Nurses: Understanding Risk & Trauma-Informed Documentation #059

This week we are examining maybe one of the more uncomfortable conversations that we have when we talk about creating change and striving for trauma-informed patient-centered care: folks concerned about their level of risk. What does it mean if we truly trust patients?

If we really embrace folks making autonomous decisions about their health, where does that leave us in our role as healthcare workers?

How do we think about the risks associated with poor or unexpected outcomes? What have we been taught or taken in about liability as it relates to prenatal care? And these are the important, necessary conversations that I believe have to happen if we are ever want to reach a different relationship with those who are in our care.

Our guest today, Jen Atkisson, is a labor and birth nurse, clinical educator, speaker, patient and nurse advocate, and a consultant on standard nursing care.  We invite your reflection as she shares with us, what reasonable and prudent nursing care really looks like. We are diving into the nitty gritty of documentations and the steps you can take to make sure you provide safe and patient-centered care.

Listen in to explore:
~How fear is used to control nurses' actions
~Understanding risk, duty, and liability
~The perpetuation of "us vs them" themes in patient safety
~Nursing the chart vs nursing the patient
~Best practices for trauma-informed documentation
and so much more!

Transcript

Maggie, RNC-OB  0:03  
Welcome to Your BIRTH Partners, the podcast identifying gaps, acknowledging biases, and co-creating a trauma informed standard of birth care with change agents across the spectrum of birth work. I'm your host, Maggie Runyon. I'm a birth nurse, educator and advocate who has been searching since 2010. The answers to how to provide better care during pregnancy, birth and postpartum. Through my own pregnancies and supporting births in home and hospitals around the country. I've seen firsthand many the systemic flaws that exist in perinatal care. Through these conversations, I'm thrilled to share with you insights and inspiration as we work collectively to transform birth care.

Well, this week, we are examining maybe one of the more uncomfortable conversations that we have we talk about creating change and striving for trauma informed patient centered care. One of the biggest stumbling blocks that we run into is folks concerned about their level of risk. What does it mean if we truly trust patients, if we really embrace folks making autonomous decisions about their health? Where does that leave us in our role as healthcare workers, for many of us brings up uncomfortable memories, feelings, situations we've been in where we've had to question our responsibility. What are the expectations put on us by ourselves, and system? How do we think about the risks associated with poor or unexpected outcomes? What have we been taught or taken in about liability as it relates to perinatal care. And these are the important necessary conversations that I believe have to happen if we were ever to reach a different relationship with those who are in our care. I'm certain that our guest today, Jen Atkisson, who is a labor and birth nurse, clinical educator, speaker, patient and nurse advocate, and a consultant on standard of nursing care will have some insights that surprise us. She has over 15 years of unique experiences in nursing and consulting. And much of her education practice has gone into sharing information about patient safety, and legal questions that come up with an expert witness who's reviewed cases in over 20 Different states, and invite your reflection, as she shares with us what reasonable and prudent nursing care really looks like. We are diving into the nitty gritty of documentations, and the simple steps you can take to make sure you provide safe and patient centered care. On to the show. 

Yeah, well, welcome you and I am really excited to have this conversation with you. I think it's going to resonate with a lot of our listeners, and how we think about like liability and charting and kind of all of these pieces that go into like the the nitty gritty piece of providing care for folks during birth. So if you want to just tell our listeners just a little bit about kind of yourself and why you're here why you care about prenatal health

Jen, RNC-OB & Expert Witness  2:40  
care. Oh, my gosh, I care so much. I'm a nurse. I've been a nurse for 15 years, I always knew I would go into for when my grandfather who's like a rancher from Oklahoma, he's passed away now asked me, I was like five, he's like, Oh, Jenny, do you want to be president? And I said, No, I'm going to be a gynecologist. So very early knew, knew that this was my path. How could I do medical school thought I do midwifery. I really, really love being a birth nurse. I've been really lucky to get to the birth nurse in Portland, Oregon. And although I've learned so much and had to go through so much, you know, maybe like grieving around earlier practices or things I was taught in general, I would say Portland has been a fairly healthy birth environment in a lot of ways that other you know, now I have this other part of my work that I've been doing for about eight years, which is as an expert witness and doing some like risk management, consulting and teaching and things like that, in addition to like, I'm still a staff nurse, I will never leave the bedside it like evens my keel, it's like my thing. But I also have this other way to help, right by doing case reviews and expert witness work. So I do that's kind of where things have coalesced. My professional life is, gosh, I'm still at the bedside. And I teach a lot of things teach fetal monitoring, you know, I teach trauma informed care, different aspects to that. And I never really was didn't much teaching around like risk liability. You know, those sorts of words that we say that we could say misuse actually quite a bit and realize that that's a real sweet spot that especially for trauma informed care, folks, or people who try to be trauma informed educators, we hold a lot of trauma around the legal aspects of our care, because one that's scary. We don't want to lose our jobs, things like that. And the idea of harming someone is deeply, deeply distressing to nurses. So, you know, that's kind of where my current passion lies is taking what I get to see as an expert witness. It's a very secretive world, right? It's secretive at the hospital. It's secretive amongst people who do what I do. And I kind of decided like, well, that's not cool. That's doing nurses a real disservice. So that's kind of what I'm up to right now.

Maggie, RNC-OB  5:22  
Oh, yeah, well, I just, I mean, your whole like journey through nursing, obviously, we always talk about the the flexibility that is inherent with, you know, a nursing degree in different ways you can take it and I love how you've been able to really carve out different ways to kind of fill up your cup ways that can really make you feel it feel like you're making a difference in all these different facets, and how much you do to educate and help to inform the rest of us. And that's kind of how I first found, you know, your work through mutual friends. And I was just really struck by how much of that piece of like, risk management, how we perceive our responsibility, concerns about liability, litigation, all those things, how much that impacts us, like a dramatic level, as you know, as birth care providers, obviously, particularly in, you know, the hospital setting. But this is also something that does come up when we talk about, you know, community birth and how that works. And I think a lot of the rub that we get between those two, so I was interested in things that you were just saying about, you know, trauma informed care, certainly when I'm doing education, concerns about risk.

Jen, RNC-OB & Expert Witness  6:23  
Sure, yeah. That is a real fear. I think that that fear, you know, makes a lot of sense. So, sometimes just telling ourselves like, yeah, of course, that makes sense that I'm nervous about this. This is a message that's out there that really gets pushed. And I you know, I don't know exactly where it's all started. But, you know, I can only assume it comes from the power structures that are in our birth system. Fear is an amazing motivator, and an amazing way to, to lead. It's an effective leadership technique, right? It's not healthy, it's toxic, it's gross, it is highly effective. And so, you know, one exercise sometimes I'll do with folks is just, when I say different words, how does it feel in your body, right? When you say, in the court of law, like rule, like everybody goes, you know, but when I say literally, like, immediately, you fill it in, so make money, but when you say something like patient safety, it's so much more benign, they're the same thing. They're the same thing. There's no lawsuit without preventable patient harm. Now, I do see cases, you know, I do both plaintiff side, that's the more patient side, I do defense work, which is, you know, even understanding how these structures are set up. The fence doesn't mean I'm defending nurses defense means technically, I'm working for the insurance company that insures the hospital. So liability is a word nurses don't have liability, no one has liability, we have a duty liability is who's financially responsible? Well, it's the two people who have to carry liability insurance, your hospital and your providers out of the birth setting. I don't, you know, that's not my area of expertise. I don't know how that works. As far as who has liability, that would not be my expertise, I don't see those cases. They're very, very, very rare compared to the unbelievable amount of cases. I think I got last week, I got six new cases last week, from all different parts of the country. So liability just refers to who's financially responsible nurses have a duty. And that's a duty to meet the standard of care. So, you know, it makes sense, though, as opposed to having nurses be really confident patient advocates, it's so much easier to run a hospital based on this idea that we need to get patients to comply with a certain way of doing things because we have been taught that we're competing for safety, right? My time at work. It's that idea that as a nurse, if this patient does this thing, I'm now in danger. I am unsafe. I have this, you know, in quotes risk this liability and it makes us at odds with our patients, reverses. We understanding we don't have liability, we have a duty and when we keep the patient at the center of that and they make choices. They may choose wrong in our minds, right. They may choose something that does have a bad outcome. And there might be a case I think filed, because like I've had that that's a case I have right now a patient, you know, opted into a VBAC, and did have that very rare thing. And, you know, one of the main assert assertions that's being made is, we should have never let them even try. And you're like, No, no that like, that's the route we're going on.

That's the thing you want to do. So you know, they, they may. So this, this obviously is, you know, can be distressing for the people involved. It's very rare that this happens. But every once awhile, sure, it can pop up that the patient chose a thing. We supported them in this choice. There was a bad outcome. But really why this case is coming out? Most likely, I don't know for sure. But most likely is because once the bad outcome happened, everyone in the hospital goes silent. Right, and then you go into lockdown. So I don't necessarily know that it's because this, you know, or is it this is just like, their only chance to get information. And that is, that is some of the work I do. I turned down a case last week. That is, the care was I like this care was so good. This was better than probably 99% of the patients get. So part of my work, and that was to help the patient understand a little bit and get some closure and healing. Yeah, so it's just a weird, it's a very messy word world. And nurses do get put in that in the pinch point or in the crosshairs, a little bit of feeling like we don't get to advocate the way that we want to, because there's this competitive element. Now that's been put into play.

Maggie, RNC-OB  11:49  
Oh, yeah. Such a bad feeling. Oh, I think they were just like two really, things that popped out in, you know, what you were just saying? And I think one of them is that us versus them feeling that comes up a lot when we talk about how, how care is being directed, you know, the idea about who is making decisions. And so often it feels like we As for myself, you know, as a nurse, it feels like we're pitted against, you know, that the patient's interest. And I think there's just there's a whole conversation to be had around like understanding patient autonomy, what is going on there? Where does that conflict with what we are taught in school, how we are trained, and then how that plays out, like as we as we go through care. And I don't know, if you want to speak to that at large, and in particular, maybe how it comes up in documentation, because, you know, obviously, a lot of your work like focuses around that piece of it. So I'm wondering if you want to dive into that a little bit.

Jen, RNC-OB & Expert Witness  12:42  
Oh, my gosh, documentation, I get teased a lot because I only talk about it so much. Because that is I think a point in our risk management strategy, or whatever you want to call it is just focused on so much. And is so so unimportant in a lot of ways. It's, you know, I was looking at the A one convention, and there's even, there's always, always a Guaran fucking tee it always a course called something like this. This one's called, you know, I don't know, I'm gonna get thrown out a one. But obstetrical documentation, minimizing your liability, and it's being given by the president of a one, she's worked as a CNS for a long time, has not worked as a labor nurse or in risk management for greater than 20 years. And to just the title alone is, is wrong, minimizing your liability? Your documentation can't minimize liability. nurses don't have liability. Like, you can tell I'm getting hated.

Maggie, RNC-OB  13:47  
No, but that inflammatory language, absolutely. Like it's used, it's weaponized. It's used in a way to like, get nurses fired up. And I think it creates anxiety for us that it isn't there. So I want to hear your passion.

Jen, RNC-OB & Expert Witness  13:58  
They think that there's this idea that charting, and we get so many mixed messages. So this is where that feeds into that trauma response. We've all heard if it can go in a flow sheet. Don't write a note. We've also heard write lots of notes cover your ass. We've heard you know, all these mixed messages. And I think we get we hear a lot about it because it's an easy place for people to assert themselves. When some authority it doesn't take a lot to really, like speak with a lot of authority on on documentation, just by virtue of like that. You've been a nurse, there's a lot of like, well, I heard and, you know, and people can get really caught up in that. I've seen courses sold for like many hundreds of dollars. One came to my email and it was like, save your license in your life. You're like, holy shit, like I was gonna lose my life. I like what but you know, I mean, that's absurd. heard, right? No one's coming to murder you for that, if not based in any way, shape, any way, shape or form. I in my course, you know, we talk about documentation like third or four. Because really, if you're involved in a case and a court case, there's been a malpractice claim, somebody got hurt. And you're thinking, I think it's really wild to me to think like, oh, I need to chart differently so that when this person what like inevitably gets hurt, and I'm dragged into this deposition, I want to be able to like, quote, unquote, defend myself. I've seen everything from people saying don't chart, no new orders. And like, I truly the case, I turned down last week, she wrote no new orders. Then she charted that her and the Chargers were reviewing this trip, I'm like, oh, homegrown, went up the chain of command, like, that's clear as they I could give a fuck that she wrote no new orders. Like, that's not like some, but there's all these little rules and tips and tricks and things out there. And they really mess us up. When it comes to documentation, you know, and you want to keep people documentation serves a lot of purposes, right? It serves, it's the patient's record, it helps us get, you know, it's for charge capture. That's why all of us have epic, epic is the king of charge capture. And it can play a part in helping keep patients safe, but usually not the way most people think. So our job as nurses is to keep patients safe, as best as we can to prevent birth trauma. So we're I get interested in documentation is like, can it do one of those two things for us? And you know, and I have found that it can, but it doesn't matter if you write no new orders, continues to monitor or like, you know, things that all nurses kind of write, they don't really mean anything, but, you know, patients aren't getting traumatized from you writing those things in your chart, nor do I as an expert reviewing your documentation. I've seen lots of lots of charting, I've seen less charting. Like, it doesn't matter to me when I'm reviewing this for substandard care rang necessarily, right? Some things can give you red flags, like this person did all of their charting at the end of the shift. Oh, okay. That's make sense why she missed the late decelerations and minimal variability for hours and hours and kept increasing that Pitocin Oh, right. Right. The documentation is not the thing. It was the bad care.

Maggie, RNC-OB  17:38  
Yeah, yeah, that's the piece right there, right, what we document obviously should not be different than the care we provided. And so really, if the hair that we are giving was was great care was safe, was appropriate care, was fulfilling our job as nurses, you know, the way we communicate that via the patient record. That's not like the issue. But we're told that all the time, I've practiced at several local hospitals, and each one, you know, never to have the, you know, some sort of hospital lawyer or some sort of, you know, educator gives a whole spiel about that. And each place, it's different, just like you said, each place, it's like, never use this phrase. Oh, even the last place told you, you had to make sure use that phrase every shift or else nothing would count. You know what I mean? Like, it's all of these very seemingly arbitrary rules that are impossible to keep up with. And they keep us swirling. Yes. And feeling very anxious about, you know, like, I can be a little type A about stuff. So how many times do I then go through my charting? Each, you know, during the shift to make sure like, did I do all those six things? Okay. Yeah, I know, I checked it an hour ago, but I'm just gonna check it one more time, just to make sure like, that's not a good feeling. We've talked about how much of my energy in a shift is put into documentation,

Jen, RNC-OB & Expert Witness  18:51  
right, kind of nursing the chart versus nursing the patient. Yeah, sort of the main frustration that people get. So, you know, documentation is here to stay Epic is here to stay, we have to hospitals have to get paid. We have CMS compliance issues, we have all of those things. So I think, you know, some of the questions I like to ask is, you know, usually, people get nervous that they don't, you know, they want to cover their ass. And so, I think when we have some questions to ask ourselves around, that is usually like, you know, does the center the patient? Okay, sure. Okay, yes, I am charting that this patient is requesting an epidural or I'm that this patient is we're moving their position, we're doing whatever, you know, X, Y, or Z. Okay, you know, and like, the next one is What's my motivation for charting this, if it's my cue ate our, you know, body system assessment, and that's just required. That's an okay motivation, right? You didn't say Got to do it. Yeah, just I had to do it. Yeah, I got to do my nose at the end of the shift, I have to do my vital signs every four hours or whatever it is at your place. Again, I've seen ranges in there

Maggie, RNC-OB  20:11  
are the policy says you're supposed to be doing. Yeah. So if

Jen, RNC-OB & Expert Witness  20:15  
we just we just do or where, you know, we have to think about our motivation is especially around when, again that that fear place, the patient wants to do something that's kind of out of our norm. And we need to chart that I think it's our motivation to really think about like, I want to go over my ass, it's also, if we flip it, like we talked about earlier, I want to keep this patience, I want this patient to stay safe. And the way we can flip that on ourselves is just yeah, like charting, like what the patient wants to do, you know, making sure that they have all the information. And so when we know we have to chart these certain things, it can also be a vehicle for ensuring that that conversation happens with the patient. Right, that true shared decision making true informed consent conversation happened, because we have to chart that had happened. So again, like you said they have to match. So you know, I see this case I just had the one I was posting on Instagram that went to trial. Well, it was the verdict came in. So now I can talk about there's me a press release, it was the biggest verdict in the state's history. And reason this is pertinent is because, you know, the tracing had she was unmedicated no oxytocin, nothing tracing really, like was doing some wacky, you know, all kinds of huge decelerations and things like that they opened the or the patient had requested in a C section, her her testimony, the or was open that was documented. And then what happened was that she got an epidural and the doctor left to go do two other deliveries. Meanwhile, the tracing went really downhill. And she was left with this fairly new nurse. And then we had a, you know, bad outcome and traumatizing birth. And what was charted about that time when she asked for the C section was plan of care discussed with patient. Right, so now we have this patients like I was asking for a C section, we know they opened the O R. So those things, which what she got was an epidural, and the doctor left to go do two other deliveries. So right, the logical thing is, the doctor didn't feel like she had time to complete the C section. But did she write that the patient had requested it? No. So that's a place where like, nurses can really be like, you didn't, you did not chart all of the components of that inform had that nurse, which I'm guessing she wouldn't have. She was like, very, very new nurse. So again, there's other elements to this show lots of things, but us more seasoned nurses, and this is a thing that I know we talk about in the trauma informed birth nurses, we know what we have to document around this. So how do we use that then? Right? Because we can use policies or things like that, like, for good or for evil? Yeah.

Maggie, RNC-OB  23:14  
Yes, absolutely.

Jen, RNC-OB & Expert Witness  23:15  
is to say like, this is what has to be in this chart. So you better go back in there and talk about all of these, you know, alternative treatments, what did the patient want? What did I think was best? All that all is supposed to be in those things in those notes, not just plan of care discussed? Yeah.

Maggie, RNC-OB  23:37  
Yeah. Right. I feel like you're not that, like cases like that. It brings up so many feelings, right? Like, I'm sure for folks listening to that, like, take your time and sensations in your body, like, listen to all that piece. And yeah, everyone take a breath. Right? What would I have done? In in that moment? What you know, what, what should I have done? And some of you might be thinking, you know, it's easy to judge someone, obviously, hindsight is 2020. Right? You're looking at as a net, we know how the outcome turned out. So you look back and you're like, why wouldn't they have just ran back to the or to the C section? Why would they have had this ambiguous charting? Why wouldn't they have explained whatever happened between those two conversations, you know, and I think one of the things that is interesting in that what I really loved with the presentation that you did, as part of the trauma informed birth nurse program, you know, when I was watching it, I was just like, my mind kept being, like, just blown by the fact that like, the way you communicate that like, right, this is our duty, you know, as a nurse, this is one of the ways that we support our patient is just by accurately documenting what happened, right? Like this is a record of their birth story to an extent, you know, like, we don't need to be putting in interjecting like our thoughts, feelings, assessments, judgments, all that stuff that that happens in charts that you see where people kind of make like snide comments or whatever. And it's also one of the places where we, as sometimes again, the nurse, kind of like the go between between provider and patient, like we have this ability to make sure that that relationship like the There's good communication, that everyone is on the same page and that like, as we're doing our documentation, it's like a checkpoint for us to know that, right? Like to see like, Okay, does this act like, Oh, I'm checking POC just did we actually not go into enough details here, like if I can't put them into the chart, because that means we didn't actually have like an adequate education session around that around this, this was just a, like, FYI. And the other piece of it that struck me during that, and I think maybe you could go into this a little bit, like, we've been talking a lot in terms of work here, the the power dynamics piece of it, and I've done a couple presentations this week around that, and how, how much there's so much of our standard birth care, obviously, just partying with the with the skew towards, you know, to the provider at the hospital, the system, you know, the the left here with very, very little power, and the steps that we can take, and there are many steps we can take to try to swing, you know, that balance back so that the patient really is the leader of their care, but in particular how like our our documentation of those events, and I say this as someone who has charted this many times, so, you know, in good company, but you know, like Gen Y is to walk during early labor, Dr. So and So allows Gen Z that, right, right. And I again, charted it so many times, and then you look back and you realize, like, oh my gosh, like how much was I upholding the system that like Jen, perfectly able bodied person who walks all the time? Would for some reason not be allowed to do that? Would some would need to ask permission for how to move her body during her labor, like all the ways that we set that up, and we do policies, and we like, I would have that conversation with you like, oh, okay, no, you want to walk? Let me go talk to Dr. So and So and see if that's okay.

Jen, RNC-OB & Expert Witness  26:41  
Versus I'm going to just go let them know that you're gonna walk. Yeah.

Maggie, RNC-OB  26:45  
Jen, yeah, that sounds great. Like it that would that feel more comfortable for you? Yeah, let me let you get up. And then I go, and I just say like, Hey, Doc, those are just you know, if you see it, anything on the tracing or, whatever, Jen's up walking around right now, that's where she wanted to be more comfortable.

Jen, RNC-OB & Expert Witness  26:55  
Right. So and that is how I was oh, the second way was how I almost we always had it here. And that's where I get really thrown off when I you know, fairly new to the Instagram stuff. And you see the stories, which I completely believe based on the work that I do. Just really wasn't part of my not to really the same extent in my work life, except for a very, very beginning part of my career. Yeah. Okay, where do I start?

Maggie, RNC-OB  27:23  
There was a question buried in there. But there was

Jen, RNC-OB & Expert Witness  27:25  
there's a few things. So when I talk about cases I in this one where this, she was a fairly new nurse, this hospital did not have the processes available for her or she was not trained in these processes. So this is in no way, like a piling on, I will say of the few 100 cases now. There's only been maybe like one or two where I was like, Ooh, this nurse is just not a good nurse versus we all can under see this person within this system. It's bad actor versus systemic issues. It's almost always a systemic issue. There's only been very, very few I can count on one hand where I was like, this person really should have known better that there was everything there for that. It's super rare. It's almost always a systemic issue. They didn't believe that they could do these things, right. So when we're talking about changing, that's where I think my work and like trauma informed birth nurse goes well together, because it is really about this, understanding these bigger systems and how we interact with them. Gosh, yeah, you said so many interesting, they are really lost in what you're saying. And I realized, I was like, you know, when you listen, because you're listening versus like listening to answer a question. I was like, smelling gross.

Maggie, RNC-OB  28:41  
Okay. So I think part of it too, like recognizing the power dynamic piece, and maybe how that gets reinforced? Or if you have, like, what are our tips there for how we and I, again, like we'll share more information to about Jen, like, how you can learn more with her about this facility. But if there's a couple of like tips you can give, particularly around like documentation, really think the documentation is a reflection of our action, in that sense, right? Maybe how do we how do you either learn to document better and that changes your mindset and your action about it? Or, or the opposite order, whichever way kind

Jen, RNC-OB & Expert Witness  29:13  
of goes? Yeah, that's the thing, right? Is sometimes words are super powerful, right? And we know that even from doing exercises like self talk, right, the way we talk to ourselves can start to change the way we view the world. Thoughts translate into action. So the same can be for documentation, power dynamics, I think nurses are I'm sure you found this too, so surprised to know that for the first time that they've heard that there's a power dynamic between themselves and their patient, because nurses typically don't see themselves as that way right.

Maggie, RNC-OB  29:51  
Not to right. We are saying that you think deferential to are so

Jen, RNC-OB & Expert Witness  29:54  
nice. I of course my patient knows I'm the most trustworthy love li Kai nice, cute adorable fabulous earrings. Whenever nurse, the patient knows there's a power dynamic, they are vulnerable, they have shown up onto our turf, we are in these blue scrubs or whatever color. And they are giving birth. Like they know there's a power dynamic,

Maggie, RNC-OB  30:19  
a uniform, we have a hidden language, we have access to things that they don't have access to both knowledge supplies, everything. I mean, like everything is on they know

Jen, RNC-OB & Expert Witness  30:29  
or somebody are in absolute less powerful position. So the tips I give our I always in my documentation, I always use names, right? We're centering the patient, we know whoever controls the conversation, there's a really, really good coat of whoever controls the converse, that controls the words controls the conversation, whoever controls the conversation controls the outcome. So we want to use words that the patient is going to know. So using like really plain language, also patients now I know nurses are really wound up about the Cures Act where patients can read their progress notes. And they're like, how am I going to say what I want to say? It's like, well, why can't you say what you want to say it?

Maggie, RNC-OB  31:12  
Why do you want to say to the patient when want to read?

Jen, RNC-OB & Expert Witness  31:14  
Are you being an asshole like, yeah, you are, you're being biased or something. They know that they use methamphetamine, they know they're declining the ice, they know, they know that they don't have reliable housing, like come on. Like, we're not saying a thing, whatever it might be. That way they know that they are pissed off about this induction,

Maggie, RNC-OB  31:35  
like Yeah, and it shouldn't be I think sometimes there's things like that where we want to like communicate to each other something that we don't want to say to the patient, maybe. And again, that's like the major red flag that should be the fight to us like Oh, then it's not appropriate for me to chart this. If I haven't actually discussed this with a patient like, Oh, I'm concerned in postpartum, you're very teary. You're seeming very emotional upset of all these things. So rather than just being like, Oh, hey, Sarah, I'm gonna get in here and recommend that case management come see us here. And we do this. And so this Jen's I them, right, Hey, Jen, I've just you know, I can't help but notice what's you know, what's going on what's going through your head right now and having a conversation so that if they were to see that that's not going to be like, they're being attacked by the charting attack by the nurse, it's like, Oh, I'm just sharing about this conversation we had so that we're all in the loop. So when I'm not here in a few hours, everyone's still understands where we've been on so far.

Jen, RNC-OB & Expert Witness  32:24  
Right? And this doesn't happen. And you know, I think a case where this really, so my mother has influenced my care so much. She is not a nurse. My father is actually a nurse, my mother's not she was like, a broker she worked in, like Silicon Valley in tech, in her younger days and stuff like that. But she just, you know, two things that she really imparted on me was, you know, everyone remembers their nurse, and don't ever be somebody's bad memory. I think that was her version of telling me to be trauma informed. That was very early. And then the second thing is she when we left for college, my sister and I, you know, we had our long term family practice, doctor, she thought, when she went for her checkup, he was asking how things were. So she gave a lot of information about like, I'm feeling really sad, and blah, blah, blah, my daughters are gone, you know, typical things that anyone going through that would. And the next visit the chart, the paper chart was left open. And she saw all these words on there to describe her and her mental health, that just, you know, she was just, like, stabbed in the back. Like, she couldn't believe that those that he had taken from that conversation and written these things in her medical record, with never saying, like, it sounds like you're depressed. And then she could have been like, no, no, no, I'm just, she was sharing more of like, I've known you a long time. friend did not realize that he was, you know, writing his interpretation of it, right, essentially calling her like, I think she might have even seen as the word crazy in there. Like, that's crushing.

Maggie, RNC-OB  33:54  
I mean, like the sense of betrayal you have, right in that situation. And that just really, and I was like,

Jen, RNC-OB & Expert Witness  34:00  
I think at that point, I was in nursing school, and it really was just like, oh my gosh, like, yeah, when something like that went to have that and so I read everything back to patients. I read everything and now they can see these things, right? We have the Cares Act that they can read all of their progress note, but I've always you know, always use names you always lingo really over the top with our like clinical language. You can say Pope you don't have to say bowel movement, like you can. I don't know what that Yeah. Although most patients would know what bowel movement is. But like, you can use the regular terms in there. You can put in like, what they're experiencing things like that. And I always read things back to them for two reasons. One, like, Is this accurate? This is what I'm putting, especially if I'm going to be you know, hopefully the patient and the doctor and I are all having conversations together. But we all know that sometimes they went back to the office or so and if you're the intermediary between mean, the best is that everyone's talking? Obviously, we know sometimes the nurses the intermediary. So before I go, I like, this is what I'm going to say to them is this. I want to advocate for what you want. You know, there's sometimes like, a decision to be made like, and you know, it's coming up on that, like, Labour's really slowed. And we've tried lots of things and you know that like the Pitocin conversations going like, and you can say, like, how are you feeling? Are you was that a thing that you're like, ready for a year hoping for more time because I can make that go one way or the other. Right? Right. And then you chart that and then you go say, hey, they're not this is or so I always read back things, or if like, something scary has maybe happened. And actually, this piece, this debriefing piece, this reading, this talking is actually coming to become a joint commission requirements. So we're going to need to start having systems in place for nurses or providers to be able to do a well, so after they say, after traumatic events, the patient needs to be debriefed by somebody who's trained to do this. Most likely, it'll be like your social, it's probably not going to be your obstetrician. You're probably gonna be like a social worker, or a special nurse or somebody like that. How we define traumatic situate, you know, the, I think Joint Commission, things like hemorrhage, Shoulder Dystocia.

Maggie, RNC-OB  36:25  
Right. So there'll be a big hole for a while until we're able to work through the nuance there a nuanced,

Jen, RNC-OB & Expert Witness  36:31  
right, yes. So those are the three things I, I think can help nurses to use the documentation as an advocate. I mean, there's other ways to use it for maybe like patient safety that, you know, I've written about, or we talked about in the course, but as to be an advocate, I would say that those are the three big things is just always use their name, always use a partner's name. Always use really plain language as plain as you can, and read back everything and just make that a habit.

Maggie, RNC-OB  37:02  
I love it like those are. So those are accessible, right? Like this is not. And they can also be used in in many ways in whatever other style, you're used to documenting. No, like, those are things that can be put into place, you're used to writing PT, for patient instead of just saying, Jen, great, like, that's a tradition I made a couple of years ago, and you know, my practice, I was like, oh, yeah, there's no reason I can't just write out, Jen, Stephanie, maybe whoever. And I feel like that part of like reading it back how powerful that would feel. Because I think many of us too, obviously, I've been on the patient side of healthcare many times. And if you ever go back and like look at your chart, or you're looking over something, and you're reading back the note, and you're like, oh, they had no idea what I was talking about, that like this thing that's written here, like that was actually not my concern with this visit. So Huh, no wonder we didn't get to the place I thought we would get in this visit. Because turns out we'd had a fundamental miscommunication about why I was there, what my concern was, you know, right. And like how frustrating that feels. And so how, like, simple that is for us be able to do and just help, like, it supports our patient and knowing like, yes, you're saying this, I'm writing that same thing. Read Oh, no, you made this. Okay. And like, how? I just wonder how many, you know, like, think back to that case you had earlier where, you know, plan of care discussed? Would it have changed the outcome? Maybe there's no way to know if that conversation had happened if they had made sure they were documenting exactly what was happening so that both the patient and the provider perhaps understood each other's perspective, and came to an actual mutual shared understanding of what was going on how different that would have felt for like everyone involved in that care, who then experiences a bad outcome, because bad outcomes do happen sometimes, to know that, like, okay, but we all were like, we were all on the same page, we were all tracking all of this. And it was this kind of unavoidable thing, instead of feeling like, oh, maybe we missed something here, like how different it feels to be able to do that. Yeah, I mean,

Jen, RNC-OB & Expert Witness  38:51  
this in this case, there were other providers who could have been called to come to support these three active you know, this one provider is getting felt the need felt like she was getting pulled in three different directions, you know, in the chart can really help with that situational awareness. So yeah, if to chart patient requesting the section Oh, are opened, going to give her an epidural. Instead, you might have called your partner like that, or I'd have been red flag

Maggie, RNC-OB  39:21  
there to add flag, something's not right here. This isn't right.

Jen, RNC-OB & Expert Witness  39:25  
Or I just think that in the little ways that we do it, like do we right, you know, things from the perspective of us and the provider, are we charting things from the perspective of the patient, that practice can help us become better advocates? I think I think it is that like, the words create the thoughts create the reality, like, I don't know, it's like labor nurse manifesting or something? I

Maggie, RNC-OB  39:50  
don't know. Yeah. Yeah,

Jen, RNC-OB & Expert Witness  39:52  
I do think that words are incredibly, incredibly powerful and we get casual with them. part it's a coping mechanism, right? We can be gruff or use things where you're like, Oh, you would never say that in front of a patient because we're just, it's out in the trenches together, you know, that sort of talk. But it's really nasty that it because we don't realize how much it really affects the trickle down to the unit culture or things like

Maggie, RNC-OB  40:22  
a Unicode Yeah, we talked about, you know, the medical jargon piece of it over clinicization and terminology. And then there's like the dark humor piece, you know, the dark humor piece, you'd rather laugh and cry. So that's not a healthy coping mechanism. You know, how that plays into, like, our understanding, like our own secondary trauma where we need to do support we need. And absolutely that plays into both, you know, when patients hear us at the nurse's station, as we're talking about this stuff, and in the way we treat them, when we're talking to our colleagues, when our language and our behavior like dehumanizes, those who are in our care, absolutely, that that flows into the way they receive care from us, you know, like, we can't pretend to they're separate entities.

Jen, RNC-OB & Expert Witness  41:02  
No, no, and there is an inherent, I think, like, when we start to change back into that more, you know, fine tuning our advocacy skills, even with our words, with our documentation, things like that, it can be hard because there isn't a necessary grieving period. That comes when you with dealing with the times, then you have it and I have been the first case I ever reviewed. I was just so struck with not that, you know, my hair has never been questioned. I've never been involved in a lawsuit as a named party. But I realized, like having that 30,000 foot view, there could there certainly could have been a time that I missed a thing or, you know, I said the wrong thing to say, oh, gosh, or something like that. And I curled up in a ball into my bed for close to two weeks with that first case, just realizing like, wow, I could have done something and I would never know. So I do think that nurses sometimes it's easier to grasp onto the like, chart this chart, John, that that that to really think about the ways in which our words are powerful, because it's hard as good, caring, lovely Beings of Light. Everybody can be harmful. Everybody can be toxic. Absolutely. Absolutely. So but it is a really worth wild journey. It's not always easy. But yeah, there's this decision. I think every nurse comes to in their advocacy journey, that journey back to ourselves that we can be no other way. Like, I you know, I'm not I can't, I can't bear the thought of someone getting harmed, that's a much less bearable thought than then getting bitched out today. It still sucks to get bitched out, I don't think that that's good. I'm not trying to be like be a noble warrior, working on these systems. But I think every nurse comes to that point. And I've been struck at how many nurses I've met recently, who are really at that point that that true advocate point.

Maggie, RNC-OB  43:11  
I think it's some certainly the last couple years and how we have felt like, oh, maybe you've always been willing to kind of roll with the punches go with a tie. This is what they say we're supposed to do. And in many ways, the way we've been betrayed by health organizations, fiscal years as health care workers, I think has made folks be like, Oh, actually, maybe. Maybe this isn't in my best interest, either. So turns out, I'm not protecting my patients, and I'm not protecting myself. So why am I doing this and going along with this flow? And I think people are just kind of collectively reaching that sense of like, no, no, nope, not worth

Jen, RNC-OB & Expert Witness  43:43  
it. Not gonna do that. Right. So I think that's a really beautiful thing, I guess that we've gotten out of the last few years is there's going to be a critical mass at some point, right?

Maggie, RNC-OB  43:55  
Yeah. Yeah. No, it is. It's, I think it's coming. Oh, well done. Thank you so much for having this conversation. Obviously, like, there's like so many elements of this. I want to just keep like, talking about it. But I also I know I would love for you to share a little bit information about the course you have that addresses for So for folks who are feeling like jazzed about this and won't really be able to like dig into the deeper with you. Can you give a little bit of info about that?

Jen, RNC-OB & Expert Witness  44:15  
Yeah. So it started as a talk at the A one convention a couple of years ago. And then I made a little like two hour course, just the basics of the legal process. Again, when we don't understand it, it can seem a lot scarier than it is and then it morphed into now like a 12 chords. I have it open about three times a year because there is a live component, legal stuff, you can't you have to be so I feel like an extra burden to be very trauma informed and cautious with people's nervous systems around it. So it's called reasonable and prudent and because that's how nurses are described in the law. So I took that word but you know, nurse, the legally, the legal says done, the state legislatures have defined standard of care as it's their word. standard care is not our word. It's their word. It's what a reasonable and prudent nurse would do in a same or similar situation. So we didn't make it up. But the good news is that we get to define what that is. And so it's a course that has a couple live calls with it. Just to ask more questions. We go through everything through what a reasonable person nurse should know, how we communicate, that includes documentation, the skills we need to have and how we advocate. And there's a section on like postpartum care, and also a little extra special section on depositions, just because that's something that's extra freaks people out. Absolutely very familiar territory that'll open up in May, for like a week, people can sign up week or two, and then it closes. And so far, it's been really good positive feedback from the last cohort. And yeah, I like supporting nurses in this way.

Maggie, RNC-OB  45:58  
Absolutely. Well, thank you. And then where's the best way for folks to find you on the internet?

Jen, RNC-OB & Expert Witness  46:03  
On the Instagram, probably, I also have a website, people can sign up for my list. I have to say, I'm not terribly great about emailing the staff to be better about that. But just at Jen Attkisson online, you can find all my things.

Maggie, RNC-OB  46:16  
Well, thank you so much for sharing your insights and inspiration with us as we think about how we can change and be more aware of our practices and our documentation and our and our mindset, around risk and in patient centered care.

Jen, RNC-OB & Expert Witness  46:30  
All right, very good.

Maggie, RNC-OB  46:33  
What are y'all feeling in your body after that episode? I know that interview brought up a lot of complex feelings and sensations for me. And I've had the privilege of learning with them before. As you're taking this information, considering your practice, reviewing past behavior, observations of what you've seen from others, and working to bring in those three aspects of patients and documentation. Please join us over at your birth partners community, our Facebook group, as we explore putting this into action in real time. Till next time