and disruptive behaviors in an
organization, however, erodes professional behavior and creates an unhealthy or even hostile work environment – one that is
readily recognized by patients and their families. Health care organizations that ignore these behaviors also expose themselves
to litigation from both employees and patients. Studies link patient complaints about unprofessional, disruptive behaviors and
malpractice risk.(13,14,15) “Any behavior which impairs the health care team’s ability to function well creates risk,” says Gerald
Hickson, M.D., associate dean for Clinical Affairs and director of the Center for Patient and Professional Advocacy at Vanderbilt
University Medical Center. “If health care organizations encourage patients and families to speak up, their observations and
complaints, if recorded and fed back to organizational leadership, can serve as part of a surveillance system to identify
behaviors by members of the health care team that create unnecessary risk.”
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Survey data 1,700 nurses, physicians, clinical care staff and administrators plus focus groups, interviews and observations (only 100 MDs) 13 urban, suburban and rural sites 50% RNs and 80% MDs witness colleagues break rules, make mistakes, fail to offer support, or appear critically incompetent
For half, concerns persisted ≥ 1 year
20% of MDs saw harm result from their observations
23% of RNs reported considering leaving job because of their concerns Yet, only 10% spoke up Root causes and contributing factors
There is a history of tolerance and indifference to intimidating and disruptive behaviors in health care.(10) Organizations that
fail to address unprofessional behavior through formal systems are indirectly promoting it. (9,11) Intimidating and disruptive
behavior stems from both individual and systemic factors.(4) The inherent stresses of dealing with high stakes, high emotion
situations can contribute to occasional intimidating or disruptive behavior, particularly in the presence of factors such as fatigue.
Individual care providers who exhibit characteristics such as self-centeredness, immaturity, or defensiveness can be more prone
to unprofessional behavior.(8,11) They can lack interpersonal, coping or conflict management skills.
Silence Kills ‐ results
 The 10% who do
Conflict in Health Care
TAXONOMY OF CONFLICT
speak up:
observe better patient outcomes work harder
are more satisfied Task‐Based
Conflict
• Find one’s voice Relationship‐based Conflict
• Find one’s ears
are more committed to staying in their jobs
Summary of Evidence for Teamwork 
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Communication & coordination deficits drive errors
Strong Correlation between Teamwork and . . . 
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Improved Patient Outcomes
Increased Patient Satisfaction
Increased Staff Satisfaction
Decreased Moral Distress Evidence of Impact from Team Training Programs
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In healthcare (as in other industries such as aviation)
Three years for maximum effect © University of Washington School of Nursing - uwcne.org
Disruptive Behavior • Find one’s
boundaries
Thinking Exercise #2: Recall an example a professor used to help you understand your future role as a patient advocate? [Or an example you commonly use in your teaching.] 6
The Nurse as Patient Advocate
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What did you notice about these messages? The Social Worker as Patient Advocate
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What did you notice about these messages?
The Physician as Patient Advocate
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What did you notice about these messages? Advocate: Noun or Verb? Noun: The Patient’s Advocate Focus?
Benefits to patient
Benefits to professional
Verb: To advocate Focus?
Benefits to patient Benefits to professional
Interprofessional Advocacy
I am the patient’s advocate.
What are the advocacy needs of this patient and who can best meet them? © University of Washington School of Nursing - uwcne.org
Thinking Exercise #3
Formation of professional identity and agency: 1. Think of a recent “win” that: 2. Demonstrated interprofessionalism
3. Where the team was the hero 4. Illustrated a communication skill 7
Patient Advocacy and Ethics in Nursing
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Focus on principle of respect for autonomy Perpetuated a straw man argument with beneficience (i.e., paternalism)?
Limited adding our voices to the calls for justice in health care? Key Issues in Health Care Ethics Today
Futility: how do we negotiate the rising requests by non‐random groups for “more” health care than “we” believe is beneficial? Shared decision‐making: how do we navigate away from a strict legal model of pure autonomy to one that acknowledges professional recommendations?
Just Culture: how do we remove the barriers to honesty within our professional societies to justly treat the 1st, 2nd and 3rd victims of errors? Key Issues in Health Care Ethics Today
Justice: how do we help to create a culture of solidarity in the U.S. where minimum health care is viewed as a right? Costs and Financing: how do we reduce incentives for increased costs and use while increasing incentives for increased access and health outcomes?
Fidelity: how do we address disparities in patient experiences in health care where some groups are treated badly and poorly? Is Advocacy Hurting Our Patients? 
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Conflict / lack of teamwork is killing them
“Nurses are the patient’s advocate” is the language of conflict
Need language of collaboration
Address conflict in nuanced manner
 CUS –
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conflict skills – limit setting Think of advocacy as verb
Lend our voices and intellects to the pressing ethics and health issues of today! Nursing Ethics: A Short History

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Nurse as the Virtuous Person (ie, Woman)
Nurse as the Loyal Soldier (with the Physican as Captain of the Ship)

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Nurse as the Patient Advocate Nurse as . . . NURSE
© University of Washington School of Nursing - uwcne.org
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