Volume 3, Issue 10 - December 2000

Ecological Error Management for Ethical Health Care

Every day in health care, physicians, nurses, administrators, and others set out with good intentions. As they work to shelter vulnerable, ill people from a mounting variety of dangers, their jobs take on more complexities and the potential for error grows. How has it come to be that a modern hospital is a place where it is increasingly difficult to ward off preventable harms? Perhaps it is time to inspect our present day hospitals from other points of view. For instance, if we adopted the perspective of an ecologist towards the landscape of today's acute care environments, what would we see?

The Cost of Short Term Gain

In recent research,¹ studies in relational ethics ² and technology ^3,4 were used to guide conversations with ten registered nurses employed in one or more of seven urban acute care facilities in Alberta. The nurses' observations about their work, work relations, and work environments led to the use of ecological restoration and ecosystems management research to construct an ecological reading of the nurses' surroundings. Amongst other things, this ecological interpretation raises several questions about error management for health care.

To a considerable degree, nurses described extensively fragmented and disrupted settings where a preoccupation with short-term "efficiencies" and immediate results prevailed. Decisions in one part of the system were routinely separated from subsequent consequences in other areas, and relations and processes to minimize problematic situations were often weakened or absent. As one nurse observed, "in this mode of rush, rush, rush, you often feel like you are not doing things as well as you could, and maybe there are details being missed."¹

In several cases, nurses noted that fiscally driven changes to charting, supplies, or other systems reduced their ability to provide cost-effective patient care, as scarce personnel were diverted to search for equipment, fetch medications, or otherwise shore up reduced environmental supports. Similarly, most participants observed that although large-scale cuts to full-time staff met immediate budget shortfalls, longer-term staffing requirements led to unexpected overtime and recruiting costs with rising sick time, disability claims, resignations, and orientation of new staff. Most of these observations reflect the complexities and constraints of modern health care that are documented in a growing body of research. In short, it is becoming more evident that as goes the integrity of the overall environment, so goes the integrity of patient care.

The limits of one exploratory study do not offer definitive conclusions about preventing and managing errors in modern hospitals. At the same time, the nurses' examples support the arguments of other experts that the ethics, the environment, and the error management practices of health care systems are all critically linked. The question becomes: What can we learn about error management from the ecological lessons of nurses' work?

Ethics, Ecology, & Error Management

The goal for ecological restoration of damaged habitats is to assist the recovery and management of an ecosystem's ecological integrity.⁵ Crucial aspects of ecological integrity include the diversity and reproduction of an ecosystem's species, the capacity for resilient responses to nature's threats and opportunities, the pollutants and practices of local and distant industries, and the daily habits and activities of its human and other inhabitants. Unfortunately, the ecological integrity of our industrialized environments is under siege, with deepening consequences for the health of humans, other life forms, and the home places we share.

In the research of Gunderson, Holling, and Light, excessively industrialized habitats are associated with extensive fragmentation and a loss of resilience that increase a habitat's vulnerability to harms, and even to full-scale disaster.⁶ As modern ecological sagas like the Grand Banks remind us, a narrow, short-term focus on the efficient production of a few variables within an environment (e.g. fish, lumber, coal) often erode the longer-range welfare of the greater whole. The present research suggests that the questionable "efficiencies" which plague over-industrialized ecosystems also assail most modern health systems, with similar damaging effects. For instance, all of the nurses reported rising pressures to move fast, cut corners, and maintain the "production line" at a breakneck, assembly-line speed. Most also described scenarios where against their better clinical judgments, "getting patients through" the system assumed greater urgency than the careful assessment of patients' readiness for a procedure, transfer, or discharge.

Licht notes that the chain of events leading from a small, naturally occurring forest fire to a full-scale disaster begins with an ecologically vulnerable habitat that cannot handle much more in the way of threats.⁷ Whether infestations of pests, excessive logging, or other assaults have already fragmented its structures and processes, the ecological integrity of the ecosystem is too reduced to keep a small burn from becoming a large wound. With decreased resilience, the capacity for effective response is lost.

Many of the nurses' concerns suggest that when health systems are re-engineered without sufficient attention to the ecological integrity of a hospital's habitat, a similar loss of capacity results. For instance, one nurse recalled a woman who shifted between units for special diagnostic tests. When the minimum required stay expired after a specific test, the woman was promptly transferred out of the ICU to make way for another patient. The patient and chart arrived from ICU with the note "stable to transfer", but with limited numbers of experienced staff, a relatively new, casually employed nurse was assigned. Despite her own heavy assignment, the charge nurse spent much of the shift helping the newer staff member to assess the patient and obtain necessary medical attention. Still, things deteriorated into irreversible harm.

While some nurses felt more supported by their co-workers and managers than others to maintain good nursing care, all stated that the relentless pace and volume of their work increasingly jeopardized their efforts to minimize harm. Some even noted that when things went terribly wrong, the press of the next task overtook any constructive scrutiny of events: ".even poorly run codes, there's never the opportunity to debrief. You know we don't even discuss what happened pre-code. Like was it an artery? How did we get to this point?" ¹

As international shortages of qualified health care practitioners deepen, we cannot afford to ignore the ecological lessons of nurses' work. Can we do better? Work in ethics, ecology, and error management all says that we can, and for the integrity of our care and care environments, we must get on with the task.

Strengthening Integrity

George Webster says that at the heart of our efforts to strengthen the ethical integrity of health care organizations, the questions we need to ask are: "Who are you to me, and who am I to you?" and "What kind of a world do we want to live in?"⁸ The nurses' stories suggest that to a significant extent, the ethical integrity of health care organizations is closely linked with its ecological integrity and actual capacities to support healing. Nurses who felt supported to deal constructively with errors, described unit cultures that exemplified a relational, questioning, and therefore more ethical counter to the environmental threats of an over-industrialized health care world. Everyone shared responsibility to see what must be done, and the ethics of a safe environment were everyone's concern.

The question arises, how do we enhance our ability to ecologically scan our health care environments? To some extent, the root cause analysis of sentinel events outlined by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)⁹ addresses our need to think more ecologically. When serious mistakes or sentinel events occur, the root cause approach includes a systematic search of several concerns about treatment that align with Bergum's relational understanding of ethical "treatment" in health care.² There are questions of whether the patient has been adequately clinically treated, but there is also concern for how the patient and family feel treated by the staff and the organization. If practitioners are in error, questions about how they are treated by those who have been harmed, by their fellow practitioners, and by management are explored. In turn, these matters of treatment are considered in connection with the way the organization treats its responsibilities to every party, including the patient, family, staff, managers, as well as the board, risk carriers, regulatory bodies, and the community at large.

The approach of root cause analysis departs from the habits of organizations that routinely "solve problems by criticism, by disciplinary action, or by dismissal of employees".¹⁰ In effect, the process of the inquiry assures staff and patients alike that errors are dealt with promptly, honestly, and accountably. Questions are asked about "system breakdowns, holes in the medication administration process, staffing, environment, safety, orientation processes, competency, communication, technological support, and other factors that contribute to errors".¹¹ From these types of initial queries, further questions about the relations, processes, and structures that support better future outcomes can be plotted, and an ethically, scientifically, and ecologically adequate response to error comes into view.

Root cause analysis will not eliminate all error in health systems or their workers, and more research is needed to strengthen our health system in the most ecologically sound ways. Still, Johnson and Roebuck-Colgan argue that root cause analysis "can provide the emotional healing an organization needs to recover after a sentinel event occurs".¹⁰ If the ethical integrity, ecological integrity, and healing capacities of health care environments are linked, the task before us becomes clear. Ethical error management requires that we develop ecological knowledge to safeguard the science and healing of modern health care.

References:

1. Marck PB. Technology and Registered Nurses' Work in Acute Care: A Healing Inquiry. Doctoral dissertation, Faculty of Nursing, University of Alberta, September 2000. Alberta Association of Registered Nurses, University of Alberta Dissertation Fellowship & Alberta Heritage Foundation for Medical Research Incentive Grant.

2. Bergum V., "Ethics as Question," in Expanding the Boundaries of Care. Medical Ethics and Caring Practices, ed. Tamara Kohn and Rosemary McKechnie (New York, NY: Berg Publishers Inc., 1999), 167-180.

3. Borgmann A., Technology and the Character of Contemporary Life (Chicago, IL: University of Chicago Press, 1984).

4. Feenberg A., Critical theory of technology (New York, NY: Oxford University Press, 1991).

5. Society for Ecological Restoration, Official Definition of Ecological Integrity, http://www.ser.org/ 1996.

6. Gunderson L.H., Holling C.S., and Light S.S., eds., Barriers and Bridges to the Renewal of Ecosystems and Institutions (New York, NY: Columbia University Press, 1995).

7. Licht D.S., Ecology and Economics of the Great Plains (Lincoln, NE: University of Nebraska Press, 1997).

8. Webster G. and Murphy P., "The Ethics of Everyday Healthcare" (paper presented at the Calgary Regional Health Authority Acute Care Nursing Conference, Calgary, AB, May 8, 2000).

9. Joint Commission on Accreditation of Healthcare Organizations (JCAHO), "Minimum Scope of Root Cause Analysis," 1999. Available at http://www.jcaho.org.

10. Johnson KM. and Roebuck-Colgan K, "Organizational Ethics and Sentinel Events: Doing the Right Thing When the Worst Thing Happens," The Journal of Clinical Ethics 10 no. 3 (1999): 237-241.

11. Johnson C, "We Made a Mistake. Caregivers and Administrators Bring Medication Errors Out in the Open - Especially with Patients," Nursing Management 31, no. 4 (2000): 22-24.

Have you started planning your Bioethics Week activity?

The Network staff would like to remind all Albertans of the upcoming Bioethics Week across Alberta from February 12-18, 2001. We would like to encourage all individuals, groups and institutions who have an interest in bioethics to help mark the week by putting on an event that encourages open dialogue and discussion around ethical issues in the health setting.

Apart from hosting an event, individuals may participate in Bioethics Week in a number of ways from attending other Bioethics Week events to taking the time to enrich one's own understanding of ethics by reading about ethical issues in health, attempting to analyze a particular case that one has faced from an ethics perspective (i.e. with the intention of considering the values that underpinned the question at hand) or simply by engaging one's coworkers in various discussions about bioethics.

A reminder also to those who are hosting an event for Bioethics Week to register their event with PHEN for listing on the PHEN web page so a comprehensive list of the various events happening across the province can be maintained. Find out what's going on in your area and get involved!

Views offered in this article are those of the author and do not necessarily reflect the position of the Provincial Health Ethics Network.