Complicating Forgiveness

IMG_2754Forgiveness sounds so warm and fuzzy and facile. And religious: Forgive us our debts (or trespasses) as we forgive our debtors (or trespassers)…. Like a joyous sunflower turning its laughing seedy face toward the warmth and the light.

But wait. That sunflower looks decidedly sinister. Could there be a dark, prickly underbelly to forgiveness? Is forgiveness always a good thing?

These are questions I’ve been asking myself as well as ‘asking’ various experts through an extensive search of the academic literature related to forgiveness (mainly within the fields of philosophy, psychology, and counseling). These questions have led to more questions: Can you forgive someone or something like an institution–a hospital system for instance–for wrongdoing in the absence of an admission of guilt and a sincere apology? What constitutes a sincere apology? What constitutes sincere forgiveness versus a too-quick-to-give (or forced into) ‘cheap grace’ forgiveness? Do you have to forget to forgive? What is self-forgiveness and why is it important? What are the power dynamics, including gender dynamics, embedded in forgiveness? Who has the ‘right’ to forgive? Are there some instances of wrongdoing (like the atrocities of the Holocaust and of various genocides around the world, or like severe child abuse) that are of such great magnitude that they are unforgivable? Can there be reconciliation without forgiveness?

Forgiveness and its close relations of shame, guilt, righteous indignation, anger, revenge, restitution, reconciliation, and restorative justice are highly relevant to health care, to public/community health, and to all health care providers. There are the all too frequent medical errors leading to patient injuries and deaths. There are the ‘second victim’ casualties to health care providers involved in medical errors. There are the just and unjust cultures of hospitals, medical systems, and health regulatory boards. There are the U.S. Public Health Services’ infamous Tuskegee Syphilis Study and its lingering effects. There are worsening environmental justice issues, racism, gender-based violence, police brutality, and global health inequities.

Within health care provider education in the U.S. we now include course content and interprofessional mock trainings on ‘error disclosure.’ We try to identify and intervene with incompetent or ‘bad apple’ students. We have student counseling services for students struggling with emotional issues. We have (or rather we should have) faculty development trainings on how to provide clear, constructive student performance feedback in a supportive, non-shaming way. But we don’t really have a place for open discussion of forgiveness, shame, vulnerability, and uncertainty. We’re all about measuring and having students attain ‘competencies.’

The closest I ever come to teaching about forgiveness, vulnerability, and shame is when I touch on the concept and practice of cultural humility in my community health course (the best description of cultural humility is the short video Cultural Humility: People, Principles and Practice by Vivian Chavez). As social worker, therapist, and researcher Brene Brown points out, we can’t have constructive conversations about race, class, power, and privilege without addressing shame. If you haven’t already seen it, I encourage you to watch her 20 minute TED talk “Listening to Shame.” It reminds me of how much I love the profession of social work.

Out of the thirty or so scholarly books and articles I have read on the topic of forgiveness, here are the ones I found most helpful, provocative, and powerful:

  • The Sunflower: On the Possibilities and Limits of Forgiveness, by Simon Wiesenthal (Shocken Books, 1976, 1997). The first part of this book is Wiesenthal telling the story of his experience as a Jewish prisoner in a Nazi concentration work camp in Poland. He was picked at random by a Nazi nurse to visit a young, dying SS officer who wanted to ‘confess his sins’ to a Jewish person and ask for forgiveness. Wiesenthal sat for hours by the patient’s beside listening to him–at one point he brushed a fly away from the patient’s bandaged head–but he stayed silent and did not forgive him. The episode bothers him and he asks people what they would have done in the same or similar situation. The remainder of the book is comprised of responses from various theologians (Jewish, Christian, Buddhist, and Muslim) and philosophers. This is a book that will haunt you long after you’ve finished reading it.
  • Before Forgiving: Cautionary Views on Forgiveness in Psychotherapy, edited by Sharon Lamb and Jeffrie G. Murphy (Oxford University Press, 2002)–and especially Sharon Lamb’s chapter “The Good, the Bad, and the Ugly: Psychoanalytic and Cultural Perspectives on Forgiveness.” She writes about power dynamics and gender politics vis-a-vis forgiveness. “Gender conformity then is ‘met’ when a woman forgives her wrongdoer and lets go of resentment, even at the cost of self-respect.” (or safety as she add in the case of abuse and intimate-partner violence).
  • “Shame, guilt, and the medical learner: ignored connections and why we should care,” by William Bynum and Jeffrey Goodies, Medical Education, 2014, 48:1045-1054.)
  • For an amazingly rich sci-fi take on the topic of forgiveness, there is Ursula Le Guin’s book Four Ways to Forgiveness, the first part of which is titled “Betrayals.”
  • In the realm of fiction, Naseem Rakha’s novel The Crying Tree (Broadway, 2009) is carefully researched and beautifully written. It’s a fictionalized account of the complicated grief process of the mother of a murdered teenage son who forgives and befriends her son’s murderer while he awaits his execution on death row. This novel is based on Rakha’s work as a journalist covering the death penalty in Oregon.

Forgotten Nurses

This week I read the poignant and humorous essay “Lullaby” by Rebecca Ashcroft about her work as a night shift nurse at a hospital (In: The Healing Art of Writing. U CA Press, 2011). She makes the case for why night duty nursing works best for her while she is raising two children. She gets to go to soccer practices and piano recitals. But she doesn’t gloss over the downsides of night nursing—the falling asleep at inconvenient times and in inconvenient places, the mood swings/crabbiness of sleep deprivation, etc.

Night shift nurses are sometimes referred to as the forgotten nurses. Most patients in hospitals (if they are lucky) sleep through most of the night and never really remember the nurses who check on them in the wee hours of the morning. Nursing leadership and the rest of hospital administration acknowledges their essential function, but rarely actually see them. Working night shift is often considered a career stall if not an outright career killer, because of the invisibility to daytime administration. It’s also sometimes looked down upon as the ‘easy shift’ since not as much is going on during the night—no tests or surgeries being scheduled for patients. The hard part of night shift nursing is the pesky sleep issue for nurses, so it still comes with a pay differential.

Early in my career when I worked as a hospital nurse on a spinal/brain injury rehab unit, I chose to work evening shift. This was when they still had three 8-hr hospital nursing shifts instead of the more common 12-hour shifts they have now. I liked evening shift because it wasn’t as hectic as daytime shift with its PT/OT/procedures, so I got to spend more time one-on-one with my patients, as well as with their families. When I worked in a nursing home as a nurses’ aid I sometimes was asked to work an evening and a night shift back-to-back when they were understaffed. I remember stumbling home after those double shifts as if I were drunk. Indeed, sleep deprivation can be as bad as alcohol intoxication for basic brain functioning. Not safe for driving home after work and not safe for patient care duties.

Research shows that night shift nurses have higher “sleep debt,” worse circadian rhythm disorders (think chronic jet lag), higher risk of obesity (poor eating options at night plus hormonal/metabolic imbalances from night duty), and higher rates of certain types of cancers (especially colon cancer). Lack of adequate sleep and working too many consecutive hours is linked to higher risk of serious patient adverse events. This is why there have been significant changes by accrediting bodies limiting hours of medical residents (to 80 hours/week). This is similar to aviation rules mandating maximum number of hours that pilots and flight attendants can work. The aviation rules are better enforced since it is a federal mandate through FAA. Limits to medical resident hours are voluntary and rely on self-report.

Ann Rogers, who is Associate Professor at the University of Pennsylvania School of Nursing is an expert on the issue of night shift nursing, health and patient safety. In Patient Safety and Quality: An Evidence-based Handbook for Nurses (AHRQ, 2008) she has a chapter entitled “The Effects of Fatigue and Sleepiness on Nurse Performance and Patient Safety.” There’s a handy algorithm for nurses to use in assessing risk due to sleep deprivation/disruption. It starts with “Have you had at least 7 hours of sleep in the 24 hours prior to starting your shift? It includes “fatigue management” strategies, including naps and caffeine use. Seemingly not endorsed by Starbucks, she writes, “Caffeine should be used therapeutically. Caffeine should not be consumed on a regular basis or when alert.” (p 11)—then “Do not consume caffeine outside of work.” (p. 12) This does not seem to be very practical advice. The short naps strategy can work, but only if supported by colleagues and administration. Many nurses do not even get to take uninterrupted scheduled lunch breaks—which is when sanctioned naptimes could occur.

Hospitals provide 24/7 nursing care, so night shift nursing is an essential—if forgotten, overlooked, or undervalued—part of heath care. I raise a toast (of my double-tall vanilla soy latte) to all you dedicated if sleep-deprived night nurses out there!

Temporary Nurses and Patient Safety

1966 Nurses Strike - San Fransisco Where It Al...
Image by nursing pins via Flickr

California is the only state that mandates minimum nurse to patient hospital staffing ratios. So when hospital nurses go on strike in California, the hospitals postpone elective surgeries in order to reduce patient numbers, and hire temporary nurses to maintain the mandated nurse staffing levels. The recent patient death from a medication error by a temporary nurse at Alta Bates Summit Medical Center in Oakland during a nurses’ strike, has drawn attention to temporary nurses and patient safety.

Late last month more than 23,000 nurses at Sutter, Kaiser, and Children’s Hospital Oakland had a one-day planned strike protesting proposed cuts in employee benefits and patient services. Sutter hospitals locked out the nurses for four days after the strike, saying they had to sign five to eight day contracts with the firms who brought in the temporary nurses. During the lockout a temporary nurse reportedly administered a nutritional supplement through a central line (into the bloodstream) instead of through an abdominal feeding tube. Hospital spokespersons have called it a highly unusual medication error, but quickly added it didn’t have anything to do with the lockout or the use of temporary nurses. Nurses’ union officials have said the patient death wouldn’t have happened if they hadn’t been locked out after the strike. They have filed a complaint with the National Labor Relations Board over the lock out. And they have stated that it reveals that the use of temporary nurses endangers patient safety.

So what is the evidence in terms of temporary nurse staffing and patient safety and quality of care? An oft-cited study by Linda Aiken published in 2007 in the Journal of Nursing Administration, did not find that hospital patient safety was negatively affected by use of temporary nurses. However, her study used survey/self-reported data, and only included Pennsylvania hospitals. A recent large national study found that emergency department medication errors associated with temporary staff were more frequent and more likely to be life-threatening than those by permanent staff (Pham, et al, Journal of Healthcare Quality, July/August 2011). The authors point out that the use of temporary nurses (and other hospital staff) is on the rise due to work-force shortages and perceived cost savings to hospitals.

Unique Closure


This week I reviewed Washington State Nursing Care Quality Assurance Commission records for Kimberly Hiatt—the 1,500 pages allowed under public disclosure. I had requested these records in order to look at the primary sources unfiltered by journalists or people close to the case. I also requested them as data for a journal article I am preparing on health workforce regulatory systems. Kim’s story continues to disturb me. I won’t repeat her story here, since it has been told in many other places (and most completely/accurately in my opinion by JoNel Aleccia/MSNBC). Instead, I will share my main impressions, thoughts, and unanswered questions.

My overarching impression is that the entire cascade of events contributing to Kim’s suicide could have been prevented. A secondary impression is just how complex our health care system is—how prone to errors of all sorts, not just medical errors, but errors of judgment by people in various levels of the healthcare hierarchy. It is not any one person’s—or one institution’s—fault. However, all along the way, individuals with power could have significantly altered the course for Kim. And nurses were turning on other nurses within this cascade of events. Not only nurse administrators, but also nurse colleagues of Kim’s. (I should note that there were also nurse colleagues who were quite supportive of Kim–and these show up in the record as well.)

But some of Kim’s colleagues were making unsubstantiated accusations, including a sophomoric and trumped-up sexual harassment charge by seemingly homophobic co-workers (and from the record, not handled well by hospital HR). This sexual harassment charge by a female nurse against Kim involved the fact that Kim was openly gay. That this could happen in a modern-day US hospital is dismaying. That this could happen in a US hospital in a city with the highest per capita population of lesbian-identified women is appalling. Then there was the more recent charge (by an ICU nurse) of Kim abandoning a patient. An investigation of this charge found that physicians had called Kim into help with a difficult parent conference, and Kim had arranged coverage for her patient.

Nurses could have prevented the negative outcome: shame on us.

Kim had worked at Seattle Children’s Hospital for 24 years on several different units. This was her first major medical error. The Cardiac Intensive Care Unit where Kim worked had just offered her a permanent position. Her last performance review dated 8-24-10 signed by the Director of ICU rated Kim’s performance as a 4/5 “Leading Performer.” Annual job performance reviews going back to 1994 are similarly high, with a peer writing, “Without a doubt, Kim is one of the most skilled nurses on our ICU.” Then, immediately after the medication error, in a report to the Nursing Commission, this same Director of the ICU (and a nurse herself) expressed concerns about Kim’s nursing practice—that she “failed to partner with leadership and work to correct the situation that could have caused her to make the failure.” Kim had immediately reported her medication error—had helped the medical staff remedy the situation—had disclosed her error to the baby’s parents with the support of the lead physician—then had been escorted off hospital property/put on administrative leave, and soon after was fired. Where exactly was Kim’s failure to partner with hospital leadership?

The initial report of an adverse event sent from Children’s hospital to the Nursing Commission stated: “an overdose of medication to an infant, who died as a result” even though it was not clear (and remains unclear according to the medical examiner’s final report) that the overdose contributed to the baby’s death. It was also reported this way in a memo by the CEO of Children’s hospital—that was then picked up by KOMO News and the Seattle Times. Guilty until proven innocent. The Nursing Commission member’s e-mails/memos acknowledge this “heavy media attention” as pressuring them to make Kim’s ‘case’ high priority. How might this have prejudiced the Nursing Commission’s decision-making process for Kim? The Nursing Commission member in charge of Kim’s investigation is herself a Chief Nursing Officer of a hospital. How might that lens have affected the Nursing Commission’s decision-making process for Kim?

The Nursing Commission refused Kim’s lawyer’s repeated requests for copies of their complete investigative materials—including the final medical examiner’s report—so that he could adequately advise Kim on her options before she was required to sign the final Stipulation of Informal Disposition (the final disciplinary action/sanctions). Why was his request denied?

The Stipulation sanctions included a $3,000 fine, 48-month probationary period where Kim needed supervision for giving medications, Commission approval of any future jobs, and reporting of her discipline to the National Practitioner Databank—as well as made public on the Department of Health website. The Department of Health staff attorney assigned to this case wrote in an internal e-mail “Talking Points” prior to the final settlement, “Tell (Kim’s lawyer) his client may take it or leave it…” Kim signed this Stipulation. A week later she killed herself. Upon being notified of her death, the Staff Attorney for the Nursing Commission advised closing Kim’s case as “a unique closure.” As of today, Kimberly Hiatt shows up in the Washington State Provider Credential Search Database as having an expired nursing license and having had no disciplinary actions.

What does all of this say about the deficits in our health care system? What can nurses—and others—do to prevent this sort of treatment of a nurse? Can anything be done to reform the health professions regulatory system? Can anything be done to hold hospitals accountable for their treatment of nurses?

I realize that it is easy for me to say that nurses need to speak up more about injustices to other nurses, to stop petty in-fighting and not so petty back-stabbing. I am–as spokespersons for Children’s hospital refer to us–an “armchair safety expert who doesn’t know the details of Hiatt’s case.” Except I do know 1,500 pages of details of Hiatt’s case. It now makes less sense to me than it did before. There is no suitable closure–not even a unique closure–for Kim Hiatt’s case.

To Forgive, Divine: Medical Errors and the Consequences for Nurses, Part II

Alexander Pope dying; from the title page to W...
Image via Wikipedia

“Good-nature and good-sense must ever join; To err is human; to forgive, divine.”~Alexander Pope, Essay on Criticism

The topic of my last post “To Err Is Human” hit a raw nerve for many people. Since the post, I have heard directly from numerous former co-workers and parents of NICU patients of Kim Hiatt’s who are devastated by the news of her suicide. Many other people who did not know her personally are distressed over her death, and seek to understand what went wrong at a systems level—what we can do to prevent this from happening to other nurses.  I am struck by the inadequacy, irony, and inaccuracy of the Seattle Times article last week, “Nurse’s Suicide Follows Tragedy.” Her suicide is part of the tragedy; her suicide does not follow the tragedy. The role of local media—not only the Seattle Times but more importantly KOMO News—in this tragedy is a topic I do not possess the psychic distance to be able to address.  Of course, we the news-munching public are also culpable, since we engorge ourselves on ambulance-chasing, witch-hunting, tabloid-line blurring ‘news’ stories.

I try to keep my personal blog separate from my life as a faculty member at the University of Washington School of Nursing. But on this topic the lines blur. I listened to some of my current nursing students, as well as some very wise local nurses outside of the UW, and—with the blessing and assistance of many of my UW colleagues—we are offering a forum/panel discussion on Tuesday May 10th, 3-5pm Hogness Auditorium, UW Health Sciences Building. It is open to the public, so please join us if you can. The tentative title is the title of my last blog post, “To Err is Human: Medical Errors and the Consequences for Nurses” because—well, that is what the panel discussion will be about. So far for the panel we have top-ranking representatives from the Washington State Nursing Care Quality Assurance Commission, the Washington State Nursing Association, an area suicide prevention program for health care professionals, and Joanne Silberner from the UW Department of Communications (to discuss the role/responsibilities of the media). For those of you who don’t know, May 10th is during National Nurses Week.

As I told my students this week, the news of the suicide of Kim Hiatt has re-opened wounds of my own. The topic of a future post (and a chapter in a book I am writing), I experienced the fallout in my own life of an investigation/threatened suspension of my nursing license early in my career. It was due to a (still) anonymous complaint about the scope of my practice back when the nurse practitioner role was very new and in a more conservative state than Washington. I was (I think) eventually cleared of any wrongdoing, but the stress of that time cascaded into my divorce, loss of my job, episodes of homelessness, and a bitter vow to leave nursing. The overwhelming feelings of shame, isolation, betrayal/loss of trust in the health regulatory system, led me to contemplate suicide. I did not have the media hounding me. It has taken me 25 years to be able to process those events and be able to talk about it with other nurses. Silence can be deadly.