1. Miller, Lisa A. CNM, JD

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When you make a mistake, admit it. If you don't, you only make matters worse. - Ward Cleaver, father on the television show Leave It to Beaver.


Sounds easy, doesn't it? Turns out, thanks to our marvelous brains, that it is not so easy after all. Right, smart, best thing to do, but not easy. As many of you know, I am a voracious reader and I have been recently fascinated by a book that has not only helped me understand why it is so difficult for clinicians to admit error, but also why it can be so hard to get clinicians to accept any responsibility for mistakes or poor judgment. The book, Mistakes Were Made, but Not by Me, written by Carol Tavris and Elliot Aronson, explains in a clear and often humorous manner why it is just so difficult for people to accept responsibility for errors, bad decisions, and incorrect beliefs even when confronted with indisputable evidence. Apparently, we have a natural tendency not only to deny our mistakes, but also to actually construct fictions and use self-deceptions that help us in our denial!!


In other words, the next time you catch little Johnny (or little Julie, no sexism here) in the act of raiding the cookie jar before dinner and you get a loud denial or a finger pointed elsewhere,* do not be surprised and do not get too upset, it is simply the child's natural response to the emotional discomfort created by something social psychologists call cognitive dissonance. And it is just as common in adults, including nurses, doctors, and midwives. The term cognitive dissonance describes the emotional discomfort human beings feel when they try to hold 2 disparate ideas, beliefs, or opinions in their mind at the same time. In Johnny or Julie's case, the 2 competing concepts are (1) being a good kid who makes Mom and Dad proud and (2) my hand was caught removing several cookies from the cookie jar before dinner, a big no-no. The dissonance between these 2 truths causes emotional and mental discomfort, and the child will try to reduce this discomfort by any means possible, including lies and blame shifting. And cognitive dissonance does not fade away as we reach adulthood. In fact, as our mistakes become more serious, the emotional and mental discomfort we feel becomes more intense, and we turn to amazing feats of self-justification to eliminate or reduce the tension. It is often impossible for us to simply say the words "I'm sorry, I made a mistake" without diminishing the apology by rationalizing our behavior. Tavris and Aronson's book helped me finally understand a colleague's behavior that had left me stymied for years.


For many years, I knew and worked with a clinician who was absolutely brilliant with great clinical skills. She was extremely well-read and a good critical thinker. But she was unable to ever admit to have committed any mistake. She could not apologize and take responsibility for any error, no matter how small or trivial. If an apology was ever tendered, it was always appended with the reason the error had occurred, and the reason was always someone else's fault or a situation beyond her control or something, anything, as long as it was clear that it was not really her fault. I now understand her behavior completely. She was a perfectionist who prided herself on being the best and doing the best, and most of the time this was the case. On those rare occasions when she was not at her best, cognitive dissonance was so strong in her that it was simply untenable to her psyche to fully (and solely) accept responsibility for any mistake.


To my knowledge, the colleague I just described never made errors that resulted in harm to a patient. But what about the cognitive dissonance experienced by clinicians who do make such errors? Imagine the emotional and mental distress of these 2 psychologically inconsistent beliefs: (1) I am a good and dedicated nurse (or midwife, or physician) and (2) my error contributed to the death or injury of a neonate. The cognitive dissonance in this situation would be overwhelming. It should therefore come as no surprise that it is difficult and often impossible to get clinicians to openly admit and discuss errors without resorting to blame shifting and finger pointing in these situations. We are hard-wired to reduce cognitive dissonance by creating fictions that justify our actions and absolve us of responsibility.


The odd thing is, once you are familiar with the concept of cognitive dissonance, you begin to recognize it as well as become aware of your automatic responses, even in trivial situations. For instance, I recently caught myself justifying bad behavior while I was traveling. At one of my conferences, I was grabbing a handful of the sweetener I prefer (the yellow packages) to keep in my purse as I had neglected to bring my usual stash from home. As I scooped up a dozen or so packets, I noticed that a participant saw me. She did not say anything; in fact I doubt she even noticed. But I had my moment of cognitive dissonance: (1) I am stealing sweeteners from the hotel and (2) I am a good and honest person, not a thief. So I started to explain to the participant (read witness) that I usually would not take so many but that I had forgotten my stash at home, that the hotel could certainly afford it given what they were charging for coffee, that everyone did it and it is not really stealing, and so on. About 30 seconds into this monologue, I began laughing because I recognized what I was doing-justifying my bad behavior so I could reduce my cognitive dissonance over the pilfering of sweetener packets!!


Recognizing cognitive dissonance as it occurs can help us face the emotional discomfort associated with mistakes and errors and allow us to learn and adopt preventive strategies in future practice. Although it may be a much more difficult task when the problem is a poor outcome versus stolen sweeteners, it is imperative that clinicians make every effort to avoid the trap. The Beav's father was right. We can learn from our mistakes, but only if we can admit them. It reminds me, I made a mistake when I wrote the introductory line of this column: "Mistakes were made [horizontal ellipsis] but by who?". The correct sentence should read: "Mistakes were made [horizontal ellipsis] but by whom?". I am sorry, please accept my apology, it was my fault and it will not happen again.


Lisa A. Miller, CNM, JD


President, Perinatal Risk Management and Education Services, Chicago, Illinois


*When I was a kid, I always blamed an imaginary pal named "Dubby." This started when I was very young. My parents believe that initially this was an attempt to blame my younger brother, whose name was Bobby, and that my language skills simply were not well developed enough at the time to spit out his name correctly under the stress of being caught misbehaving. Regardless of the reason, "Dubby" became the one who got blamed whenever anything went wrong, and not only by me, but by my little brother as well, who probably figured that blaming "Dubby" was (a) a good bet because he had already been identified as a bad actor and (b) the smart move because blaming me, his elder sister, could result in bodily harm. [Context Link]