Reflection on empathy: patients experiencing miscarriage in the emergency department

Discussion board post for NURS608 Philosophical and Critical Foundations in Nursing, posted on July 7, 2022. Post is in response to thread about challenges of empathy in nursing.

I would like to respond to your statement, "It does not take extra time to be empathic and yet when I was busy, it seemed like empathy was the first thing that started to unravel from my practice" (course instructor). This resonates with me, along with the experiences that [my peers] have shared.

As an emergency department nurse, it is not uncommon that we work short-staffed and manage high patient turnover, among high patient loads. In the ambulatory zone of the department, in particular, it is nearly impossible to find the time to form therapeutic relationships with patients. This space is task-based and its flow depends exclusively on nurses completing tasks. In fact, when we train nurses in this zone, we actually tell them to not overthink things and just complete the tasks as they are ordered/required so we can flow patients through as fast as possible. Is this the right way to nurse, or even safe? Probably not. Unfortunately, it is a systemic flaw that relies on so many external factors, including hospital funding when emergency departments see more patients in less time.

One of the most ethically challenging situations I face in this department is when dealing with patients who are or have suffered a miscarriage, which actually occurs more often than I am comfortable with. These women are, understandably, distraught and anxious and upset and angry and a whole slew of other emotions. Yet they are allotted approximately 30 minutes (at best) of time in a private examination room before we have to usher them out to the waiting room to await imaging, treatment, or specialist referral. On one occasion, I was managing the exam room flows and was being pressured by doctors and other nurses to clear the rooms so they could see more patients. One of the patients was a woman who was having a miscarriage. I used every ounce of politeness I could to ask her to return to the waiting room, because I myself felt ethically distressed at having to do so - she was clearly upset, bleeding profusely, and appeared exhausted. She glared at me and said, "Do you have any kids?" At the time, I did not, and I said as much. She responded, "Then that explains why you don't even care." And she grabbed her stuff and left the room.

That was probably the most gut-wrenching experiences I had working in the ER - such a small moment, but I, honestly, hated myself in that moment for having to do that. Ironically, that was also early in my own pregnancy, but it did not feel right to share that information with this patient. I understood how she felt more than she realized, but this is the reality of our health care system today, and is very much the thing that motivates my activism for change.

Could I have advocated for her to stay in the room longer? Maybe, but I had in fact already tried to stall the doctors for a while for this patient. Could I have requested that she have a private space to sit while she waited? Maybe, but we had a waiting room of 30 patients with multiple hour long wait times, among which there were other miscarriage patients who probably also deserved a private space that we could not accommodate. Could I have fast-tracked her treatment and ultrasound? Maybe, but would that be fair to the query acute appendicitis patient, or the lady with acute gallbladder pain, or the man with the potential perforated bowel also waiting for ultrasounds? There is sometimes no winning in emergency nursing.

It very much feels, in the ER, that empathy is necessarily removed from the way the system operates, in order to accommodate for larger patients numbers and to encourage some degree of patient flow. This issue seems it will only get worse, with the trends our country is seeing in increasing ER wait times, increasing patient acuity, and a rapidly aging population that is going to need hospital care where there is no space. Nurses will be challenged ethically more than ever.