The other day a reporter from Nurse Zone called me to tell me she was doing a story on things nurses can do to improve relations with physicians. Her name is Jennifer Larson and she is committed to the issue, which is great. When we discussed the issue, she mentioned the idea that nurses could be physician whisperers, kind of like horse whisperers who calm down skittish horses. I pointed out that the very idea of a”physician whisperer” is a total replication of the age old nurse doctor game which Leonard Stein wrote about several decades ago. rain which nurses placate or otherwise indirectly manage physicians rather than dealing with them in a respectful but assertive manner. Larson wrote a very good article about dealing with physicians but I would add quite a bit more. In fact, I believe we have to get rid of the traditional and very outdated and dysfunctional “secrets” or “secret of managing” doctors, aides, or anyone else mentality. Nurses as well as any other staff that have been in a traditionally deferential or subordinate relationship to higher status players have to take advantage of the opportunities presented by the movement to enhance patient safety and encourage interprofessional practice and develop the capacity and skills to deal with people in a direct, respectful but assertive manner. Rather than being so obsessed with leadership, nurses have to develop a concept of assertive team membership and learn the skills that have been utilized in aviation and other high reliability industries so that they can become true and full members of the health care team. The way to do this is to mobilize IAA — Inquiry, Advocacy and Assertion.
So here are my Seven Non-Secrets to more Effective Team Relationships, particularly when nurses or others are dealing with traditional high status players like physicians.
Step One — Never Apologize!!! Ever. As RN Paulina Bleah has written in an essay in a soon to be published book I have written with physician patient safety advocates David L. Feldman and Michael Leonard called Collaborative Caring: Stories and Reflections on Teamwork in Healthcare, nurses typically apologize to physicians when they ask them to do their jobs. A nurse calls a doc in the middle of the night, or anytime and begins with an abject apology (i.e. “oh Dr. Smith, I am so sorry to bother you), asks a question and then ends with an abject apology as if Dr. Smith has amnesia and didn’t get it the first time. Don’t apologize to anyone for asking them to do their job. Would you apologize to your lawyer for calling them and giving them a case or asking for advice? I wouldn’t since those nine of ten words and seconds of the apology would have cost me $20 bucks or more.
Step Two — Enter the Circle of Care. Don’t Position Yourself in the Outfield!! How many times have you seen the following? A group of physicians is talking together, or there is a supposedly interprofessional rounds going on. The physicians are standing in a circle. An RN comes up to them to talk about a serious clinical issue. She/he positions herself/himself outside the circle. No one invites her/him in. She/he does not move in. Or consider this “interprofessional rounds” that I described in my essays on Teams and Team Intelligence in First Do Less Harm. The “team” included an attending physician, a pharmacist, and two nurses – the bedside RNs caring for the patient the group would be discussing. As Dr. S discussed a series of patients, she stood with her back to the two nurses and addressed the residents and med students. For the next 15 minutes her stance never altered. She never turned to include them in the conversation. The two bedside nurses stood on tiptoe or craned their necks in an effort to hear what the doctor was saying to the residents and medical students. The two nurses never moved next to the wall even though there was plenty of room there. If you are in this situation, which many nurses confront every day, move into the circle, be part of the team. Do not place yourself on the outside.
Step Three – If You Are Invited to the Table Sit at the Table . In a previous blogpost I described a situation in which nurses and other non-MD professionals are attending interprofessional team meetings. Rather than sit at any seats at the conference table in the center of the room, nurses place themselves at the periphery, in the chairs on the outside of the room, even though there are empty chairs at the table. They do this, I am told, because those chairs are “reserved” for physicians and administrators. Who reserved them? No one really. So help create real interprofessional practice. Sit at the table.
Step Four – If You are Invited to the Table, Speak. How many times have I sat in a meeting to which nurses were invited and yet they said nothing. This is not just a phenomenon I have observed with bedside nurses. I have watched PhD RNs sit silently or speak only about narrow nursing issues when I know they have lots to say about broader systems issues. (Nurses claim after all that they are the ones who are holistic and have a broad understanding of health care system problems) I understand the nervousness people feel when they are in a mixed group, particularly one with high status players. So if you are going into such a meeting, role play it, practice, rehearse but speak up. If you don’t pretty soon people will wonder why they bothered inviting you and you will be either disinvited or further dis-regarded. Remember, silence speaks volumes.
Step Five – Insist on Equal Naming Practices. Nurses –even older nurses – constantly allow themselves to be called by their first name while they call physicians –even young ones – with title and last name. As in Dr. Smith, this is Suzy. This form of naming practice, unknown in the outside world where first names are now routine – delivers a very specific message about status. Nurses are not important, physicians are. Nurses not only allow this practice but reinforce it. Nurses who are on a first name basis with physicians typically change this practice when in front of patients. The physician they referred to by first name only suddenly becomes Dr. Smith when in the presence of a patient. When I ask nurses why they do this, they insist that it’s important for the patient to respect their physician. Like a mother in front of a child, they are telling the patient that they must respect their daddy. This not only serves to put the nurse in a one down position, it tells the patient that they must be deferential to the doctor. Don’t nurses deserve respect? And if respect resides in the last name and title, why don’t they insist on being called Nurse Smith? And how can they allow physicians to call patients by their first names if they insist the patient call the physician with last name and title? How can nurses claim to be patient advocates, if they are advocating for this paternalistic definition of the authority of the physician? This practice should end. To see how to do that please read what Bernice Buresh and I have to say about this in our book From Silence to Voice.
Step Six – Understand the Difference Between Respect and Reverence. Healthcare is totally confused about the difference between respect and reverence.
Webster’s Dictionary defines respect thusly, “a feeling or understanding that someone or something is important, serious, etc., and should be treated in an appropriate way.” http://www.merriam-webster.com/dictionary/respect?show=0&t=1405269538
Reverence on the other hand is defined as ”profound adoring awed respect.” Reverence is the attitude religious people feel toward God, or priests. Is this the way we want to view physicians? How can people intervene to appropriately challenge a physician, administrator, chief nurse, whomever, if we hold them in awe?”
Step Seven – Learn How to Speak Up. Nurses have been tutored in silence for centuries. This kind of tutoring still goes on. I recently wrote a blogpost about a student nurse who said he was “crippled by shame,” because his clinical instructors told him not to point out that attending physicians hadn’t washed their hands. “You don’t want to be considered to be a loud-mouth or know it all,” the instructor told the student. Nurses need to stop teaching each other how to shut up and need to help each other to learn how to constructively speak up.
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
Bedside manners: a dramaturgical approach to exploring interprofessional collaboration
School of Nursing, University of California, San Francisco, CA, USA
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.
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.
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.
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.
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 just wanted to share this article that my daughter just wrote. It’s not about healthcare but it’s very important.
The Desperate Choices Behind Child Migration
As someone who just returned from living and working in El Salvador, I’m still having a hard time adjusting to our mainstream media’s never-ending wave of know-nothing commentary on the subject of immigration. A case in point is the column penned by New York Times columnist Ross Douthat on Sunday, June 22nd. Douthat expresses alarm about the “current surge” of “unaccompanied minors from Central America” who are dangerously crossing the U.S.-Mexico border in such unprecedented numbers that the Border Patrol and the courts are now “struggling to care for the children and process their cases.”
What has caused this “children’s migration?” According to Douthat it is “immigration reform’s open invitation”–“the mere promise of amnesty” that has now worsened “some of the humanitarian problems that reformers say they want to solve.” Douthat is a conservative but his solution is a familiar, bi-partisan one: “let’s prove that a more effective enforcement system can be built and only then codify an offer of legal status.”
That immigration policy proposal, per usual, totally ignores what’s really driving the big increase in border crossings by impoverished young Central Americans and what the U.S. government could be doing to make staying in Central America a viable choice.
The “Push Factors”
To see things differently, it helps to put yourself in the shoes of others. Let’s imagine that you are poor single mother living in Apopa, a dangerous city next door to the capital, San Salvador.
You work cleaning houses for $15 a day. Your neighborhood is completely gang dominated. When you take the bus to the house where you work you are often late because the police check the bus and make all the men disembark for body searches. There are some mornings when you wake up and send your daughter to the corner store for eggs and she sees dead bodies in the street. They could be the bodies of a neighbor or a storeowner who refused to pay the extortionate demands of the local gang. Just a few days ago, walking with your son you were caught in a shoot out between two rival gangs. You could do nothing but duck and cover and try to comfort your wailing child.
Your son is 12 and one of the gangs–let’s say la Mara Salvatrucha (MS), the country’s most violent–is starting to recruit him. They want to use him as courier to send messages and deliver drugs. Perhaps more frighteningly, your older daughter, 14 now, is attracting the attention of an MS leader in the neighborhood. You tell her to reject his overtures, but you know how hard it is for any young woman to spurn such a relationship—or end it, once it has begun.
No Rural Refuge
You think about just packing up and moving to the countryside, but you have heard stories. Your next-door neighbor, an office worker, faced gang pressure to pay a fifty-dollar a month extortion fee. So she decided to move back to her hometown, a tiny village in rural San Vicente. But even small towns in El Salvador aren’t safe these days. After your neighbor moved back home, her nephew, a 16 year-old scholarship student was killed in the middle of the afternoon in his own front yard, right across the dirt road. He wasn’t the slightest bit involved in any gang activity. All he did was date the ex-girlfriend of a gang member.
In Apopa, you try to keep your kids inside as much as possible. And you worry. You worry about how you will pay the rent and find the money to send them to high school, let alone college. And you think about sending them to la Usa. Your brother lives in Maryland. Maybe he could cover part of the cost of their journey? You know the journey is dangerous but what other choices are there?
How many American parents have ever had to weigh such terrible options—the danger of daily life for their children versus the dangers of illegal immigration? How many have experienced the emotional pain of resulting family separation—first from parents leaving for work in Los Angeles or Maryland, with their children staying behind, and now from the stream of children and teens following the same route north in search of a safer and better life?
Forced to Leave
In February, with my U.S. passport in hand, I left El Salvador and hopped on a plane headed for the U.S. – adios gangs, adios fear, adios poverty. I left behind many Salvadoran friends who will never be able to do the same thing. Just a few months later, a bright young man from one rural community I often visited left to join his father in Washington State. To me, with a steady job and money in the bank, his beautiful mountainside community seemed like paradise. But the young man couldn’t gain admittance to the one affordable, public university in El Salvador and couldn’t find a job. While Douthat bemoans the fact that Border Patrol agents are “neglecting other law enforcement duties” to deal with the influx of child migrants, I am hoping they will be too busy to catch my young friend and that he will reach his destination safely.
The vast majority of Salvadorans, like other Central Americans, don’t want to migrate to the U.S. They love their families and communities and would much prefer to stay and work or go to school in their own countries. Creating stricter immigration rules and deporting more children will not stop this wave of forced migrants; only giving them the chance to survive and prosper at home will.
U.S. Policy Impact
The U.S. Government could do a lot to make life better in El Salvador and Honduras. But right now they are doing just the opposite. In El Salvador, the Obama administration is currently undercutting efforts by the Salvadoran government to support sustainable, small-scale farming. The U.S. Ambassador has threatened to deny a multimillion-dollar aid package if the FMLN government continues to buy seeds from local farmers, instead of from foreign companies like Monsanto, as part of their highly successful Family Agriculture program.
Meanwhile in Honduras, since the military take-over of June 2009 the U.S. has been supporting a corrupt, illegitimate regime responsible for increased economic inequality and violence. I have participated in a number of human rights and electoral observation delegations to Honduras and heard from community leaders about the hundreds of murders of women, gay people, activists and union leaders that have occurred under the watch of the post-coup regime. If I were Honduran, watching right wing hard liner Juan Orlando Hernandez “win” the presidential election through blatant fraud and intimidation would have been the last straw for me. I would have left too.
I am no Harvard trained political analyst like Ross Douthat, but I know that only a dramatic shift in U.S. foreign policy will help change conditions in Central America and ease the humanitarian crisis at our border. The U.S. government must stop pushing free trade and privatization and start funding social programs. But most of all it must stand up for human rights. And these include the right not to migrate but to stay, study, work, speak out and live happily in your own home country.
Several weeks ago, I was talking with nurses, physicians and other healthcare professionals about their efforts to enhance patient safety at a large and prestigious teaching hospital. The group was very committed to improving teamwork and communication among interprofessional staff. One of the biggest problems the institution faced was encouraging nurses and non-physician professionals to speak up and discuss or point out safety problems. The institution had done some safety training and was very concerned about quality and process improvements. But what I call “the by-stander problem” – people not pointing out safety issues when they saw them and raising safety concerns when they had them – was, nonetheless, a constant barrier to patient safety and staff satisfaction. When we talked further about the issue of safety culture and psychological safety – the pre-requisite of people feeling they can speak up — people admitted that toxic hierarchies often made people feel that providing input and feedback would not only be unwelcome but even risky. They were trying to flatten the hierarchy but this was hard, many confessed. Read more >>
I just flew to Orlando on Friday to attend a conference at the AWHONN (Association of Women’s Health, Obsterical and Neo-Natal Nurses). On the flight I sat next to a wonderful former Labor and Delivery nurse who is also a mid-wife and clinical educator. She told me the story of her husband’s recent hospitalization. It was a long and drawn out saga that lasted for months. It also involved an endless battle with nurses and attending physicians and residents who did not welcome her knowledge and input as a skilled healthcare professional, discounted her concerns, and neglected to find and treat a complication of surgery that almost killed her husband. “If I had not been at his bedside day in and day out, he would be dead, “ the nurse told me. “I am certain of it.”
Every nurse or doctor I know has told me much the same thing. They are fearful of leaving a relative or friend in the hospital without being at that loved one’s bedside. They almost all report that their knowledge and expertise – of medicine, nursing, pharmacy or of the patient who is a friend or relative – is not welcomed by hospital or facility staff who tend to view them as “know it alls,” interlopers trying to interfere with the patient’s care. Ask yourself the following question: Would you ever fly in an airplane if people told you you would have to hire your own private pilot to sit in the jump seat in the cockpit to oversee what the captain and first officer are doing? Have you ever talked to a pilot or flight attendant who told you they wouldn’t fly if they didn’t have a friend or relative who was a pilot supervising the airline professionals on the flight deck? Read more >>