Friday, September 14, 2001

Team, What Team? We’re fighting like cats and dogs. Can we recover?

This past May 2001 in my column entitled, "Teamwork or Why Did You Come to Work Today?" I wrote of the virtues of true, interdisciplinary teamwork and offered some suggestions as to how you might proceed to achieve that goal. Perhaps some (all?) of you who read that column thought that I had my head in the clouds and that real life never worked as I described. Well, even those of us who aspire to outstanding teamwork are forced to confront ugly realities from time to time and indeed, we’ve had some episodes in our ED these past months, which have been discouraging. Yet, we are not resigned to failure and to the "bunker mentality" where physicians and nurses go to their separate corners and communities to shore up their egos and disparage one another, rather we are re-energized to address our failings anew.

In this column for the past 18 months I’ve tried to encourage leaders to aspire to finer service and clinical performance in their emergency departments. Aspirations and plans are fine and important, but execution and implementation are everything. Realistically, every new effort will fail in some way, small or large. It is how one addresses those failures that can give hope for ultimate success of the effort or lead to disillusionment among colleagues and ultimate failure of the leader’s vision.

I’ve been extraordinarily fortunate to work with a wonderful team and this month I’m asking Barbara Sommer, RN, CEN, CNA, MA, Director of Clinical and Administrative Operations at Maimonides Medical Center Department of Emergency Medicine to share her thoughts on our communication and teamwork failings and our plans for renewed efforts at team-building.

Excellent customer service for our patients, their families and the community comes out of quality care and excellent communication with our workplace colleagues. Using our customer service skills in communication with our colleagues in the workplace, especially active listening skills helps develop partnerships between physicians and nurses. Through active listening we demonstrate concern for and understanding of the other professional’s point of view and thereby bring both our minds and efforts to bear in providing quality care to our patient. Unfortunately, we’ve recently experienced two episodes where active listening was pushed aside as if only one professional’s view mattered, in so doing; the nurses’ concerns for the patient were demeaned. Was it not for each nurse’s strong personal commitment, serious consequences would have befallen these patients.

The first instance involved the dosage of a medication and the second involved a treatment. In both instances the nurses’ question was taken as a challenge, rather than an effort at clarification or initiation of a professional dialogue. Each nurse was discouraged by the physician’s response and feeling uncertain and insecure, sought support through discussion of the problem with their colleagues. Fortunately, because of our management structure, colleagues in our department include the senior physician leaders as well as our nursing colleagues and nursing management staff. Thus, despite the initial blow to professionalism and professional self-assurance experienced by these nurses, we’ve been able to help them understand that their questions were asked on the patients’ behalf and thus were not only appropriate, but also necessary. This support from senior physician and nurse leaders was our key to reducing resentment among nursing staff who otherwise may have built greater barriers over the issue. But what of the physicians involved?

Unfortunately, neither physician acknowledged either their behavior or their potential error to the involved nurse. The physician involved in the potential medication dosing error kept his own counsel and the physician involved in the other episode later acknowledged in an email to our medical director that the nurse’s suggestions may have had merit and greater patient benefit than his own approach.

These failings of communication and perhaps professional maturity force us to acknowledge that we must do more to improve communication among our staff and customer service behaviors. We will make improving communication and these behaviors a departmental priority in 2002.

We approach this challenge recognizing that changing what is in each professional’s own mind is not our task; it is their behavior we wish to change. Behaviorism may or may not fit with your approach to management, but training staff members to behave in a particular fashion in a particular situation, coupled with regular reinforcement has been shown to change behaviors and hold the change as staff members themselves recognize improved results, usually gaining job satisfaction as a consequence. There are different approaches for improving communication among professionals who work together and establishing the team-building, nurturing and listening environment in the workplace.

MedTeams™ has gained great recognition of late for its data-driven development and focus on reduction of errors specifically in the emergency department. If you are looking for an "evidence-based" approach you probably can’t do better than this rigorous but expensive program.

Yet, fundamental customer service skill courses whether offered by Disney, Ritz-Carleton or a more locally/regionally based training organization may be as effective in inducing the behavior changes you seek. While the course content differs, the training goals and the process of training all disciplines together are similar. Focusing on the specific forms of communication most effective in facilitating patient care, reducing error and supporting professionalism, team-building and mutual regard; customer service skills training backed up by continuing reinforcement inside the ED, establishes the team environment and identifies appropriate behaviors. Consequent to the change in behavior, professionals develop both a sense of accomplishment about their patient outcomes—including quality of service and patient satisfaction—and mutual respect among the professional clinicians and technicians at the bedside. This improved staff satisfaction improves external customer—our patient’s—satisfaction.

Leaders acknowledge failures of implementation quickly—"Fail fast." I was taught. Yet if accomplishing your vision is important to you, choosing another approach, including going beyond your own efforts and seeking the help of outside experts is not evidence of failure as a leader, rather it a sign of personal and professional maturity, subordinating one’s ego to the needs of the organization. Just as the physician who is open to learning—indeed, "correction"—from a nurse colleague, enhances patient outcomes and safety.