'I wanted to make sure this didn't happen to another kid'

By Louise Kinross

Laura Oxenham-Murphy is the interim director of Quality, Safety and Performance at Holland Bloorview. Laura first thought about improving hospital care when she was a child. That's because at age eight, she was on the receiving end of a medical error. "It ended up having a huge impact on my life," Laura says. We spoke about how this experience spurred her career.

BLOOM: Can you tell us more about your story?

Laura Oxenham-Murphy: When I was eight I was scheduled to have a routine surgery to remove three child teeth. That was that, and I was supposed to go on my merry way. But the surgeon that was operating on me had the wrong patient chart. He ended up doing a procedure that was completely incorrect and removing three adult teeth.

It meant three or four follow-up surgeries that I wouldn't have had to have. And quarterly visits to a specialist, who lived over an hour from my house, from age eight to 18. What was most significant was that the incorrect surgery was visibly obvious for many years. For all of junior high I was missing teeth. It wasn't pleasant.

BLOOM: Why did you have to have the follow-up surgeries?

Laura Oxenham-Murphy: They removed enough adult teeth that the bone disintegrated, or stopped growing, so when I was old enough to have a permanent implant put in, the bone structure wasn't there. I had to have bone grafts and the recovery from that involved missing a lot of school. Then I had to have surgeries for permanent implants. It was painful. And none of this had to happen.

BLOOM: How did you initially cope?

Laura Oxenham-Murphy: Even as an eight-year-old you're concerned with what will people say, or what will people think at school? I'm going to look a bit different from other people. At eight, I didn't really understand why this happened. Why did he make the mistake?

When I went back to follow up with a different specialist, even as a child I could recognize that he was trying to cover up what happened and minimizing it. 'Well, you might have had to have these teeth taken out anyway' was the argument he got into with my mom. I piped up: 'No, I specifically remember I was told it would only be my baby teeth and it wouldn't have affected my adult teeth.'

BLOOM: How did that experience lead you into quality?

Laura Oxenham-Murphy: From a young age I wanted to make sure this didn't happen to another kid. At first I thought that meant going into clinical practice.

But my mom is a health-care practitioner and she said if you really want to make change at a system level, you should consider doing a master's in health administration and work in an administrative and leadership capacity. That spurred me into taking a pretty non-traditional route into the role I have today. I went straight into the administrative role, as per my mom's coaching.

BLOOM: Has not having a clinical background been challenging?

Laura Oxenham-Murphy: It can be, and certainly comes up from time to time, primarily in job interviews and when I meet new colleagues for the first time. However, I think I'm able to bring a different lens and ask different questions.

That said, when working on quality and safety improvement projects I make sure to have a strong team that always includes clinicians.

I don't regret the path I've chosen. When I got into my master's and was able to take a couple of elective courses in quality improvement, that's where it hit me. Yes, yes, this is what I've been thinking about since I was 10 years old!

BLOOM: What is a typical day here like?

Laura Oxenham-Murphy: Oh boy. You may have a plan for what you hope to accomplish, which are mostly projects at a strategic level. But then incidents, complaints or concerns come up, and most often those are things that require immediate attention, so your plan for the day gets derailed. I manage urgent risk cases as they come to me, or privacy concerns.

I work closely with the people on my Quality, Safety and Performance team, as well as others across the hospital. We're a very close-knit QSP team, so to meet deadlines and get the work done, I rely on my colleagues. It's a very dedicated team and I'm proud to be part of it.

I spend a lot of time in meetings, and work with my counterparts in other hospitals to further the quality agenda at a system level. We share resources and best practices we can take back to our own organization.

BLOOM: What's the greatest challenge of the job?

Laura Oxenham-Murphy: The unpredictability. Some days you might have nothing out of the ordinary, and you're able to get into a good flow on some of our projects and initiatives. Other days, one thing after another happens and you're not able to open your e-mail till 5 p.m.

BLOOM: How do you manage stress?

Laura Oxenham-Murphy: I wake up at 5:30 every morning and exercise. We have a bare-bones home gym/yoga studio and my husband and I are both very committed to getting each other out of bed. We go down to the gym or if the weather permits, we go for a run. It's the only time we get to spend together on weekdays as our jobs pull us in different directions in the evenings.

I wouldn't be able to do what I do here without that. We'll exercise for 45 minutes to an hour, then spend time together eating a solid breakfast of oats, coffee and some fruit. I find it really grounds me. And we try as much as possible not to talk about work.

BLOOM: What's the greatest joy of your job here?

Laura Oxenham-Murphy: I love when there's been a risk issue and I'm able to interact with clients and families, as well as front-line staff, and we're able to come to a resolution, or even to see small differences, that shift the relationship to a more positive one.

I love bringing together passionate people—clinicians, leaders, clients and families—to work collaboratively on a particular quality improvement initiative, and supporting their capability and commitment. We are so fortunate as a hospital to have such a highly engaged group of clinical and non-clinical staff, and I see my role as enabling our staff in their commitment to quality and safety.

BLOOM: What's an example?

Laura Oxenham-Murphy: One of the things I'm most proud of is our recent success with our last Accreditation cycle. It's not about the exceptional results we received from the surveyors. What I'm really proud of is playing a role in having our clinicians, leaders and clients and families partner together more closely on quality and safety.

BLOOM: How often do you work with parents and kids?

Laura Oxenham-Murphy: On a weekly, even daily, basis. When I'm wearing my risk and privacy hat I'm dealing with clients and families. In the quality world, I'm interacting with family and youth leaders. Interacting with our clients and families is truly one of my favourite parts of the job, and really helps to ground me in what we are collectively striving toward.

One of the interesting dichotomies to get my head around is the perspective of how we merge, or think about, what are the important issues from the perspective of family leaders—a cohort of individuals that are very educated about the system and how to navigate it, and have a clear vision of where they want it to go—with a family that is concerned because their child didn't get the correct medication at a certain time.

BLOOM: What are common risk issues?

Laura Oxenham-Murphy: There's a lot around informed consent. Parents saying something wasn't explained in a way that they understood, or that resonated for them. When there's a complex family dynamic, there might be two parents who have varying custody arrangements, and one wants to go one way and the other disagrees.

There are concerns about timely access to services or delays in treatment. With all risk cases, I partner closely with clinical teams, Client and Family Integrated Care and Bioethics together with the client and family to come to a mutual resolution.

BLOOM: How does your firsthand experience with a medical error help in these discussions?

Laura Oxenham-Murphy: I believe it helps me empathize a little differently. It's not something I would ever say. I would never use the words 'I know what you're going through,' because clearly I don't. Every experience is different. But in the back of my mind, I can call up some of those feelings and emotions that I experienced, and my family experienced, which can help me relate to what a family is feeling.

BLOOM: What have you learned from families?

Laura Oxenham-Murphy: I've learned so much, I don't even know where to start. One of the things I've appreciated the most about working here is the opportunity to interact with patients and families and family leaders. It's helped me to come back to that true sense of why I want to do what I'm doing, and why I'm committed. I want to promote optimal experiences for patients and families and when I get to have conversations with them, it grounds me and makes why I've started on this journey more tangible.

BLOOM: If you could change one thing about children's rehab, what would it be?

Laura Oxenham-Murphy: I think making the system easier to navigator for our clients and families. So getting certain services doesn't require being connected to the right people and knowing the right questions to ask. If there weren't gatekeepers, and people could just come and learn about different services that were available. If the solutions were simple, we would have implemented them.

Also, from a health equity perspective, I've been thinking a lot about how we ensure our services are meeting the cultural needs of the diverse population we're meant to serve. I credit Aman Sium with helping me understand this better than I had previously. 

Read More

Rude words from doctors and parents harm care

By Louise Kinross

In 2015, a team of Israeli researchers studied the impact of rude comments by another doctor on medical teams while they did a simulation of caring for a very sick premature baby.

The words, from an expert the participants were told was observing them, included that he was “not impressed with the quality of medicine in Israel” and that medical staff in Israel “wouldn’t last a week” in his NICU in the United States.

Twenty-four NICU teams participated and teams were randomly assigned to hear the expert’s rude comments or to hear his neutral comments. The teams that experienced the rude comments scored less well in their diagnosis of the baby’s problems and in how they performed tasks like resuscitation and asking for the right lab tests. They were rated by two judges. “Rudeness exposure [by a medical superior] can adversely affect the cognitive functions required for effective diagnostic and medical procedural performance,” the researchers conclude, and may be a source of devastating medical error.

In a new study published in Pediatrics this month, the same scientists look at what happens when an actress, playing the role of the baby’s parent in a simulation, belittles the medical team. In this study, four Israeli medical teams performed five emergency scenarios. Three of the teams were confronted by a mother who accused them of misdiagnosing her child, threatened to move the child to another hospital, and said: ‘I knew we should have gone to a better hospital where they don’t practice Third World medicine!’ The control team was not exposed to rudeness.

Two teams were given a preventative intervention—one was a cognitive bias-changing game and the other a therapeutic writing exercise. The 20-minute computer game before the simulation showed angry and happy faces and provided feedback that made them less sensitive to negative emotions. The writing exercise involved having one team write about the rude event after it happened. The teams that experienced the rude comments from the mother scored less well on how they diagnosed the baby and intervened, as well as how their team shared information and workload. The researchers showed that the pre-simulation computer game reduced these negative effects on care, while the post-intervention writing exercise was ineffective.

BLOOM interviewed lead investigator Dr. Arik Riskin, a neonatologist at Bnai-Zion Medical Center in Haifa, Israel, by e-mail to learn more.

BLOOM: Why was the study about parent rudeness needed?

Arik Riskin: The study is important because it increases awareness that there are many factors related to human behaviour, relations and communication between [health workers] and between them and their patients or families. We are not robots, we are human beings with feelings, and we react to social situations and behaviours as do other humans. But, in the case of [health workers], the impact can be devastating, because we are dealing with patients, treatments and life-and-death decisions. The remedy starts from awareness and recognition that there may be a problem with this issue. Awareness is important for us as medical team members, but it’s also important to our patients and their families and to healthcare management authorities dealing with ways to decrease medical errors and improve care and patient safety.

BLOOM: How did you define rude behaviour?

Arik Riskin: Rudeness is defined as insensitive or disrespectful behaviour enacted by a person that displays a lack of regard for others. Rudeness should be regarded as a form of uncivil behaviour. Workplace rudeness may include insulting comments, denigration of a person’s work, spreading false rumours, social isolation and bad manners.  Rudeness, particularly with respect to speech, is necessarily confrontational at its core. What constitutes rude speech depends on the culture, the setting and the speaker’s social position in the culture. Rudeness is primarily concerned with violations of human dignity or respect.

BLOOM: What are common causes of rude parent behaviour in the NICU?

Arik Riskin: I would pay a fortune to find out the answer to this question. However, I’ll share with you some of our insights from our experience. Many times rude behaviour is a late response to an incident or some stress (and the NICU experience is very stressful) that the parents experienced before, sometimes even a few days or hours before.

The rudeness is not necessarily turned toward the [health worker] that was involved in that previous incident, and may be unrelated to the parent's infant or to the NICU or hospital. It can be some argument between the parents or in their larger family.

However, when it hits the physician or nurse out of the blue, they start thinking ‘What have I done wrong?’ This starts the process of rumination—thinking over and over ‘Why did I get this insult?,’ drains their cognitive resources and eventually can affect their ability to treat patients.

BLOOM: What were the main findings on rude parent behaviour?

Arik Riskin: Rudeness has robust, deleterious effects on the performance of medical teams.  Moreover, exposure to rudeness debilitated the [collaboration] recognized as essential for patient care and safety.

BLOOM: How does rudeness impair a medical team’s ability to provide good care?

Arik Riskin: Teams exposed to mild rudeness by the patient’s mother had diminished team performance with respect to outcome parameters relating to diagnosis and intervention, and process parameters including team information and workload sharing. These findings not only replicate our earlier findings demonstrating the [negative] effects of rudeness expressed by a senior colleague on individual medical performance, but extend them by demonstrating that similar effects are elicited by rudeness from other sources and are manifested at the team level.

In this study, we also demonstrated that these deleterious effects of rudeness are not restricted to individuals, but also to teams. This is important because—based on the assumption that teams can often overcome and compensate for individual performance limitations—medical work is increasingly structured around teams. Our findings demonstrate that when rudeness is present, the very collaborative processes that generally enable teams to outperform individuals may break down.

To the extent that rudeness impedes team helping and workload sharing, teams may not be able to deliver the heightened level of patient care that practitioners have come to expect from them.

BLOOM: Why was the computer game some teams played effective in reducing the negative effects of rudeness, while the writing exercise others did wasn’t?

Erik Raskin: Prior to the simulation, teams in the preventative cognitive-bias modification intervention engaged in a 20-minute computer game in which they looked at a series of morphing faces, were asked to move a cursor to indicate whether the emotion was more of anger or pleasure, and then received immediate feedback on their choice.

During this game, the computer determined the participant’s threshold to threat—that is, the angry faces—and then gave them feedback designed to raise this threshold and ‘immunize’ them from devoting substantial attention to minor threats.

Examination of the manipulation checks showed that those in the computer intervention viewed the mother as ruder than those who experienced the rude comments with no intervention.

As designed, the computer intervention ‘immunized’ participants’ medical and therapeutic performance and teamwork by shifting their attention away from the implicit threat posed by the mother, likely preserving cognitive resources for the tasks at hand. The computer intervention operated not so much by mitigating the appraisal of rudeness, but by making team members more resilient to it.

The teams who did the writing exercise worked on the simulation with rudeness first, and then went to a debriefing room where they were asked to write a paragraph or two about how they thought the mother of the infant felt when it seemed to her that the team was unsuccessful in treating the baby.

By the end of the day, those in the narrative group did not view the mother as ruder than controls. These results suggest that while writing about the experience from the mother’s perspective facilitated participants’ positive reappraisal of her rude behaviour, it failed to help them overcome the cognitive disruption caused by it.

BLOOM: Is there a danger in making health workers less emotionally responsive to families?

Erik Raskin: As mentioned in my answer above, the computer game didn’t make health workers less emotionally responsive. On the contrary, it just ‘immunized’ them, thus changing their focus and less disturbing them in their work.

BLOOM: Are there times when a parent questioning the care is appropriate?

Erik Raskin: Parents questioning the care is always appropriate. They have the right to ask questions. In my opinion we can use it as a means to help us do better, think again about the diagnosis, re-think treatments given and other options of treatment. Generally, this is a good interaction with parents, and many physicians and nurses, like me, see parents as our partners in the goal of giving the best treatment to their children, helping them survive and grow, and go home, as healthy and happy as possible.

There is a big difference between real questioning and seeking explanations in the best interest of your baby, and rude comments, insults and blaming of the physicians and nurses. [In the latter case], parents throw all their stress and frustration (because the infant was born prematurely and is very sick) on the medical team that is trying its best to save their infant, give life and treat as best as they can.

There is also the issue of timing. We allow parents in our NICU all day long, including in rounds, but parents must understand that we also need to treat, to do resuscitation and other procedures, and to look after other babies. So we are not all the time available to answer every question. They should be patient and understand that sometimes we simply don’t have time to talk to them immediately, and we’ll be happy to do so later when we have time.

So, please don’t start shouting at us, making rude remarks about how careless or less attentive we are. This makes us feel bad, makes us ruminate about ‘What have we done wrong?’ and drains our cognitive resources in a way that eventually hurts our performance or even causes us to do unintentional harm.

BLOOM: A media story about your study includes a quote from a doctor who says that outside the NICU, parent rudeness is often a legitimate reaction to poor care and system problems. Is it possible that this could also happen in the NICU?

Arik Riskin: Sorry, but I disagree with this statement. Rudeness is never a legitimate reaction—not in the NICU, not outside the NICU and not anywhere else. This is not a nice way to express your concerns. It is a totally unacceptable form of communication among people in general. It is an act of incivility that is no less harmful than aggressiveness or bullying. 

Parents should and can express their concerns about treatment, and if they think it’s poor care, they should tell this to the medical team. If this doesn’t help, they can talk to their superiors, and if this doesn’t help, they can ask to go and get the treatment in another facility. The problem is that many times it’s not poor care, but mainly frustration on behalf of the parents because their infant is really sick and doing badly despite all the treatments given to him or her.

But, I’m ready to hear this from parents, too, and I’m not ashamed to consult another expert and seek another opinion, as long as it is for the best care of my patients. Unfortunately, many times nowadays parents are confused by a general atmosphere that is very criticizing [about] everything. This is reinforced by the media ‘looking for headline news,’ attorneys looking for law suits, and family members (who think they are supporting the parents by questioning everything, but cause the parents lots of confusion and eventually mistrust in the care their baby gets.

Parents need to have some trust and faith in the team taking care of their baby in order not to lose hope, which is so important for them, and us too. Parents should ask questions, should learn and read about their infant’s condition, and should inquire about the diagnosis and possible other treatments. But at a certain [point] they need to have some trust and confidence in us as medical team members, coming days and nights to do our best for their babies.

BLOOM: Are there differences in how parent rudeness vs medical staff rudeness impacts medical care?

Arik Riskin: Both are as bad, having devastating effects on individual team members and on medical teams’ performance as a whole. We haven’t compared both sources at the same time in the same settings, so I can’t guarantee which is worst. But based on our studies and the studies of Professor Erez and colleagues on rudeness in other settings, both have very bad influences on the [person targeted] and on those who witness it.

BLOOM: What advice would you give parents?

Arik Riskin: Try to be as patient and polite as possible. We understand that you are in real [distress], and are there for you. We even understand when you are not so nice to us because you are sad and worried. But, being sad or worried and even frustrated doesn’t necessarily need to make you rude to us.

Being rude simply doesn’t help and might actually cause the opposite by distracting us and disturbing us from doing our best. 

I have worked with many parents over the years and those that had a positive attitude to all that was happening, despite all the stress and hard times they were going through, coped much better than other parents. I believe that this attitude gave them hope, which is so important in tough times. I think they may have also been more open to the support we are willing and trying as best as we can to give to all the parents of the sick infants and preemies we’re taking care of.

BLOOM: What measures should hospitals put in place to try to reduce rudeness by senior medical staff or among medical peers?

Arik Riskin: Awareness is also important among team members, educating us to treat each other with dignity and respect. The days when a senior physician or charge nurse could be rude to a resident or trainee are over…not because it’s impolite and unfriendly, but because it [endangers] our patients.

By highlighting the impact that adverse social contexts may have on team-level [collaboration], our findings provide the foundation for a wide range of interventions aimed at enhancing patient safety. Our results suggest that instituting protocols and procedures aimed at bolstering the defenses of medical teams to the cognitive distraction and drain elicited by rudeness can help mitigate the devastating consequences of these events, even when they can’t be prevented.

BLOOM: Do you feel there’s a role for narrative writing and reflection, even though the intervention used in your study didn’t show a benefit?

Arik Riskin: Yes, I would definitely not quit this possible route of interventions, especially not reflection, which is an excellent learning tool for medical teams.

BLOOM: Have you considered doing a study to look at the impact of rudeness by medical teams on parents of premature babies? Some parents have traumatic experiences related to being talked to in a callous or dismissive way, or in hearing their child being talked about in a degrading or disrespectful way.

Arik Riskin: This is an important subject, which I’m sorry to say still exists as a problem. I haven’t done research on it, but I know that many others have studied this important aspect of communication.

Teaching physicians and other health workers to talk nicely, gently and politely with parents is no less important than the medical treatment we provide. I recall my first lesson in neonatology as a resident. The director of our NICU then, the late Dr. Berger, taught me. We went to talk to a mother after a delivery. The mother was very stressed and frustrated even though her baby was improving. Then Dr. Berger sat with me and told me her insights about how mothers feel after delivery, and how we need to talk to them and support them. She told me this was my first lesson in pediatrics and in neonatology—How to talk to a mother—and it was more important than any other lesson I’d learn.

I carry this important lesson with me and pass it over to my students, residents and fellows. I still find talking to parents the most challenging, but also the most rewarding, part of my work. I look at them as our teammates in the long, long [journey] we have to go together to make their infant survive and to be as healthy and happy as possible.

Read More