Bedside Manners Commentatry
Just wanted to post this commentary that I wrote for the Journal of Interprofessional Care on our play Bedside Manners. Hope you find it of interest.
2014 Informa UK Ltd. DOI: 10.3109/13561820.2014.902257
COMMENTARY
Bedside manners: a dramaturgical approach to exploring interprofessional collaboration
Suzanne Gordon
School of Nursing, University of California, San Francisco, CA, USA
Introduction
This commentary provides an overview of a new arts-informed text which includes a play, workbook and a DVD (Gordon, Hayes, & Reeves, 2013) designed for health and social care professions to help them reflect on a range of critical factors related to how they collaborate together. As well as describing the play and workbook, it also offers a scene from the play to provide an insight into the type of issues explored in this text.
The play
Bedside Manners is a play about the importance of interprofessional teamwork in health care. Its goal is to create a work that raises critical patient safety and workplace issues in a balanced way. In the play, the reader will find nurses and doctors and other health-care professionals who communicate poorly and those who communicate well. We have also tried to convey our conviction that poor communication between members of the health-care team is not simply an individual problem – a question of a few bad apples spoiling the barrel – but is rather a system problem that stems from how health and social care has historically developed. Although it is beyond the scope of this commentary to describe that historical development, suffice it to say that the problems of contemporary interprofessional team relationships have a long history and are shaped not only by economics but also by other factors such as gender, culture, and ethnicity.
Although the play is meant to simulate real life situations and thus stimulate discussion about interprofessional collaboration and teamwork, and hint at ways that professionals can develop the skills necessary to create and sustain a genuine interprofessional approach to their work, it is primarily a work of theater. Its goal is to help those who work in health-care approach a very hot topic in a way that is both interesting and thought provoking. To that end, we have developed various ways of mounting a production of the play. The play is always performed as readers’ theater – this means that rather than memorizing their lines, actors hold a script in their hands and read from it. The actors of course rehearse, as time permits, but reading rather than memorizing saves a lot of time.
To perform the play, we sometimes use two professional actors as well as asking doctors, nurses, or other health-care personnel who are in the institution or at the conference in which it is produced to be in the play. When actors are used along with real health-care personnel, they can significantly enhance the per- formance. Sometimes we have used professionals, sometimes drama students, or amateur actors. The play, however, can be performed with an entirely non-professional cast who are assigned the role of one of the over 20 different characters in the play. The play works very well with no professional actors in it at all.
In either case, we encourage the institution or group licensing the play to cast nurses as doctors and doctors as nurses, and to invite other staff to also take parts in the play. The very act of working together to rehearse and perform the play is, in itself, an exercise in teamwork. The general rule of thumb in rehearsals, which do not have to last more than a couple of hours before a performance, is that everyone is on a first name basis, and that everyone, no matter how highly elevated in the health-care hierarchy receives and graciously accepts guidance from whom- ever is directing the performance.
We have found that this exercise in teamwork pays off. Nurses who are used to taking orders from doctors and who may be more deferential suddenly see chiefs of services who are politely told that they have to work on how to better deliver their lines. People separated by status hierarchies are having fun together, flubbing lines together, improving together, and then putting together a performance that is very well received and that generates interesting conversations in which they take part. The dynamic of watching a performance done only by professional actors shifts in a positive direction when an audience watches colleagues grapple with tough issues on stage.
We have been deeply impressed by what occurs when, for example, a chief of trauma surgery plays a nurse and an ICU nurse plays a doctor. Human beings are moved and motivated by role- playing. It can be a transformative experience. It has been amazing to watch as the initial distance between cast members dissolves as they work together, feel satisfaction after the performance, and post-performance discussion or workshop. After the performance, we usually conduct a discussion and use theatrical techniques to enlist the audience in re-scripting scenes in which lack of teamwork has created patient safety and other workplace problems.
To date, Bedside Manners has been performed in over 60 hospitals, health professional schools, or health-care conferences. Because the play has different scenes that function almost like interchangeable modules, we have been able to adapt it to different health-care settings. Because the original play focuses almost exclusively on the hospital setting, we adapted the prologue to include comments from clinic staff and sometimes substitute a clinic scene for a hospital one. We have thus been able to include other professions in the play – for example, pharma- cists, or physical therapists, or nurse practitioners and physician assistants, or even billing clerks who have conflicts with physicians.
Below we have included one scene from the play to provide an insight into the nature of this work:
Scene 6: Singing the first code blues
(Think of this scene as a ‘‘Saturday Night Live’’ sketch – go for the comedy. The nurses can either deliver lines from the ‘‘RN’’ music stand, or they can be grouped around the doctor.)
Dr. Stephanie Long: I remember my first code like it was yesterday. It was the middle of the night and I was fast asleep, dreaming about a place where I didn’t have to report every change in temperature to my resident, when my beeper went off. I ran down the stairs and was told that this huge man was in V-tach. An EKG magically appeared in my hand. (She mimes holding it up and looks puzzled.) I had no idea what the hell I was doing.
Code nurse 1: You want a liter of fluids?
Dr. Stephanie Long: I nodded. Another nurse hauled in paddles, glass vials, and other vaguely familiar things, and said,
Code nurse 2: Should I put some gel on his chest?
Dr. Stephanie Long: I nodded again. Another nurse began to draw some blood, and after a few seconds asked,
Code nurse 2: Would you like me to draw some blood.
Dr. Stephanie Long: I nodded. Suddenly, two paddles appeared in my hands, just like I’d seen so many times on television, and once in that class we had to take a few weeks before.
Code nurse 1: Do you want to put them on the patient’s chest, to assess his cardiac rhythm?
Dr. Stephanie Long: I nodded.
Code nurse 1: Still V-tach.
Dr. Stephanie Long: Another nurse yelled,
Code nurse 2: Everyone stand back and let the doctor shock him!
Dr. Stephanie Long: The nurse looked at me and said,
Code nurse 2: You’re all clear.
Dr. Stephanie Long: I looked down at the paddles still clutched in my hands. I couldn’t remember anything.
Code nurse 2: Doctor? You’re clear.
Dr. Stephanie Long: Clear? Clear. There was only one button on each of the paddles, so I pushed. There was this zapping sound. I looked back at the monitor and saw this spiky pattern. Spiky, I remembered, was good.
Code nurse 1: Pressure’s back to 100 over 60.
Dr. Stephanie Long: A nurse started dialing the phone.
Code nurse 1: You want me to call intensive care?
Dr. Stephanie Long: I nodded. Another nurse handed me the chart and suggested I sign the orders.
Code nurse 2: Great work, doctor. (Nurses sit.)
Dr. Stephanie Long: Throughout medical school and training, there are two rules that are constantly being pounded into each student’s brain. The first is that it’s OK to admit that you don’t know something. This is based on the idea that nobody knows everything, and if you don’t know the answer, it’s much better to admit it rather than go off half-cocked and possibly screw something up. The second rule is that no matter what, under no circumstances, should you ever, ever admit that you don’t know something. The idea behind this is that we’re doctors, damn it, and we need to act. After all this training, we have to know something and it’s better to take your best guess and go with it full-cocked, instead of just standing around doing nothing like an idiot.
I preferred the first rule. In fact, as Patient Safety Officer in my hospital I have tried to perfect it. Because if you don’t know something as a student, you have a built-in excuse: You’re still learning. But somehow, there’s this idea that once you make the jump to doctor, you have all the answers. But as it turned out, I was no different the day after graduation than I was the day before. I guess the most valuable lesson I’ve learned is that no one can ever know all there is to know, and that it’s important to listen to anyone who may have valuable information to share, whether the source is a resident, a pharmacist, or the patient’s husband.
This scene provides a useful example of Leonard Stein’s doctor–nurse game in action (Stein, 1967; Stein, Watts, & Howell, 1990). The doctor is aware that she does not know what she is doing but has been socialized not to acknowledge this. The nurses are also aware that the doctor does not know what she is doing but pretend that she has instructed them to do what she does not even know she needs to do. Everyone is engaged in a game of pretend. Although the doctor, reflecting back on this from a position of expertise, has, thankfully, recognized that value of teamwork, this is sheer serendipity. She could easily come to believe the myth that she knew everything all along and that few others have anything to contribute to her practice. Imagine this scene done differently. Imagine what would have happened if the intern had come in to the room, approached the nurses and said, ‘‘I have no idea what I am doing. I know you have done this many times. Can you guide me through it?’’ And then imagine if the nurses had told the doctor what to do and why. That is what needs to happen if we are to have real teams and real interprofessional practice. Real interprofessional practice will also require one additional step that is off stage and not in the play. The nurses would also have to resist any temptation to complain afterwards about an intern who didn’t even know what to do during a code. Throughout the play, we see that good interprofessional collaboration is multilayered and that remedying poor collaboration is equally complex.
The workbook
To accompany the play and make it more user-friendly, Suzanne Gordon and Scott Reeves have also written a workbook, which explains the various ways it can be performed, how to mount a performance, and how to lead a discussion or workshop after the play is over. The workbook includes a description of how to use a variety of theatrical exercises to encourage discussion and communication.
The DVD
There is now also a DVD of the play as performed at The US 2013 National Patient Safety Congress in New Orleans, LA, to which the patient safety expert Lucian L. Leape, MD, provided an introduction. The DVD includes teaching scenarios and slides.
Declaration of interest
The authors declare no conflicts of interest. The authors are responsible for the writing and content of this paper.
References
Gordon, S., Hayes, L., & Reeves, S. (2013). Bedside manners: Play and workbook. Ithaca, NY: Cornwell Press.
Stein, L. (1967). The doctor–nurse game. Archives of General Psychiatry, 16, 699–703.
Stein, L., Watts, D., & Howell, T. (1990). The doctor–nurse game revisited. New England Journal of Medicine, 322, 546–549.
J Interprof Care Downloaded from informahealthcare.com by University of Toronto on 06/22/14 For personal use only.
I read the scene. I love it. I am a family doc who works in two wv FQHCs. I have been studying and teaching health care communication since 2000. AAPP member since 2007.