by Mark Pijl Zieber
Mark is an Assistant Professor in the Faculty of Health Sciences
What is it about making mistakes that makes people so uncomfortable? I do not see myself as a perfectionist, nor am I highly performance driven, but there is no question that I like doing things well, and it bothers me when I make a mistake. Most of my mistakes, as is characteristic of any human endeavour, have very minimal negative consequences. Regardless of the real or perceived consequences of our mistakes, making mistakes is always a less-than-pleasant experience.
A conversation pertaining to mistakes becomes particularly poignant when discussing the provision of health services to patients within the health system. In this context mistakes not only affect the individual making the mistake, but frequently negatively impact the recipient of the care. In health sciences education, and more specifically in nursing education, much of the students’ learning occurs in interactions with real humans, particularly in hospitals. This level of intimate interaction with patients demands that serious attention be paid to the performance of student practitioners. In this essay I will explore how human-performance factors influence how mistakes are perceived and managed within a professional health-care program at the University as well as other learning contexts.
A number of years ago I was teaching nursing students at the Chinook Regional Hospital when a student approached me. She was clearly distressed, anxious, and upset. My first thought was that she was ill and needed to go home. However, amid a torrent of tears she told me that she had made a medication error. The medication error was, in my experienced perspective, clinically insignificant, but to the student it was a traumatic event that caused a cascade of psychological, emotional, and physical symptoms associated with great personal distress. Thankfully, we were able to work through the process of managing the mistake and the student moved on. It is this interaction that caused me to undertake this research project to explore how nursing students perceive and manage the mistake experience.
To Err is Human, but Not in Health Care
The reality of human performance is that our brains are naturally prone to error. Psychology, and pure common sense, have demonstrated that humans are prone to performance accuracy problems and will continue to be prone to these issues in the future (1). This tendency for error is not a new or revolutionary finding from a scientific perspective, but where the human propensity to err manifests—and is managed—uniquely, is in the education of new health-care providers. Health professions disciplines such as nursing have the unique privilege of intersecting strangers’ lives at a time when they are experiencing a health challenge, generally one of the most vulnerable times in a person’s life. Health-system users demand care that is accurate, precise, and free of mistakes; health-care practitioners generally demand this perfection of each other as well. This expectation for quality care is one that health-care providers such as registered nurses take great pride in delivering. This expectation for perfection, however, has a dark side and some unique challenges in health professions education.
The culture of perfectionism within the health professions creates a number of difficulties for experienced, novice, and student practitioners (2). When an experienced practitioner makes a mistake within the health-care system they frequently report feelings of guilt, fear, and even depression (3). There is often little support from peers and administration (4). As a result of the socially deleterious nature of the experience, practitioners may be reluctant to admit and report mistakes (4). There is a culture within health care that is unaccepting of mistakes, which can lead to a reluctance among health-care providers to admit and properly manage mistakes (5) and can lead to practitioners covering up mistakes and to an overall resistance to mistake-avoidance initiatives (1).
Students, as novices and learners within the health-care system, feel the same fear as experienced practitioners. However, these feelings are greatly magnified due to their inexperience, lack of clinical competence, guest status on the nursing unit, and fear of failure or dismissal from the education program. This fear goes beyond the natural discomfort of learning new skills and capabilities to include the fear of potential consequences to people who are often strangers (6, 7).
Students’ Unique Mistake Experiences
The fear of making a mistake, especially among novice practitioners, is a deep-seated source of distress. Many of the participants in my study reported feeling so anxious about their upcoming interactions with patients that they would get physically ill the day before they were to go into the clinical setting. The very thought that they might make a mistake in clinical practice was often paralyzing to students, causing a significant drop in both efficiency of care and capability to learn. This performance anxiety was a precursor that students brought with them to the learning environment, which set them up for poor practice (and error) experiences.
The experience of actually making a mistake was very traumatic for participants. Most participants reported a very physical reaction when they discovered that they had made a mistake. Participants reported feelings of dread, fear, and panic. The experience of making a mistake in the clinical setting was found to be a major psychological event with repercussions that endured for days, months, and even years, frequently impacting all aspects of their lives. Some respondents described how the error impacted their emotional, social, and even spiritual lives. Some respondents reported that their self-esteem failed to recover even months after the event.
Another troubling finding of this study was how students struggled to know how to conceptualize the mistake and what to do about their mistake. This struggle points to the need to prepare students proactively for the eventuality of making an error in practice. At present, in nursing education, the unwritten rule for students is do not make a mistake…ever. Since all humans are naturally prone to making mistakes (8), I explored the scholarly literature to see how other professional programs, such as medicine, pharmacy, and physiotherapy, prepare their students for the inevitable reality of making a mistake in their practice sphere. Unfortunately, there is no evidence of any systemic efforts to prepare students for mistakes or to mitigate the psychological consequences following mistakes in professional practice.
Another significant finding of the study was the effect that the student’s support system and personal resilience had on how the student progressed through the mistake experience and whether the experience became a learning opportunity. Support from the instructor was pivotal to how the mistake experience was conceptualized, but support from peers, friends, and family was also a significant factor. Personal resilience was also an important factor in the ability of students to successfully navigate the mistake experience. Some participants were able to fairly rapidly create a positive and constructive conceptualization of the mistake experience, while other participants were unable to do so. Knowing what causes this difference in personal resilience between participants was not revealed in the study but reveals a significant question for the future, particularly as it relates to how the educational process can enhance personal resilience in novice practitioners.
Helping University Students Navigate Mistakes
While the context of this study was within health sciences education, there is a need to prepare and support students through mistakes and imperfect performance. Students in all disciplines struggle with imperfection, and in some educational settings the stakes are high, such as in “real-world” settings. Students in co-op programs, for example, are immersed in community experiences in which their contributions and relationships are not strictly academic: they have a real impact in the real world. Similarly, students in laboratory experience—such as chemistry—strive to gain the results they need for their academic learning but also strive for safety. Students in fine-arts programs such as music have a considerable performance aspect to them, which continues beyond graduation. Making a mistake in a live orchestra performance, for example, is probably one of a musician’s worst nightmares. So, how are students prepared for the inevitability of making such a mistake? Students may be told to continue the performance, but additional assistance may be required to deal with the emotional and psychological consequences in the wake of the performance error.
Based on this present study, as well as my years of clinical teaching, I propose a number of suggestions for the preparation of students for the inevitability of making mistakes in career roles.
First, educators must recognize the activities in which students are likely to make mistakes. These activities constitute an important part of the learning process, and instructors should use their vast experience and expert knowledge to anticipate mistakes and create support mechanisms to allow students to use mistakes as a learning activity. Mistakes do not have to be—in fact, should not be—associated with significant levels of trauma.
Second, educators have a duty to prepare students for the eventuality, not the possibility, of making mistakes. Participants in this study demonstrated an amazing ability to precontemplate various destructive and catastrophic consequences—sometimes with little resemblance to reality—of making a mistake. The power of this imaginative practice, which can be paralyzing for students, can be mitigated by preparing students for the processes and procedures that occur following a mistake. This proactive preparation also clarifies the responsibilities and roles that students have in correcting the mistake and mitigating any harm to the patient that might occur. Participants in this study did not express any desire to escape responsibility for their errors; they just needed to know how to react and what to expect.
Third, educators need to treat human-performance issues, such as mistakes, as a normal expression of human cognitive capability. It is our job, regardless of the discipline or knowledge area, to help students improve their performance. We need to control the power that the perception of mistakes has within our own minds as well as within the minds of our students. Mistakes are a serious matter, but a reasoned and evidence-based perspective that balances the known limitations of human cognitive performance with initiatives to improve student performance is the key to practice safety and effective learning.
Is it possible to overcome the discomfort and fear that making mistakes has on us as humans? Probably not, but it is possible to mitigate the deleterious effects of making mistakes and hopefully transforming mistakes from a traumatic process into a learning process.
References
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2. Pauly B, Varcoe C, Storch J, Newton L. Registered nurses’ perceptions of moral distress and ethical climate. Nursing Ethics. 2009;16(5):561-73.
3. Serembus JF, Wolf ZR, Youngblood N. Consequences of fatal medication errors for health care providers: A secondary analysis study. MEDSURG Nursing. 2001;10(4):193-201.
4. Wolf ZR, Serembus JF, Smetzer J, Cohen H, Cohen M. Responses and concerns of healthcare providers to medication errors. Clinical Nurse Specialist. 2000;14(6):278-87.
5. Sparkman CAG. Legislating apology in the context of medical mistakes. AORN Journal. 2005;82(2):263.
6. Anderson JG, Ramanujam R, Hensel D, Anderson MM, Sirio CA. The need for organizational change in patient safety initiatives. International Journal of Medical Informatics. 2006;75(12):809-17.
7. Melo K, Williams B, Ross C. The impact of nursing curricula on clinical practice anxiety. Nurse Education Today. 2010;30(8):773-8.
8. Reason JT. Human error. New York: Cambridge University; 1990.