NR 307A Week 8 Equity Course Reflection Example

The Word "Difficult": One Automatic Reaction to Families Who Ask Questions, Caught Twice in Eight Weeks

Student Name

College of Nursing, Chamberlain University

NR 307A: Advancing Equity, Inclusion, and Diversity in Healthcare

Instructor Name

Month Day, Year

The Word "Difficult": One Automatic Reaction to Families Who Ask Questions, Caught Twice in Eight Weeks

The Reaction

The reaction this reflection follows is a single word that arrives in my head before I have decided anything: difficult. It arrives when a family member asks for something I did not offer, such as a printed list of medications, the name of every drug in an IV bag, or a call from the doctor that evening. I first wrote it down in my Week 2 self-audit, after I felt irritated by an older Black man's son who asked for his father's medication list, and realized I had felt the opposite about a white daughter who asked for the same thing a week earlier. I called her thorough. The reaction came before I had done anything, and the difference between the two families was not in their requests.

I have kept to that one reaction because it is the part of this course I can actually test. FitzGerald and Hurst (2017) found in their review that health care professionals show implicit biases at levels similar to the general population, and Hall et al. (2015) linked these biases to differences in how clinicians communicate. Neither review says how to remove a reaction. What they suggested to me is that I could notice it and decide what to do after it arrived.

The First Encounter, Week 2

The first encounter was the one I described in the self-audit. The son was polite and specific. He asked for a list with each drug and its purpose, because his father had been sent home from another hospital on a medication he was not supposed to take. I gave him the list and answered his questions, so my actions were acceptable. But at handoff I said to the oncoming nurse, "The son in 14 is a little difficult." I had not planned to say it. That sentence went into the next shift with me, and the oncoming nurse went into the room already expecting trouble. My action at the bedside was fine; my handoff passed the reaction along.

The Second Encounter, Week 7

Five weeks later, at 0200, a Filipino woman sitting with her mother, who had pneumonia and a new confusion, asked me three times in an hour what was in the new IV bag, why the oxygen had been turned up, and whether the doctor would come before morning. I felt the word arrive. This time I noticed it before I spoke. I stopped outside the room, wrote the word on the back of my paper report sheet, and went back in. I answered her questions and asked what had happened the last time her mother was in hospital. She told me that her mother had been given a sedative during a previous admission and had fallen out of bed, and that no one had told the family until the next morning. Her questions were not about me. They were about the last time she had not asked.

At handoff, I told the oncoming nurse: "Her daughter is staying overnight and wants to know about any new medicine before it is given, because her mother fell after a sedative last time. She is very helpful with reorienting her mother." That sentence was the change. It passed on what the family needed instead of my reaction to it. Davidson et al. (2017) recommend that family members of critically ill patients be included and kept informed, and the daughter's questions were exactly the kind of participation that guidance describes.

What Changed and What Did Not

The reaction did not go away. I felt it in Week 7 as clearly as in Week 2. What changed was the gap between the reaction and what I did, especially in what I said at handoff, which is where my reaction had been reaching other nurses without my noticing. I also cannot say that the reaction is now equal across families. I only have two encounters, and the families were different in many ways besides race. The claim this reflection can make is narrow: I noticed the reaction at the moment it arrived, I delayed what I said until I had asked one question, and I changed the handoff sentence. A colleague could check the last part by listening to my report. Between the two encounters, I also noticed the word three more times, each after a family member asked a question late at night. Twice I caught it before I spoke and once I did not; on that night I told the oncoming nurse that a patient's wife was "a lot," and I only realized what I had done on the drive home. I am including that night because the pattern is not that I have stopped, but that I now notice more often than I used to, and the misses are visible to me when they happen.

The Attempt That Went Nowhere

In Week 6, I tried to change one arrangement on the unit that feeds this reaction. Our handoff tool has a free-text field labeled "Family concerns." In practice, nurses use it to warn each other about families, and the word difficult appears there often. I proposed to our unit practice council that the field be renamed "What the family has asked for," so the entry would record requests rather than judgments. The council discussed it for five minutes and decided that the field name is set by the electronic record vendor and cannot be changed locally before the next system upgrade, which is scheduled for late next year. A council member suggested adding a line to the handoff education instead, and that is now on the agenda for the spring.

The attempt did not produce the change I wanted, but it taught me where the change has to be made. My reaction is mine to manage. The field where it gets written down belongs to the organization, and the organization moves on a different schedule.

Where This Leaves Me

I will keep writing the word on the back of my report sheet when I feel it, and I will keep one question ready before I respond: what happened the last time? I will take the handoff wording to the spring education session. I do not expect the reaction to disappear. I expect to keep catching it, and to keep it out of the report I give the next nurse.

References

Davidson, J. E., Aslakson, R. A., Long, A. C., Puntillo, K. A., Kross, E. K., Hart, J., Cox, C. E., Wunsch, H., Wickline, M. A., Nunnally, M. E., Netzer, G., Kentish-Barnes, N., Sprung, C. L., Hartog, C. S., Coombs, M., Gerritsen, R. T., Hopkins, R. O., Franck, L. S., Skrobik, Y., . . . Curtis, J. R. (2017). Guidelines for family-centered care in the neonatal, pediatric, and adult ICU. Critical Care Medicine, 45(1), 103-128. https://doi.org/10.1097/CCM.0000000000002169

FitzGerald, C., & Hurst, S. (2017). Implicit bias in healthcare professionals: A systematic review. BMC Medical Ethics, 18, Article 19. https://doi.org/10.1186/s12910-017-0179-8

Hall, W. J., Chapman, M. V., Lee, K. M., Merino, Y. M., Thomas, T. W., Payne, B. K., Eng, E., Day, S. H., & Coyne-Beasley, T. (2015). Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: A systematic review. American Journal of Public Health, 105(12), e60-e76. https://doi.org/10.2105/AJPH.2015.302903