A Non-Negotiable for Teamwork

As I think about patient safety and teamwork , I have been reading a lot about how other high reliability, safety-critical industries have achieved better performance in these areas than health care.One of the reasons that high reliability industries are safe is because they recognize that safety is a function of teamwork and that teamwork is not possible with the recognition of a very specific kind of group cognition – what cognitive anthropologist Edwin Hutchins calls “distributed cognition.”In his work on aircraft carriers and aviation for  his book, Cognition in the Wild, Hutchins laid out a theory of distributed cognition that is crucial to our understanding of how genuine teamwork functions in complex endeavors. This, by extension, helps us understand what it will take to create true Teams in health care:

“All divisions of labor, whether the labor is physical or cognitive in nature, require distributed cognition in order to coordinate the activities of the participants.Even a simple system of two men driving a spike with hammers requires some cognition on the part of each to coordinate his own activities with those of the other.When the labor that is distributed is cognitive labor, the system involves the distribution of two kinds of cognitive labor:the cognition that is the task and the cognition that governs the coordination of the elements of the task.” [i]

Put in everyday language, what Hutchins is saying is that all the participants in a real Team are thinking not only about their individual work but also about how their individual work meshes with those of the other people with whom they are working.They need to know how to do – and how to think about – their individual task.But they also need to think about how their task, knowledge of their task, and knowledge of the changing context in which their task is performed, affects the activities of those with whom they are working – even if those people are not working right by their side at the moment.

Distributed cognition is much too complex a phenomenon to elaborate on in this short discussion, but one of its fundamental elements is the recognition that the people on your team are, in fact, thinking about their work, and not just doing “mindless work.”On the aircraft carrier that Hutchins describes, those involved in the crucial activity of navigation – the constant effort to figure out where one is and where one is going – combine different “… sources of data that are reasonably independent.” One crew member plots by means of visual bearings, another by means of radar, another by means of ocean depth.Each crew member, however, values the information gathered by the other – a fact that affords the team as a whole “the opportunity for the detection of error through the comparison of independently [calculated] representations.”That is, one crew member does not dismiss the other’s data and concerns because that crew member is lower in status, or acquired their information through direct observation rather than through “objective measures.”

A Danish nurse once told me about a lecture she’d attended given by a military General to a group of health care professionals: The General told the group that when an army is in battle, and a private says, “Stop! there’s a mine,” we don’t say, “no we won’t stop because the person providing this information is just a private.”We all stop.You in health care, he told the audience, are [also] on a battlefield, but when the equivalent of a private – say a nurse – tells a surgeon to stop, you don’t ignore the directive because that person giving it is “just a nurse’.”

The point?In the army everyone implicitly, if not explicitly, recognizes the concept of distributed cognition and acts accordingly.Meanwhile, in health care, concerns about status often lead people to devalue the important information those of lower status actually have.

This is not true in healthcare.Doctors tend think that they are the only people who have minds and actually think critically.They, therefore, devalue what nurses have to say because they don’t understand that nurses bring a different perspective – different that is, not inferior.And they aren’t the only ones who fail to recognize the reality of distributed cognition.RNs mimic physicians in their relationships with people who are lower on the occupational totem pole.Consider the term advanced practice nurse, for example.This term suggests that a nurse practitioner, nurse midwife, or nurse anesthetist – to cite only a few examples – is the only one who has an advanced practice, while a bedside nurse is what… inteferior, retarded?Or consider the RN who looks down on the Licensed Practical Nurse (LPN) or aide because only the RN has critical thin king skills – and thus cognition worthy of the name.We will never be able to keep patients safe unless all those who work in health care recognize that everyone who is near or around the patient has a valuable perspective and valuable information which must be both acknowledged and respected.

[i] Edwin Hutchins.Cognition in the Wild. (Cambridge:MIT Press. 1996) P.176

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