1. Kennedy, Maureen Shawn MA, RN, FAAN


Refusing to see what we know is there.


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Asked whether they see themselves as patient advocates, most nurses would probably say they do. I remember working with nurses who guarded their charges like mother (or father) bears, making sure patients and families were treated appropriately by everyone involved in their care.

Figure. Maureen Shaw... - Click to enlarge in new window Maureen Shawn Kennedy

But I also recall times when patient advocacy took a backseat to politics or convenience, when it was easier not to challenge the status quo, even if that meant ignoring unsafe practices. There's a term for this: willful blindness. It refers to conscious avoidance, a choice not to know about, or act on, something that one should or could know. Last May, Margaret Heffernan, author of Willful Blindness: Why We Ignore the Obvious at Our Peril (Walker and Company, 2011), spoke at the American Association of Critical-Care Nurses' annual meeting in San Diego. She gave many examples, including the shady business practices that led to the collapse of Enron, the Catholic Church's cover-up of child sexual abuse crimes perpetrated by members of its clergy, and the U.S. government's cover-up of human rights violations against Iraqi prisoners at Abu Ghraib. In each case the evidence of wrongdoing was apparent, yet many people chose not to see it, and did nothing.


At one place where I worked, there was a chief of service who was notorious for ordering unwarranted bronchoscopies. Several nurses had complained, but nothing happened; the other physicians didn't want to challenge their important colleague, even though his orders put patients at risk. Only when a newly hired pathologist sided with the nurses and brought the situation to the hospital board, warning of potential lawsuits, was action taken.


But nurses can turn a blind eye, too. Most of us probably remember nurses we didn't want to work with because they were incompetent, had a poor attitude, or otherwise just didn't measure up. Maybe there was some problem everyone recognized but kept silent about, and when that nurse was finally "let go," everyone breathed a sigh of relief. (An extreme case: convicted serial killer and nurse Charles Cullen, who was passed along from hospital to hospital, even though many people later said they'd felt sure he was involved in patient deaths.)


And what of the larger issues in nursing and health care that our health care system repeatedly fails to address? Myriad studies have found associations between increased RN staffing and decreased patient mortality. A systematic review of staffing studies through 2012 by Paul Shekelle, funded by the Agency for Healthcare Research and Quality (AHRQ), lends further support. Though acknowledging that the evidence falls short of demonstrating causality, the AHRQ review graded "the strength of evidence for increased RN staffing and lower hospital-related mortality as moderate." A recent longitudinal study by Grant Martsolf and colleagues (also funded by the AHRQ) evaluated nearly 18.5 million patient discharges from hospitals in three states and found that increased nurse staffing levels were "associated with reductions in adverse events and length of stay while remaining cost neutral." So why are we still making excuses for poor nurse staffing levels? Another area in which research findings have largely been ignored is the impact of the 12-hour shift on patient safety. It's well known that 12-hour shifts are associated with increased error rates and thus are detrimental to patient safety; they're also detrimental to nurses' health, especially when nurses work extra shifts. As the American Nurses Association's position statement on nurse fatigue notes, "Shifts longer than 8 hours may be unsafe when work is physically and cognitively demanding." Nurses have fought against mandatory overtime for these reasons; and yet we continue to choose to staff this way because it's convenient for nurses' schedules. Doesn't evidence-based practice apply to us?


Willful blindness afflicts nursing academia, too. For example, many senior faculty and department chairs insist their names be added to all articles written by students and colleagues, even when they haven't met any of the criteria for authorship. Such unethical practices harm the credibility of our scholarly work.


Individually and collectively, we must address our blind spots, however inconvenient this may be. And we need our professional organizations and accrediting bodies to support us with stronger policies, accreditation criteria, and bylaws. Keeping our eyes shut only serves to maintain unsafe and unethical practices.