20.04.2019 Feature Article

The America That Is Not For Me: Part 27

The America That Is Not For Me: Part 27
20.04.2019 LISTEN

“No mockery in the world is so hollow as the advice showered upon the sick. It is of no use for the sick to say anything, for what the adviser wants is, not to know the truth about the state of the patient, but to turn whatever the sick may say to the support of his own argument, set forth, it must be repeated, without any inquiry whatever into the patient’s condition. ‘But it would be impertinent or indecent in me to make such an inquiry,’ says the adviser. True; and how much more impertinent is it to give your advice when you can know nothing about the truth, and admit you could not inquire into it (Florence Nightingale, p. 101).”

How right and prophetic Nightingale was! What she is saying is in fact an experience I’ve personally encountered on many occasions whenever I sought medical intervention or assistance in an American hospital. Some medical doctors especially tend to see themselves as the embodiment of human knowledge, namely seemingly omniscient mortals with finite knowledge who are somehow convinced that they know more about the intimate, personal details of their patients’ bodies and states of mind than these patients do. This is very unfortunate if not provocatively sad.

The formal education of these medical doctors in particular―in addition to the elitist status society generally assigns doctors―causes some of them to look down on others, for instance, their readiness to disregard other forms of knowledge, including what patients have to say about their own bodies and states of mind, with an air of intimidating condescension. These healthcare professionals ignore the fact that patients are authorities on their bodies and that specialized aspects of the finite knowledge of healthcare professionals take the form of an affirming complementarity of patients’ self-knowledge.

Caring science is about partnership in the knowledge market of clinical relationships between healthcare professionals and their communities of patients, after all. Thus caring science feeds on interpersonal relationships. Finally, my views on caring science are not so much about the traditional, authoritarian medical model as patient- and family-centered care. R.D. Laing’s The Politics of the Family and Other Essays and Jean Watson’s Nursing: The Science and Philosophy of Caring reinforce the dichotomy in the methodological approach to caring science and the philosophy of caring.

Here is another interesting hypothetical scenario to consider:

Introduction: The Power of the Patient-Centered Clinical Method

Patient-centered care is the pillar of clinical relationships. It dictates how health care professionals and other clinical staff operationalize the interests, care plans, satisfaction, and safety of their community of patients. Patient-centeredness tends to bridge the professional, clinical, and institutional gulf between patients and healthcare professionals as it provides a dialoguing platform on which patients willingly participate in the protocols of their own care strategies.

Patient-centered care therefore looks at the patient within a holistic framework of clinical assessment, and of the strategies of care execution. This involves considerations of spirituality, political correctness, respect for cultural differences, effective clinical communication strategies, and proper application of clinical hygiene, where health care professionals do not impose their opinionated professionalism on patients to the virtual exclusion of patients’ participating voices in the execution of their protocols of care. Nightingale concurs that inquiries about the protocols of patient care should be based on sufficient data (Nightingale, 1969, p. vii).

Yet patient-centered care does not exist in a vacuum. It thrives on mutual respectability, beneficence, justice, non-maleficence, respect for life and for autonomy, compassion, fidelity, kindness, love, family relationships, and trust. As a team of scholars describes it ((Millensen, Shapiro, Greenhouse, & DiGiola lll, 2016, para. 2), patient-centered care:

"Emphasizes respect for patient values in individual care decisions as well as the role of patients and families as advisors and essential partners in improving care practices...It is characterized by a two-way partnership."

These ethical values overlap with my core personal beliefs and professional philosophy about the patient-centered clinical method. These values also underscore my zero-tolerance approach to patient neglect. Also, I strongly believe family relationships are important facets of patient-centered care that healthcare professionals should not ignore.

As a nursing student during one of my recent clinical rotations, I witnessed patient neglect and a measure of disregard for the input of family members in the care of their family member. I am writing about them in hopes of not repeating them in my future professional practice.

An Interesting Case Study
A patient who had undergone surgery self-reported a pain score between 7 and 9 on a medical pain scale of 0-10, 0 being no pain and 10 being worst pain imaginable. The nurse I shadowed responded accordingly to the pain as she saw to it that I correctly administered the recommended pain medications to this patient.

Under her supervision, I retrieved the pain medications from the pyxis and administered them using the six rights for safe medical administration. Before then, I had performed a head-to-toe assessment of the patient, asked subjective questions, took vital signs, and conducted a focused pain assessment in the hip area using the PQRSTU acronym, where P stands for palliation/provocation, Q for quality of pain, R for region/location of pain (or radiation of pain), S for severity of pain, T for time/onset/duration of pain, and U for understanding patient’s perception of pain.

The nurse and I then checked up on the patient every hour to assess her pain level, to find out from her whether she needed assistance with anything, to inspect her IV lines and surgical site, and to dress the surgical site. Patient self-reported a pain score of 4 on a medical pain scale of 0-10, a significant improvement over a period of about five hours since the nurse and I assumed our shifts at 7am. Her condition seemed to look up for the most part. She thanked us profusely.

The patient’s two children, a man and a woman, showed up. The two, especially her daughter, nagged about everything from the bed sheets, why her mother had been kept in bed rather than in the couch next to her bed, why the hospital still continued administering her provider’s recommended pain medications to why the physical and occupational therapists were not there with their mother. In addition, she wanted stronger pain medications for her mother rather than the ones her mother was already taking. She turned the room’s relative quietude into a disruptive storm of psychosocial disarray.

The daughter would not take the nurse’s clinical position—and even her own mother’s claim—that the pain medications were working. Filial insistence convinced the mother otherwise, namely of the rightness of her daughter’s opinionated demands, and she instantly changed her initial story, succumbing to her daughter’s insistence that she be given a new regimen of pain medications. The nurse and I found ourselves in a state of cognitive paralysis—shocked.

My Reaction
Our genuine efforts appeared to amount to nothing in the reckoning of the patient’s daughter. The nurse and I became jittery, sweating profusely and trembling at the mere sight of the nagging lady. The lady’s demanding and commanding tone, unwelcoming body language, and intimidating affect forced me out of the room almost immediately.

I absconded to the staff restroom and locked myself in, contemplating the lady’s behavior and its implications for the professional practice of nursing. My disabling preoccupation with the lady’s behavior put me beyond the immediate acknowledgement that my abscondence could potentially translate into patient neglect. I did not however give any serious thought to this line of thinking and legal, clinical interpretation, and absconded in my helpless moment of thoughtless confusion.

I should also stress that raw fear gave wings to my unplanned abscondence, having momentarily lost my presence of mind in the heat of my thoughtless confusion. Fear factor therefore drained the strategic, professional and clinical contents of my presence of mind, a difficult situation that partly led to my divorce from the actualities of my clinical and psychosocial expectations.

What’s more, rather than seeing fear as a tactical psychophysiological response to a difficult situation, and taking full advantage of it to realign and redefine my clinical, professional and psychosocial focus, I deferred to the disorganized wisdom of my innermost insecurities instead. And then from nowhere I suddenly remembered the following lines from Bob Marley’s “Running Away.”

I was stuck with my questioning shadows which I could not run from!

I needed a moment of catharsis. I needed a moment of decompression!

I needed a moment of self-reflection!
I needed a moment of self-assessment!
I needed a savior!
I needed to salvage my drowning self from the dire situation, from my cognitive suicide, and this powerful song provided that long-sought psychological and emotional relief.

The end result was self-resurrection given that the song jolted me out of my dead-coffin of strategic cluelessness into an ideational, professional oasis of Joseph Schumpeter’s creative destruction. Creative destruction then threw a lifeline to my sinking self in the form of diplomatic reincarnation. I soon recalled my human relations skills and sociality from my subconscious den, by which time it was too late to put them into practice.

I instantly became a thoughtful mutant, fully conscious of my psychosocial and emotional limitations in the specific arena of human relations.

I then run to myself!
I returned to myself!
I eventually became myself, thus merging with the silent yet eloquent dictates of my spiritual, intellectual, and emotional capital, although my nagging conscience consistently denied me respite from my daring constellation of shortcomings. I no longer saw myself as a “saint.” George Orwell made the following critical, insightful observations in his 1949 essay―titled “Reflections on Gandhi”―after he had read Gandhi's autobiography The Story of My Experiments with Truth (Kwarteng, 2015):

"Saints should always be judged guilty until they are proved innocent…Sainthood is also a thing that human beings must avoid…the average human being is a failed saint."

I was a nagging dead "saint" secretly hidden in a sarcophagus of cognitive paralysis, confused as ever!

Regardless, I thought to myself that we needed to do right by our patients no matter what! Yet I was not the only one who walked out of the room. Other nurses did same. These nurses crowded around the nurses’ station to criticize the lady in hushed tones. I didn’t partake in the criticism because I felt it amounted to unprofessionalism. Here, I came to the stark realization that my near-death experience with the protocols of human relations was a disappointing sham, a false dream, and that I could even always do better in spite of my crippling shyness and selective mutism.

Concluding Remarks: Hypothetical Solutions
The question is, how does one effectively deal with disagreeable family members in the context of the patient-centered clinical method, especially where family members make medical decisions that clash with those made by their hospitalized competent family member, in such a way that neither the integrity of the patient-centered clinical method nor the concept of patients’ rights and responsibilities is not violated, and what happens to healthcare professionals who are verbally abused by patients and their family members, healthcare professionals who are doing their job?

Looking back however, either the nurse or I should have rushed out for the physical and occupational therapists, resettled the patient in the couch, replaced the bed sheets, and reported the matter to the charge nurse.

The nurse should have reported the lady’s concerns to the patient’s provider. I think the word nagged was inappropriate, perhaps even too harsh, as the lady had a say in her mother’s care. I regret it now. That nursing as a profession is part human relations part customer service is not lost on me.

I also think I should not have absconded. In the future I will make good use of therapeutic communication, empathy, professionalism, and respect for and acknowledgement of family in patient-centered care to address difficult psychosocial and clinical expectations. This is important for improving patient outcomes. I also think what a patient says about pain is final. This goes to the heart of Bob Marley’s “Running Away”:

"Every man thinketh his burden is the heaviest…who feels it knows it."

That innocuous sense of physiological, phenomenological, physical, and intellectual relativity represents the defining professional anthem and strategic logic of the patient-centered clinical method.

In the end everything else about my clinical experience remains the same!