“Have no fear of perfection – you’ll never reach it.” – Salvador Dali
“It is no sin to attempt and fail. The only sin is to not make the attempt.” – Suellen Fried
PROBLEM: Many nurses hold themselves back, quite unintentionally. They fall prey to perfectionism, a dead-end path.
I’m an enthusiastically anti-perfectionist nurse. I make mistakes, because I do complex and challenging work, often under adverse and unpredictable conditions. When circumstances demand it, I make quick decisions and act on them. I carefully look for any errors, address them, learn and move on. How about you? Are you perfect? MUST you be perfect? Be honest: as a nurse, what’s your gut reaction to these attacks on perfectionism? I ask because it’s a crucial point. Many nurses embrace perfectionism tightly, desperately: we must never make mistakes, do everything right and right on time, find a way regardless of work conditions. Otherwise, we fail: we become ‘bad nurses.’
Surely such nurses must be superhuman: how else to explain such clearly impossible expectations? In psychiatric practice, we call this cognitive error black and white thinking: in this case “perfect” versus “bad” with nothing in between. Such thinking badly distorts reality, often leading to inaccurate assumptions, poor decisions, and costly mistakes. Psychologists call these kinds of normal mental mistakes cognitive distortions. We all have them often, especially when stressed, rushed, or dealing with complexity and chaos. Stress? Rushing? Complexity? Chaos? Sounds like nursing, doesn’t it? It’s no wonder we make some cognitive mistakes: black and white thinking is just one of them. Human brains rely on lots of shortcuts to keep up with events. These shortcuts save us time and energy but also lead to errors. In this case, we mistakenly choose between perfectly good or perfectly bad, ignoring all the gradations in between. “To err is human” isn’t just Shakespeare: it’s science.
So we demand perfection, but deep down we know we can’t live up to it. What can we do? Some nurses rationalize away mistakes, convince themselves they “weren’t my fault” or somehow didn’t happen or don’t matter. Too many nurses desperately (try to) hide their errors, flaws, and fears. Some lash out at others. Others do the minimum, make the fewest decisions possible, refuse to help colleagues, all to avoid errors. They desperately try to find ways to do the impossible, BE the impossible, or at least feel like it. It’s all driven by fear. Nurses even attack new learning: how can you improve if you’re already (have to be!) perfect? Learning also involves risk. Errors perhaps! Hence the all too common mantra: “That’s the way it’s done because we’ve always done it that way.” Safe, predictable, yet stagnant. If Florence Nightingale thought that way, she’d have become a housewife instead of inventing professional nursing and modern hospitals. Happily, she refused: she waded in, made lots of mistakes, and learned as she went. She beat herself up for not meeting her own impossible standards, but she didn’t let it hold back her progress. Do you?
With perfectionism, you’ll never quite feel secure, confident, or worthy. It could all fall apart any moment, right? One mistake, any mistake! What if “they” figure out you’re a fraud: a not-perfect “bad” nurse? Wow: what a punishing way to live! I get gray hairs just imagining it, yet I know many nurses who seem to have lived it for decades. I’m deeply impressed, honestly, that they’ve survived it for so long.
Some nurses insist we need perfectionism. How else can nurses “toughen up” and keep our standards and performance high? It’s a compelling story, yet it’s also contrary to everything known about cognitive science and human performance. It’s the exact opposite of evidence-based practice: it’s myth-based. These days no one knows everything, and new science comes in at a rate no one can digest. We all have things to learn, room for improvement, and that’s a good thing: it’s why we can hope for a better future and help make it so. Better beats perfect because it’s both real and reachable.
There are two general targets in quality improvement: individuals and systems. Systems approaches offer far better results. Where I live, there are legally protected ways to internally report errors. Such incident reporting is specifically designed to promote systems improvements. Filing such an Incident Report lessens liability, but nurses look at them as trouble, “getting written up.” Why? On paper, managers use reported errors to find ways to prevent more such errors. In reality, they often seek the cheapest, easiest path, using “blame and train.” They simply blame someone and offer them mandatory training and/or punishment: problem “solved.” It’s perfectionism’s dark side.
I once attended a lecture by a US National Transportation Safety Board (USNTB) official. He said that pilots and other airplane crew members were often severely sleep deprived and fell asleep on the job. One crew member even fell asleep in flight in front of a TV crew doing a story on the issue! He told us about an accident he’d investigated. An entire crew – pilot, copilot, everyone – fell asleep on a long flight. The autopilot handled things fine until one of the engines failed. The autopilot steered hard to account for it, but only the pilot could make the necessary adjustments, and he was asleep. So the plane gradually tilted more and more to the left until it triggered an alarm. The pilot woke up and made a disastrous mistake: he forced the stick from hard right to straight. This large commercial jetliner flipped over sideways, completely upside down and around again to upright, losing thousands of feet of altitude and nearly ripping the wings off.
Question: how could flying possibly be safe with pilots falling asleep? First, let’s imagine a “blame and train” approach. Would it help? It would certainly look decisive, yet it wouldn’t really change anything. Sleep deprivation would persist, and pilots would continue to fall asleep. Accidents would continue, much the way errors tend to continue in health care. But airlines focus on systems instead. The auto-pilot adjusting to the lost engine was one such system: it protected the passengers for some time while the pilot slept. The lecturer described a never-ending, ever-growing array of adaptations. Each time an error occurred, they’d adjust systems somehow to make that error easier to avoid and/or less likely to cause harm. The systems approach assumes people aren’t perfect and it seeks ways to better protect us from our mistakes. NTSB was exploring ways to help pilots stay awake, for instance. As a result, airlines have a far better safety record than do car drivers, or hospitals for that matter.
Here’s another example. Imagine an Electronic medical record (EMR) system that lets you give 100 units of insulin to a patient with a blood glucose of 50. It confirms the right patient, medicine, and time, but can’t tell you that the medicine should be held, that you might well kill the patient. Now imagine you’re busy and distracted and you mistakenly give that insulin. Awful, of course! Perfectionism says you’re to blame, end of story. Yet a minor tweak to the EMR system could help all nurses prevent such an error. That’s a systems approach: assuming and accepting human fallibility allows improvement, not just blame.
Now, I can’t tell you not to expect “blame and train” from managers. I suggest you practice evidence-base care on yourself. Forget about perfection, it’s is a harmful myth that actually hurts performance over time. I don’t advocate sloppy nursing practice, far from it. Clearly, nurses must give the best care possible. I merely hope to show you how to achieve the best performance possible with the least pain and waste. I’m a nurse. I know how it feels to fear mistakes, to fear doing harm or getting in trouble. We’re human. People aren’t perfect. We make mistakes, especially with challenging work under difficult circumstances. We’re affected by the conditions under which we work, by staffing, systems, and fatigue. We need to face reality if we want to move forward to a better place for everyone. We can do better, BE better, if we aim to learn from our errors, not attack them, to adapt and grow, not stay the same. It’s far more promising and effective to improve as often as possible than it is to cling to punishing myths:
GOAL: DUMP PERFECTIONISM. WE CAN DO BETTER, HAPPIER.