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Competency is no reason for complacency
MAY 2003, VOL 77, NO 5 EDITORIAL
Competency is no reason for complacency
P
erioperative nurses are the most competent nurses around. Our practice is enforced strictly and has concrete guidelines, specific recommended standards of practice, and clear role performance expectations. Perioperative nursing certification boards maintain high evaluative testing standards to determine competency. Any nurse who circulates, first assists, manages, or educates and who has been practicing for any length of time has all the skills built into his or her muscle memory. Performance is almost automatic. This is the realm of the expert. There is a hidden trap, though, that is waiting to ambush even the most competent nurses. It is called complacency. Complacency is a feeling of self-satisfaction, contentment, and, sometimes, smugness.' Taken to the extreme, it can be a fault. This occurs when complacency interferes with taking action when it is needed. Complacency can lead to procrastination (ie, if we ignore this, it will go away) or indecisiveness (ie, why make a decision to do something different when nothing is wrong). Complacency occurs when people feel satisfied, so it is reasonable to expect that complacency would affect the most experienced nurses rather than novices. The RN who is learning a new role often is too fearful to be satisfied or content with his or her practice.
EXAMPLES Consider the following fictional scenarios. In scenario one, an excellent and experienced nurse has been working for some time in the cardiovascular room. She knows coronary artery bypass graft (CABG) surgery down to the smallest detail. She is organized and prepared before surgery, and much of her activity is finished quickly. She feels satisfied and is happy with her performance. Her manager leaves her alone because she causes no trouble and the physicians are happy. In other rooms, however, things are not going as well. There are new personnel and changes in procedures; new hospital regulations are being implemented, and there is a lot of discontent. The CABG nurse tells herself that it does not affect her, and she is staying out of it. It is just too bad if others are having problems, but they probably are not as good at their jobs as her. Things progress until they explode in the OR. The manager is demoted, and a new one is appointed. New policies and innovations are put into place, and the new manager demands that they be followed. This means the CABG nurse has to change many of the ways she did things in the past, which leads to confusion, inefficiency, and delays. Competency is affected because of past complacencyin this case, ignoring the rest of the unit, which resulted in a lack of anticipation and planning for 908 AORN JOURNAL
the future workplace. In scenario two, a physician retains a private surgical assistant (SA) whom he NANCY J. GIRARD brings along whenever he is scheduled to perform surgery. The perioperative nurse in the room knows the SA comes with the physician and is credentialed to be in the OR. She also knows that the SA is somewhat slack in his duties. The nurse, while an expert and competent, does not feel that she should say anything to the manager about her observations or interfere with the SA's back table and medication preparations. After all, things always had gone well in the past. One day, a patient is scheduled for a biopsy of a nodule on the thigh. The SA's duties include preparing the local anesthetic for the physician to inject. He automatically prepares the injection but does not check the medication with the perioperative nurse, who ignores him. When the physician begins injecting the medication, the patient becomes hysterical with pain. The pain does not cease, and upon investigation, it is found that the SA drew up clear formalin that was in a sterile container for a specimen rather than the clear local anesthetic agent, which also was in a sterile container. The patient subsequently experiences considerable tissue
MAY 2003, VOL 77, NO 5
damage at the site of the injection. In this situation, a competent nurse indirectly contributed to a patient’s injury because of her complacency. Complacency can permanently maim or even kill patients we are trying to protect.’ It also can lead to legal entanglements that every nurse wants to avoid.’ SAFETY Although errors can happen to anyone in these days of short staffing, increased technology, increased workload, and more time at work, we must not let down our guard. People may say, “Complacent! Not me. I am just tired.” Maybe, but we must be aware that errors can occur. The
aviation profession has been the leader in implementing safety procedures for many years, and health care is starting to adopt some of that industry’s processes and procedures to create a safer environment for patients. Even airlines, however, who state that “statistically speaking, one would have to fly in an airliner 24 hours a day for 438 years to be involved in a fatal accident,” are concerned that complacency could affect their progress.‘ Businesses also are concerned with complacency. A. G Kefalas, a professor of management at the University of Georgia Hillel, Terry College of Business, Athens, Ga, tells about attending a conference with Coca-Cola
NOTES 1. “Complacency,” HumanityQuest.com, http://huma nityquest.corn/topic/Encyclopedias/index.asp?theme1 =complacency (accessed 5 March 2003).
2. L Johanson, “Complacency can kill,” RN 64 (August 2001) 49-50.
3. C Fleming, “Complacency in care can create legal and ethical tangles,” Nur:singMut/ers 10 (January 1999) 7. 10.
Enterprises, Inc, chairman Robert W. Woodruff, who said the biggest problem with management is complacency. He thinks managers who sit back and relax when everything is going well contribute to major hture problems in a company.i Nothing guarantees quality or safety, but we must be ever vigilant. One thing we can do is prevent complacency from impairing competence. Perioperative nurses still control the environment in the OR. They still are the ones responsible for maintaining safety and preventing injury, and they are the ones patients look to for protection. NANCY J. GIRARD RN, PHD, FAAN EDITOR
4. “Past achievements in safety: No grounds for complacency,” Air Safe@ Week 15 (August 20, 200 1) http: //www.findarticles.com/mOUBT/33-15/77355348/p 1/arti cleljhtrnl?term=september+21 (accessed 17 March 2003). 5. A G Kefalas, “People fall into complacency during good times,” Online Athens (December 30, 2000) http: //www.onlineathens.com/stories/123 1OO/bus-123 1000004 .shtml (accessed 17 March 2003).
Aspirin-resistant Patients at Higher Risk for Heart Attacks As many as 10% of the 20 million Americans who rely on daily aspirin to prevent heart attacks and strokes may not benefit from aspirin therapy because of their resistance to the medication’s anticlotting effect, according to a March 19,2003, news release from the American College of Cardiology Foundation. From January 1997 to September 1999, researchers from the Cleveland Clinic Foundation studied 326 participants with a history of cardiovascular disease. Normal aspirin therapy doses range from 81 mg to 162 mg daily; however, study participants took 325 mg of aspirin for at least one week before their blood was tested. Seventeen participants (5.2%) were found to be resistant to aspirin’s clotting effect. During a two-year follow-up period, these participants were more than three times as likely to die or suffer from a heart attack or stroke than
aspirin-responsive participants (ie, 24% versus 10%). Currently it is difficult and expensive to screen patients for aspirin resistance and prescribe alternative therapies. For example, clopidogrel can be prescribed for patients who are aspirin resistant; however, this treatment costs $2 to $3 per day compared to only pennies for aspirin. Until the cause of aspirin resistance can be pinpointed or newer, less expensive screening methods are developed, physicians should continue to prescribe aspirin therapy for individuals at high risk for cardiovascular events. Aspirin Resistance Linked to Higher Rates of Heart Attack and Stroke (news release, Bethesda, Md: American College of Cardiology Foundation, March 19, 2003) h i i p : / ! htm .ace.or~medidreleases/highlights/2003/marO3/aspirin. (accessed 3 April 2003). 910
AORN JOURNAL
Competency is no reason for complacency
P
erioperative nurses are the most competent nurses around. Our practice is enforced strictly and has concrete guidelines, specific recommended standards of practice, and clear role performance expectations. Perioperative nursing certification boards maintain high evaluative testing standards to determine competency. Any nurse who circulates, first assists, manages, or educates and who has been practicing for any length of time has all the skills built into his or her muscle memory. Performance is almost automatic. This is the realm of the expert. There is a hidden trap, though, that is waiting to ambush even the most competent nurses. It is called complacency. Complacency is a feeling of self-satisfaction, contentment, and, sometimes, smugness.' Taken to the extreme, it can be a fault. This occurs when complacency interferes with taking action when it is needed. Complacency can lead to procrastination (ie, if we ignore this, it will go away) or indecisiveness (ie, why make a decision to do something different when nothing is wrong). Complacency occurs when people feel satisfied, so it is reasonable to expect that complacency would affect the most experienced nurses rather than novices. The RN who is learning a new role often is too fearful to be satisfied or content with his or her practice.
EXAMPLES Consider the following fictional scenarios. In scenario one, an excellent and experienced nurse has been working for some time in the cardiovascular room. She knows coronary artery bypass graft (CABG) surgery down to the smallest detail. She is organized and prepared before surgery, and much of her activity is finished quickly. She feels satisfied and is happy with her performance. Her manager leaves her alone because she causes no trouble and the physicians are happy. In other rooms, however, things are not going as well. There are new personnel and changes in procedures; new hospital regulations are being implemented, and there is a lot of discontent. The CABG nurse tells herself that it does not affect her, and she is staying out of it. It is just too bad if others are having problems, but they probably are not as good at their jobs as her. Things progress until they explode in the OR. The manager is demoted, and a new one is appointed. New policies and innovations are put into place, and the new manager demands that they be followed. This means the CABG nurse has to change many of the ways she did things in the past, which leads to confusion, inefficiency, and delays. Competency is affected because of past complacencyin this case, ignoring the rest of the unit, which resulted in a lack of anticipation and planning for 908 AORN JOURNAL
the future workplace. In scenario two, a physician retains a private surgical assistant (SA) whom he NANCY J. GIRARD brings along whenever he is scheduled to perform surgery. The perioperative nurse in the room knows the SA comes with the physician and is credentialed to be in the OR. She also knows that the SA is somewhat slack in his duties. The nurse, while an expert and competent, does not feel that she should say anything to the manager about her observations or interfere with the SA's back table and medication preparations. After all, things always had gone well in the past. One day, a patient is scheduled for a biopsy of a nodule on the thigh. The SA's duties include preparing the local anesthetic for the physician to inject. He automatically prepares the injection but does not check the medication with the perioperative nurse, who ignores him. When the physician begins injecting the medication, the patient becomes hysterical with pain. The pain does not cease, and upon investigation, it is found that the SA drew up clear formalin that was in a sterile container for a specimen rather than the clear local anesthetic agent, which also was in a sterile container. The patient subsequently experiences considerable tissue
MAY 2003, VOL 77, NO 5
damage at the site of the injection. In this situation, a competent nurse indirectly contributed to a patient’s injury because of her complacency. Complacency can permanently maim or even kill patients we are trying to protect.’ It also can lead to legal entanglements that every nurse wants to avoid.’ SAFETY Although errors can happen to anyone in these days of short staffing, increased technology, increased workload, and more time at work, we must not let down our guard. People may say, “Complacent! Not me. I am just tired.” Maybe, but we must be aware that errors can occur. The
aviation profession has been the leader in implementing safety procedures for many years, and health care is starting to adopt some of that industry’s processes and procedures to create a safer environment for patients. Even airlines, however, who state that “statistically speaking, one would have to fly in an airliner 24 hours a day for 438 years to be involved in a fatal accident,” are concerned that complacency could affect their progress.‘ Businesses also are concerned with complacency. A. G Kefalas, a professor of management at the University of Georgia Hillel, Terry College of Business, Athens, Ga, tells about attending a conference with Coca-Cola
NOTES 1. “Complacency,” HumanityQuest.com, http://huma nityquest.corn/topic/Encyclopedias/index.asp?theme1 =complacency (accessed 5 March 2003).
2. L Johanson, “Complacency can kill,” RN 64 (August 2001) 49-50.
3. C Fleming, “Complacency in care can create legal and ethical tangles,” Nur:singMut/ers 10 (January 1999) 7. 10.
Enterprises, Inc, chairman Robert W. Woodruff, who said the biggest problem with management is complacency. He thinks managers who sit back and relax when everything is going well contribute to major hture problems in a company.i Nothing guarantees quality or safety, but we must be ever vigilant. One thing we can do is prevent complacency from impairing competence. Perioperative nurses still control the environment in the OR. They still are the ones responsible for maintaining safety and preventing injury, and they are the ones patients look to for protection. NANCY J. GIRARD RN, PHD, FAAN EDITOR
4. “Past achievements in safety: No grounds for complacency,” Air Safe@ Week 15 (August 20, 200 1) http: //www.findarticles.com/mOUBT/33-15/77355348/p 1/arti cleljhtrnl?term=september+21 (accessed 17 March 2003). 5. A G Kefalas, “People fall into complacency during good times,” Online Athens (December 30, 2000) http: //www.onlineathens.com/stories/123 1OO/bus-123 1000004 .shtml (accessed 17 March 2003).
Aspirin-resistant Patients at Higher Risk for Heart Attacks As many as 10% of the 20 million Americans who rely on daily aspirin to prevent heart attacks and strokes may not benefit from aspirin therapy because of their resistance to the medication’s anticlotting effect, according to a March 19,2003, news release from the American College of Cardiology Foundation. From January 1997 to September 1999, researchers from the Cleveland Clinic Foundation studied 326 participants with a history of cardiovascular disease. Normal aspirin therapy doses range from 81 mg to 162 mg daily; however, study participants took 325 mg of aspirin for at least one week before their blood was tested. Seventeen participants (5.2%) were found to be resistant to aspirin’s clotting effect. During a two-year follow-up period, these participants were more than three times as likely to die or suffer from a heart attack or stroke than
aspirin-responsive participants (ie, 24% versus 10%). Currently it is difficult and expensive to screen patients for aspirin resistance and prescribe alternative therapies. For example, clopidogrel can be prescribed for patients who are aspirin resistant; however, this treatment costs $2 to $3 per day compared to only pennies for aspirin. Until the cause of aspirin resistance can be pinpointed or newer, less expensive screening methods are developed, physicians should continue to prescribe aspirin therapy for individuals at high risk for cardiovascular events. Aspirin Resistance Linked to Higher Rates of Heart Attack and Stroke (news release, Bethesda, Md: American College of Cardiology Foundation, March 19, 2003) h i i p : / ! htm .ace.or~medidreleases/highlights/2003/marO3/aspirin. (accessed 3 April 2003). 910
AORN JOURNAL