Everyone agrees that teamwork is essential to patient care. So why do so many clinicians struggle with it, and how can they improve?
You wouldn’t think it to look at them, but the healthcare professionals who attend PBI Education’s course, Elevating Civility and Communication in Health Care, have berated coworkers in front of patients, insulted staff, shouted down clinicians who dared to disagree with them, and otherwise alienated people they work with. These are not the kinds of clinicians you would expect to behave so unprofessionally. In fact, most are experienced practitioners — physicians, nurses, therapists, and others — who have long, distinguished careers. Their patients often adore them.
So, what’s going on?
Each person has their own demons, of course, but many of these clinicians share a common resentment. In one way or another, they feel backed into a corner by forces outside of their control. For some, it’s a perceived collapse in standards. They complain about the poor work ethic of younger clinicians, who go home when their shift is over without finishing what they started. Or they fault coworkers for ineptitude or a startling lack of common sense.
Others resent the big companies that have taken over their workplaces and changed policies and procedures without apparent regard for patient safety. “Administrators seem more concerned with patient satisfaction surveys than treatment outcomes,” they say.
And many live in fear of the endless incident reports unhappy subordinates file whenever they are criticized.
All feel trapped between what is expected of them — what they demand of themselves — and an environment they see working against them.
A New Culture Makes New Demands
Physicians often complain of a loss of authority. “When I was in med school, we were taught that doctors are the captain of the ship,” says Deborah Kasman, MD, former Medical Bioethics Director at Kaiser Permanente and current PBI Civility and Communication course faculty member. “We were taught to take responsibility for our patients and for their care.” This weight of responsibility creates emotional anxiety, which can lead to rudeness out of fear.
That all began to change in 1999 when an Institute of Medicine report found that preventable errors were causing between 44,000 and 98,000 deaths each year in U.S. hospitals. Drawing on the experience of other complex, mission-critical industries — the airline industry in particular — hospitals started to promote a culture of safety founded on open communication and teamwork.
The premise behind the safety movement is that no one person can possibly know enough to ensure the safety of the passengers on a modern airliner or the patients in a modern hospital. To be successful, the person in charge has to foster communication and collaboration among all the professionals involved, whether in flying the plane or caring for a patient. Instead of being the captain of the ship, the attending physician must become a team captain.
Captain Chesley “Sully” Sullenberger, who, in 2009, saved hundreds of lives when he safely landed his crippled aircraft in the Hudson River, is a poster child for this transformation. Trained as a combat pilot, Sully joined the industry push for a change in culture. “We changed the cockpit culture from the old days where it was autocratic and arrogant and people didn’t listen to each other and didn’t build a team, and the accident rate reflected that. Now we teach them how to take a team of experts and create an expert team, and those are different skills.”
It’s not just physicians who have to adapt. The new safety culture has cast everyone in new roles — all professionals involved become co-equal teammates, rather than crew members ranked in a strict hierarchy. It can be disorienting. People who are accustomed to following instructions are suddenly asked for suggestions. Others who have achieved positions of authority resent having “subordinates” question their decisions. Many have trouble adjusting, and when the frustration level gets too high, the communication and civility necessary for the team to function is put at risk.
Learning Basic Skills and Techniques
It takes time, but most participants in PBI courses come to see the value of teamwork. But it’s one thing to understand the benefits of a team approach; quite another to make the necessary adjustments. Catherine Caldicott, MD, another faculty member for PBI’s Elevating Civility and Communication in Health Care course, says that once people realize how things are changing, they’re eager to learn the necessary skills. “They want to find new ways of communicating effectively with people, rather than just badgering or blaming them,” she says. “They’re looking at what they could do differently to improve the level of teamwork.”
Teamwork requires a different kind of leadership. Physicians and others who see themselves as ship captains, expect the kind of blind obedience that can destroy teamwork. A team captain’s goal is to forge a team of equals who raise concerns, ask for help, and play to each other’s strengths to accomplish far more than any of them could independently.
As Captain Sullenberger said, this kind of team-building leadership requires a whole new set of skills, and although things are changing, it’s still rare for clinicians to receive much in the way of training. When this type of training is needed, organizations and clinicians turn to PBI’s Elevating Civility and Communication in Health Care course, which provides participants a chance to learn what’s involved in both leading successful teams and strengthening the teams they join. Some of the key takeaways focused on during this course include:
It’s important to fill your “trust tank” ahead of time
Trust is much easier lost than gained. “Once you have berated someone in a demeaning way, you’re on their radar and it gets harder and harder to get that image changed,” explains Kasman. And the damage spreads quickly as people discuss the situation with coworkers and friends.
But the opposite is also true, Kasman points out. “If you put in the effort ahead of time, fill your trust tank upfront, people give you a lot of leeway. If you lose your temper, they’ll say ‘She’s just having a bad day.’ They might even check in with you to see what’s going on.”
Sometimes a member of the team may not pull their weight or their work may be shoddy. When you approach them with a full “trust tank”, they will know that you are operating from a position of what is best for patient care, rather than from a position of criticism. Your efforts to get them to improve will be productive, rather than destructive.
Short “team huddles” can help strengthen teamwork
Team members must be able to rely on one another. “A quick huddle before the day starts can work wonders,” says Caldicott. Sometimes called daily safety briefings, daily check-ins, or daily safety calls, these short meetings give people who will be working together a chance to clarify each other’s roles, share concerns, and discuss upcoming cases. By giving everyone a chance to be heard, huddles encourage mutual respect and foster collaboration. Reviewing past mistakes or misunderstandings helps facilitate communication.
Learn team members’ names
It sounds too simple to be meaningful, but Caldicott offers a compelling account of how important names can be. A surgeon who had alienated numerous coworkers asked a friend who was as exacting and demanding as he was, why he didn’t face similar problems. His friend responded with a simple question: Do you know everybody’s name? “He told the surgeon, ‘You have to learn everybody’s name. You have to walk in in the morning and say good morning to them. You have to show that you know who they are as a human being,’” recounts Caldicott, adding, “That was a stroke of brilliance.”
“We’re all in the same boat”
Over time, one of the course participants who had been harshly critical of coworkers came to a new understanding. “You know what,” he said, “these folks may be doing the best they can. And that’s all any of us can do. They may be feeling overworked, underappreciated or unappreciated. We’re all in the same boat. It hadn’t occurred to me to think about how they were feeling in their jobs.” According to Caldicott, “Once he truly believed this, his frustration went away.”
This kind of identification with someone else’s struggles is an essential aspect of compassion, says Kasman. “Rather than looking down on someone as being subpar, it’s considering that they may be feeling what you yourself are feeling or have felt, giving them the benefit of the doubt, and accepting your common humanity, that ‘we’re all in the same boat.’ Teamwork not only thrives on this kind of fellowship, it probably can’t exist without it.
With all that’s going on in the world, it’s sometimes hard to believe that human beings are masters of collaboration. But we wouldn’t be where we are today—we might not be here at all—if we hadn’t developed the interpersonal skills needed to hunt, farm, and live together in groups. In other words, teamwork is a survival skill. With enough effort and practice, it can also help us give our patients the care they deserve.
Kohn LT, Corrigan JM, Donaldson MS, editors. To err is human: building a safer health system. Washington, DC: National Academy Press, Institute of Medicine; 1999. https://pubmed.ncbi.nlm.nih.gov/25077248/
Forbes, “Stick The Landing: An Interview With Sully Sullenberger,” Jul 21, 2017,05:00am EDT, https://www.forbes.com/sites/kevinkruse/2017/07/21/stick-the-landing-an-interview-with-sully-sullenberger/?sh=41e89a667106