Recently I've been reminded of that old idiom, "can't see the forest for the trees" while fielding questions from some participants in the fetal monitoring classes I teach. Two stories from nurses (who shall remain anonymous) are worth retelling, as I have heard variations of these same stories over the years, and I believe they underscore how deeply many of us are living in a culture of fear rather than in a culture of safety. Both stories involve nursing response in emergency situations, and in both cases the nurses acted in the best interests of the patients they were serving. Yet in both situations, the nurses were not honored or commended, but rather disciplined. See what you think.

CASE SCENARIO 1

In a small rural hospital, with limited personnel available, a patient in labor suddenly develops a fetal heart rate tracing that requires immediate delivery by cesarean section. The obstetrician is in house, but there is no one to first assist with the cesarean. The obstetrician asks one of the experienced labor and delivery nurses to act as first assistant (she has been a scrub nurse many times, but never a first assistant). Initially, she balks, knowing it is outside the scope of her job description. But the situation is literally life and death for the infant, and it would take too long to get another physician or a surgical assistant to the hospital. The labor and delivery nurse scrubs in, and under the careful guidance of the obstetrician, they perform the cesarean and have the infant delivered in less than 20 minutes from the time the decision was made. Neonatal resuscitation results in a perfectly healthy infant bonding with mother and father in the recovery room.

The doctor has nothing but profuse thanks for the nurse, as do the parents who are happy to have a nice, loud, baby girl in their arms instead of visiting her in the neonatal intensive care unit. The next day, the nurse is called to her supervisor's office, where she is severely chastised and told that the hospital would not have been able to "cover" her had something gone wrong.

CASE SCENARIO 2

A labor and delivery nurse is working in a hospital that does not have any in house obstetricians or residents. A patient suddenly progresses to fully dilated (from 2 cm) and the nurse calls the physician and prepares for immediate delivery. She sees the bag of waters (filled with thick, particulate meconium) begin to hourglass through the vagina, closely followed by the crowning of the fetal head. At that moment, she knows 3 things to be absolutely, inarguably true: (1) there is no way the doctor is making this delivery, (2) she is not supposed to artificially rupture the membranes (AROM), as it is outside her scope of practice, and (3) if she doesn't AROM the bag of waters immediately, this infant's first breath may be the last as meconium aspiration is almost guaranteed. So the nurse picks up a Kocher and performs both the AROM and the delivery. The obstetrician walks in a few minutes later and all is well. Again, both the obstetrician and the family are full of thanks and praise for the nurse. Unfortunately, the nurse manager has a different viewpoint and writes up a formal disciplinary action, which is placed in the nurse's employment file.

Now, before I spew forth with righteous indignation, let me preface my next comments with this very clear statement: I am not advocating nurses practice outside their scope of employment or disregard any rules or regulations set by the state or their institution. But it seems that these nurses should be commended, not criticized. In both cases, the nursing managers cited legal concerns regarding scope of practice and malpractice coverage. And again, I certainly understand those issues. But I wonder what the "legal implications" would have been had the nurses stood by and allowed a bad outcome-imagine what a jury would think about a hospital that would rather see the MD struggle alone to try and do a section in an emergency? Or, one where a nurse would allow the infant to breathe in thick meconium rather than perform a simple (and at that juncture, almost certainly risk-free) AROM?

These stories fill me with many emotions. I feel honored to know nurses who stepped up, mustered their courage, and did the right thing in an emergency. Initially, I was furious with the response of nursing administration in these cases, but that quickly gave way to a tremendous sadness. A sadness for both the nurses who had been unjustly reprimanded and for those who had meted out the reprimands, because while it is a shame that the nurses who responded to the emergency were chastised, it is so much more depressing that there are institutions so obsessed with rules they cannot understand why sometimes the rules have to be broken. I am depressed because it seems there are still institutions where common sense is a limited commodity and blame is still the prevalent culture, as opposed to safety.

Philip K. Howard is a favorite author of mine who has written about the dearth of common sense in the legal system today. The problems he describes seem all too familiar-obsession with rules and rule enforcement, concentration on minutiae when larger problems loom, etc. Perhaps his 2 books, The Death of Common Sense and The Collapse of the Common Good: How America's Lawsuit Culture Undermines Our Freedom, should be required reading for all nursing managers and healthcare executives.*

In previous columns, I have talked about the art of followership, and about nursing as a profession, not a job. I have written about safety, and perinatal teamwork, and have had the opportunity to both teach and learn from literally thousands of nurses over the last 30 years. In short, I have been proud of nursing and proud to be a part of what is surely one of the most gratifying professions in the world. So it is no wonder that it breaks my heart to hear these stories from my colleagues.

I cannot change the past. But, by publishing these stories, perhaps I can provide the impetus for change. To the nurses who "did the right thing," I commend you, I applaud you, I honor you, and I hope I can be like you when I am faced with such a challenge. To the nurses and hospital administrators meting out the reprimands in these types of situations, I respectfully and in all kindness suggest that you may want to have your eyes checked, as you apparently cannot see the forest for the trees. Moreover, to everyone, perhaps it is time we all figure out how to work together and strive for a blame-free culture-a culture where rules are respected but never replace common sense, where staff are commended for responding to emergencies and administrators seek out opportunities to improve the system rather than berate the individual, and where safety prevails and fear has no place.

Lisa A. Miller, JD, CNM

President, Perinatal Risk Management and Education Services, Chicago, Illinois

^*I add healthcare executives because I do not believe that the nursing managers in these cases were acting alone. I fully believe that these disciplinary actions were a matter of policy-policies set and enforced by hospital administrations. [Context Link]