I have spent a lot of time watching doctors and nurses and other health care workers and professionals function in hospitals and other health care settings. The very first thing that impressed — or rather depressed — me when I first went into the hospital over 20 years ago was how little real communication there was between doctors, between doctors and nurses and between doctors, nurses and other professional or non-professional staff. Very few had what I have come to think of as Team Intelligence. What I noticed then and what I still notice when I go into hospitals is that there’s an awful lot of action but very little interaction. A lot of activity but not much interactivity. And how could there be when people function not just in silos but in heavily armed fortresses where they spend much of their time defending themselves against what they conceptualize as invading armies. (If health care workers and professionals only occupied silos, we’d be in better shape and it would be easier to re-form the system. Silos after all aren’t fortified.)
The inter and intra group relationships are really disturbing. The nurses who I write about are very focused on how poorly doctors treat them, but they rarely consider how they treat lower level staff — the cleaners, and LPNs and aides and so many others who make the hospital or other facility world go around. When my mother was dying in a nursing home, in 2002, I spent nine days at her bedside in a vigil after she refused to eat or drink. I watched the RNs treat the LPNs brusquely and rudely and the LPNs return the favor when they talked to aides. These aides are referred to as “nurse extenders,” as if they have no occupational identity of their own. And this term is used by people who dislike being called “physician-extenders.”
Nurses have all sorts of other ways to put each other down. Four year university degree nurses view themselves as “professional nurses,” and seem to dismiss the skill and competence of nurses who have gone to two year schools because they are just “technical nurses.” Enter the advanced practice nurse, who views her or himself as way above the two year or four year RN because he or she can prescribe and diagnose and is thus advanced. Consider the language here. You have different skills than a direct care RN — but you are an advanced practice nurse. So what does that make a veteran, expert, registered nurse who has spent 30 years honing her craft at the bedside? Is she inferior, retarded, delayed — all words that the thesaurus tells us are the opposite of advanced. I know now NPs, who refuse to even use the word nurse, or who don’t want to be viewed as “just a nurse.” How can these NPs, work effectively with RNs (which by the way an NP must become if he or she is to become an NP or APRN) if they have so little respect for the job and the person in it?
If nurses don’t respect one another, how can they expect doctors to respect them? If nurses put down one another, how can they expect doctors not to put them down?
And then let’s look at how docs treat each other. Over the years I have heard doctors — who nurses think to be the ultimate team players who stick together through thick and thin — belittle one another shamelessly. A surgeon I know commented dismissively that oncologists are just “hand-holders,” and don’t “do anything” for their patients. An internist insisted that my friend the gyncological surgeon wasn’t really a surgeon because she only did a limited number of operations. Another friend told me she’d heard an internist comment dismissively about an orthopedic surgeon who’d just had brain surgery — “oh, he’s just an orthopod,” like he didn’t really need a brain.
Junior doctors are afraid of attendings, afraid to point out problems in patient safety because they will be reamed out because they don’t know something that they couldn’t possibly know because they are novice/learners. They are afraid to admit to mistakes when we know that the way we learn is by making and learning from mistakes. In my work with doctors and nurses, I have seen a lot of tension and conflict result from the fact that the physician-in-training is trying desperately to get a nurse to help him or her cover up a mistake just before rounds (and just at nursing shift change) because he’s afraid to get reamed out by the attending. Rather than acknowledging the need for help (which he or she is not supposed to do because doctors give orders to, not ask for help from –nurses) the doc becomes demanding just when he or she should explain the problem and ask for assistance. Some nurses who think they know all about physicians misinterpret the physician-in-training’s actions and chalk it all up to those damn doctors who don’t appreciate nurses. While some doctors don’t, in this kind of case, the conflict between the novice doctor and nurse is generated by intra-group dynamics.
We talk a lot about teams in health care. And God knows patients like myself need them. But we’ll never create genuine teams unless people in health care do a lot of mental redecorating. How you think about the person who works next to you, the language you use to describe their role versus your’s is a great place to start.
About a month and a half ago, I had the honor of speaking to a group of nurses in Zurich, Switzerland. A wonderful nursing school was being closed and future students were now going to attend a university school of nursing. The event to which I’d been invited had been arranged by a highly respected educator called Ruth Oehringer, and it celebrated the school’s accomplishments as well as the fact that many nurses in Switzerland will now be educated at the university level. I was honored to be asked to be a keynote speaker and to talk about nursing visibility.
As I was waiting for my time on the podium, I watched from the audience as a quartet of jazz musicians played during the celebration. What was so interesting about their performance was the way they functioned as a team and as a series of individuals. In true jazz fashion, the musicians, who were by the way, all women, began to play together. Then, they each had a solo, and then, seamlessly, they joined together again and finished the piece. Since they played about four pieces, I was able to watch this exquisite teamwork in action four times. As I was watching, I thought, wow, this is how it should be in health care. And of course my next thought was, how sad that this is almost never how, in fact, it is done.
In this case, the musicians were able to both work as a cohesive whole, and yet separate into their individual parts at a certain moment. Each was able to shine, each was acknowledged by name but that did not compromise the functioning of the team. Indeed, when they separated, it was a statement about the team as well as about the individual player. See, each seemed to say, this is what it takes to make this beautiful music together. They demonstrated to the crowd both the I in the we, and the we in the I. This is, of course, typical of the jazz mode. Even when a band or group has a star, that star always stands back and lets the other back up players have their moment in the spotlight. Those individual moments do not detract from the star’s power or authority. Indeed, the star shines even more luminously because he or she was able to assemble such talented musicians and help them all play both together and apart. Ella FitzGerald was never diminished by standing back and let the drummer or trumpeter play, nor was Miles Davis or any other jazz great. We may not remember the names of those people who had a chance to briefly take center state, but they knew they were being recognized and I am sure they felt proud of their accomplishments and gratified that they were acknowledged.
We also see demonstrations of this kind of team power and team intelligence in other settings. When a movie is over, the names of all of those who performed and made the film possible are displayed on the screen. Some movie goers leave before they ever get to see who was best boy or did the casting or fed the crew. But those who stay are made to understand that this was no solo performance and that no matter how much star power Tom Cruise or Angelina Jolie has, they are bolstered by a supporting cast who all have names and roles.
In Santiago, Chile several years ago I was privileged to attend the opening of the Salvador Allende Museum — a museum to which many Chilean artists from all over the world donated paintings. Every important politician and cultural figure in Chile was in attendance as were ambassadors from different countries. During the opening ceremony, a lot of people spoke and were honored for their donations and contributions to the museum. Most of the speakers were of course pretty heavy hitters. But the amazing thing was that at the cermony, the workers who had renovated the building that housed the collection were also asked to come up and take a bow and say a few words. Thus there was the head carpenter, painter, iron worker etc. It was truly moving.
So what about health care. Why can’t the same willingness to ackowledge and be acknowledged take place there. or Would the star surgeon be diminished by acknowledging the nurses or other members of the team? Would that great oncologist’s reputation lose its luster, if he or she admitted that the patient couldn’t have gone into remission had a whole host of people not made recovery possible? Why can’t we do in health care, what they do in the movies? Instead, what we get is star power with no acknowledgment of the supporting cast. Or we get even worse — nurse managers who proudly display signs saying “There is no I in the word team,” at the nurses’ station. Or we get nurses who won’t even tell patients and doctors their full names. As to other “lower level” employees, well they are never acknowledged and utterly invisible.
Next time you go to a movie or a jazz or rock concert look around. There are models of team work and team intelligence out there. And they are ready to import into health care, if people would only take the time to try.