If you haven’t seen these three things happen yet, you probably will soon now that you’re on watch for them: – diagnostic overshadowing – documentation resulting in a cascade of bias – empathy failure
Together with Rebecca Callahan, I’ve written about diagnostic overshadowing before [here]. Diagnostic overshadowing is where current physical problems, symptoms or pathology gets overlooked, dismissed or downplayed because of the distraction of a documented history of a previous problem, eg: drug and/or alcohol use, mental health problems, or intellectual disability.
I was reminded of this when reading this excerpt from a recent article by Searby, Burr, James & Maude (2022):
I have a client who comes and sees me who has cirrhosis. I requested him to go and see a doctor at the local ED Department. ED don’t see him because they view him as just that junkie, just that drunk. This gentleman then has an acute exacerbation of his physical health, but it’s not seen as important…
Sound familiar? It’s not just in ED, it’s in other parts of the health system too.
Today I stumbled across a phrase I haven’t heard/read before: “a cascade of bias” (Martin, Bickle & Lok, 2022). The phrase “a cascade of bias” is in a report on a quantitative, observational study that compared the behaviour of nurses when they were exposed to either neutral or biased patient documentation. It’s embarrassing to me (a nurse) that the study found that biased language in documentation influenced how (un)helpful nurses were, and affected other aspects of clinical judgement and decision-making.
That’s a grim finding, isn’t it? It’s not just the unconscious cognitive bias of diagnostic overshadowing we have to watch out for. We have to watch out for letting that unconscious bias infiltrate our language in handover/documentation, so that we don’t inadvertently adversely affect the work of our colleagues too.
It’s easy to imagine diagnostic overshadowing (as per the excerpt above) leading to biased documentation, leading to a cascade of bias, resulting in empathy failure and poor outcomes for the patient.
That’s what my version of the distracted boyfriend meme is about.
It’s easy to be distracted from current problems, symptoms or pathology by biased documentation or past history.
Easy, but not cool.
Don’t be that guy.
References
Martin, K., Bickle, K. & Lok, J. (2022), Investigating the impact of cognitive bias in nursing documentation on decision-making and judgement. International Journal of Mental Health Nursing. doi.org/10.1111/inm.12997
Searby, A., Burr, D., James, R. & Maude, P. (2022), Service integration: The perspective of Australian alcohol and other drug (AOD) nurses. International Journal of Mental Health Nursing. doi.org/10.1111/inm.12998
End
That’s it. As always, please feel free to leave feedback via the comments section below.
Self Compassion is defined as “…being empathetic and understanding towards oneself, as you might to a close friend in times of suffering” (Aggar et al, 2022).
I’m using self compassion as a nuanced but important update to previous presentations and blog posts on the theme of self care. Why? Because self-compassion is a better fit for nurses, I reckon. As Mills, Wand & Fraser (2015) say, “…it could be argued that nursing care is synonymous with compassion.” That’s most-often compassion for others, not always each-other or our selves.
The way I see it, self care is about the tasks and strategies we use to avoid burnout. Self compassion is more of an attitude or mindset that goes beyond burnout prevention, and shifts towards making sure that we are as kind and nurturing to ourselves as we’re expected to be to our patients.
In this iteration of an annually updated presentation aimed mostly, but not exclusively, at new Graduate Registered Nurses I want to put emphasis on self compassion as a valid and sensible priority. We don’t want new grads to just survive their first year, we want them to learn, enjoy their work, and grow.
Part 2: Prezi
It’s handy to have a way where you can quickly and easily find and share presentations. PowerPoint presentations are so last century. The face-to-face presentation uses this Prezi: prezi.com/view/wsTTDmVzAJOSRpqDXs2I/
This must be the 6th or 7th iteration of a theme I’ve been banging-on about for over a decade, so I’m recycling and repurposing a lot of old ideas here. Because of that iterative process the list below is ridiculously and embarrassingly self-referential. Please don’t think of it as self-plagiarism. Think of it as a fresh new remix of a favourite old song. 🙂
Aggar, C., Samios, C., Penman, O., Whiteing, N., Massey, D., Rafferty, R., Bowen, K. & Stephens, A. (2022), The impact of COVID-19 pandemic-related stress experienced by Australian nurses. International Journal of Mental Health Nursing, 31(1). https://doi.org/10.1111/inm.12938
Australian College of Mental Health Nurses [www.acmhn.org], Australian College of Nursing [www.acn.edu.au], and Australian College of Midwives [www.midwives.org.au] (2019) Joint Position Statement: Clinical Supervision for Nurses + Midwives. Released online April 2019, PDF available via each organisation’s website, and here: ClinicalSupervisionJointPositionStatement
Chen, R., Sun, C., Chen, J.‐J., Jen, H.‐J., Kang, X.L., Kao, C.‐C. & Chou, K.‐R. (2020), A Large‐Scale Survey on Trauma, Burnout, and Posttraumatic Growth among Nurses during the COVID‐19 Pandemic. International Journal of Mental Health Nursing. doi.org/10.1111/inm.12796
Doctors Health in Queensland for doctors and medical students dhq.org.au
DRS4DRS provides support for any doctor or medical student across Australia www.drs4drs.com.au
Eales, Sandra. (2018). A focus on psychological safety helps teams thrive. InScope, No. 08., Summer 2018 edition, published by Queensland Nurses and Midwives Union on 13/12/18, pages 58-59. Eales2018
Emotional Aftershocks (the story of Fire Extinguisher Guy & Nursing Ring Theory) meta4RN.com/aftershocks
Lalochezia (getting sweary doesn’t necessarily mean getting abusive) meta4RN.com/lalochezia
Miller, Ian. (circa 2013) Nursing ring theory: Care goes in. Crap goes out. impactEDnurse [blog]. Archived blog post accessed via Wayback Machine: web.archive.org/www.impactednurse.com/?p=5755
Mills, J., Wand, T. & Fraser, J. (2015) On self-compassion and self-care in nursing: selfish or essential for compassionate care? International Journal of Nursing Studies. 52(4). doi: 10.1016/j.ijnurstu.2014.10.009.
Nurse & Midwife Support nmsupport.org.au phone 1800 667 877 targeted 24/7 confidential support available for nurse, midwives, AINs and students
Nurses, Midwives, Medical Practitioners, Suicide and Stigma (re the alarming toll of those who undertake emotional labour) meta4RN.com/stigma
Nurturing the Nurturers (the Pit Head Baths and clinical supervision stories) meta4RN.com/nurturers
Queensland Health. (2009). Clinical Supervision Guidelines for Mental Health Services. PDF
Self Compassion and Post Traumatic Growth amongst Nurses in the Pandemic (Hooray for Grey Hairs!) meta4RN.com/grey
Spector, P., Zhiqing, Z. & Che, X. (2014) Nurse exposure to physical and nonphysical violence, bullying, and sexual harassment: A quantitative review. International Journal of Nursing Studies. Vol 50(1), pp 72-84. www.sciencedirect.com/science/article/pii/S0020748913000357
Surfing the Omicron Wave (Cairns Hospital COVID-19 admission data, 14th December 2021 – 20th February 2022) meta4RN.com/surfing
At time of writing it looks like we are going to have another uptick in COVID-19 presentations (see above). Bugger. I won’t pretend to know how that will affect our local hospital and/or face-to-face and group learning. It will be handy to have a YouTube version of the otherwise interactive face-to-face presentation on hand just in case we revert to crisis-response mode like we did in January/February 2022 [more info about that here and here].
Part 5: End Notes
Thanks for visiting.
As always, feedback is welcomed via the comments section below.
meta4RN 