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health care teams
Challenges, Changes and Cures
   From High Performance Teamwork training course

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What Constitutes a
Healthy Attitude in Health Care?

What constitutes a healthy attitude in the health care situation? First, stability, competence, and confidence born of knowing you have something to contribute to another person's plight. Second, knowing that you want to make those contributions that are wanted and really will help. Third, having absolutely full attention available for the patient. This latter, of course, is not possible if there are residual disagreements among your own team.

Discomfort among your team broadcasts no matter how cleverly you may think the discomfort is disguised. Stress, uncomfortable boredom, antagonism, confusion, and frustration among team members is not only counterproductive, it actually is irresponsible of us in the sense that we are subjecting our patients to unnecessary suffering.

Staff Muck
Muck, the word I use to refer to that list of discomforts above, is common to every field of endeavor where people work together. Muck, by definition, is that feeling of discomfort that sometimes arises in our dealings with other people. Muck is an everyday phenomenon, even in some of our best teams. And muck is not in itself a problem. The potential problem lies in how we deal with it when it is there.

For an everyday phenomenon with the critical importance of muck, most of us have had little direct training or guidance, especially in our "formative" years, in how to deal with it. While our profession abounds in training in how to figure muck out, or analyze it, or categorize it, the fact remains that there is very little down to earth training in how to get rid of it constructively. Yet there it is, looking us straight in the face again and again, sometimes just a low-grade distraction but ranging up to a nearly consumptive frustration. And there we are, often left mainly to our own devices to get ourselves out of our own discomfort.

Because we are left to our own, often random, devices, we sometimes deal with muck effectively, that is, in ways that actually solve the problem, and we sometimes deal with muck ineffectively, that is, in ways that don't solve the problem, make the problem worse, or create bigger attendant problems. By and large, when we are being ineffective in dealing with muck we are using old habits: retreating from the muck or the situation we believe is causing the muck, avoiding the muck, or playing with the muck.

The Retreat
Jim and Gloria work together on the P.M. shift. Jim has had the persistent feeling lately that Gloria doesn't do her part, that he, Jim, ends up doing most of the work. He does it because he wants to do the best by the patients, but he is working with a slowly building resentment and an increasing sense of martyrdom. Jim has some muck. While he is being pretty clever about hiding his discomfort from his patients, still it spills over a little in the form of little side remarks, his indirectly communicated sense of being unjustly over-busy, his partial distraction, and, in general, a sense, which he inadvertently communicates, of being unjustly put upon. Rather than continuously remembering that he is working in the field of his active choice, Jim is feeling somewhat forced to make more contributions that he can or wants to, and he
blames Gloria.

All of that communicates, albeit indirectly, to Jim's patients.

Jim tried to discuss the matter with Gloria, but the more he talked, the more indifferent she seemed to become, until finally, Jim slammed down his clipboard and bolted out of the room, in his mind justifiably frustrated past the point of tolerance by a fellow worker who was clearly wrong and not caring.

What Jim did was to retreat. Once in that room with Gloria he was reminded of his building frustrations. He left the room in the midst of muck in an attempt to get out of the muck, his own discomfort. A retreat, then, occurs when a person who is in the muck changes his physical situation or location in an attempt to get out of the muck. A retreat can be quite dramatic, as with Jim above, or it can be very subtle. In either case, the retreat will 1) not solve the original problem, and 2) be followed by "new muck," no matter how radically we have changed our situation or location.

Retreats have this disadvantage to you: in the midst of a retreat we are muttering to ourselves, "never again." The things we swear to ourselves in these unfortunate moments are sometimes bizarre and always limiting. The extreme case is the person who, in the midst of the horrendous muck in his or her marriage, opts not to clear up the muck directly with whatever resolution will follow, but to leave the marriage in the midst of the muck as a solution to the muck. This person, then, is likely to mutter to himself in the midst of the retreat, "never again am I getting married." Whether he remembers this solemn oath or not, his ability to see people and relationships for what they are, one by one, is prejudiced indefinitely.

More importantly, the person retreating never sees how he is participating in the problem. He actually attributes the muck to the situation or to the other people, thereby sentencing himself to some version of his habitual mistakes in the future.

Any time a person is in the muck, in this example Jim and probably Gloria too, that person is participating in the problem in such a way as to help keep the problem and the muck there. That participation could be by omission, by not doing or saying something, or it could be commission, by actively doing or saying something that adds to the problem and the muck and thereby keeps it there. That participation must be there for the muck to remain.

Avoiding the Muck
Avoiding someone with whom or some situation with which you have muck not only doesn't solve the problem, it amounts to one of the biggest attention and energy drains you could devise for yourself. Imagine it. You have some muck or discomfort with your boss, and the muck seems to get worse every time you are around him or her. It just seems easier to avoid him, thereby avoiding that muck, right? Not really.

Just think. What do you have to do to effectively avoid him? You have to not bump into him. But how do you know where not to go? Even more than not bumping into him, to really avoid him you have to not think about him. But how do you remember to not think about him without thinking about him? Ultimately, to effectively avoid someone you must keep track of him at all times. He has to be on your attention, somewhere in the back of your mind, at all times. In an extreme, you've got to keep track of this guy's lunch habits so that you can effectively avoid him during lunch hour. And the more you "must" avoid him, or the situation, or the emotion you have attached to him, or the thought, or the subject, or the elevators, or whatever, the more that person or thing is on your mind.

Your distraction and preoccupation is communicating to the very people to whom you want to communicate health, your patients.

People sometimes get enamored with the process of doing away with muck, rather than focus on the result of having done away with it and getting back to actual work. That trap occurs when the goal is to be in "good communication," rather than using good communication to reach the goal of being in good teamwork on the job. People can make literally endless projects of "handling" things, with the resultant atmosphere of a nearly continuous encounter session, muck spilling out over everyone, including our unwitting patient, whose only sin was to get sick
or injured.

The assistant administrator, Ted, for example, is in certain ways, a well-respected manager--so much so that people like to be around him, to learn, to get advice, to pick his brain, and so forth. But because of certain distractions outside of work Ted has recently fallen into the habit of only being accessible to his supervisors and department heads when they have a problem. Ted has built himself a trap. The more respected he is, the more people want to be around him. But the only way they can get to him is when they have a problem. What are the meetings going to like? And Ted, for his part, is liking these meetings less and less because it always seems to be a hassle! In many subtle ways, then, Ted becomes less and less accessible to everyday communication, and in so doing, adds more bars to his own self-constructed cage.

Institutional Muck
Institutional green walls and tepid food do not communicate health and recovery. Blandness does not communicate life; it communicates boredom with life, the very phenomenon that may have contributed to the illness or injury to begin with. Processed and addictive-afflicted foods served without attention to visual and olfactory attractiveness also do not communicate health and recovery. Rather, they communicate laziness and, frankly, unconcern or ignorance of a thickening body of evidence that nutrition and attitude have a great deal more to do with recovery than we as a profession have always thought and taught.

Despite our collective habits, it remains true that hospitals, clinics, private offices, and homes with recovering patients have a responsibility to communicate health, not illness or those factors reinforcing illness. As much as possible, the physical surroundings of patients should be part of the solution, not add to the problem. We have all seen health care facilities that look more like interment institutions than physical spaces that help to communicate the steps toward recovery. The combination of drab surroundings, poor, tepid meals, and night noise (as if sleep or rest for the patient were less important than the staff keeping themselves entertained) can add up to a pretty convincing communication to patients, a sense that runs counter to healing and recovery.
The Personal Touch
Communicating health to patients includes relating to the patient as a person of equal power and ability to yours. The patient is not a victim of anything at all, at least in the sense of thinking of victims as "poor thems." The reality is that your patient is an equally able person who happens to have a problem. You have some priceless knowledge and skills to apply to that problem, and your place of work is hopefully ideally set up and equipped to help the patient to solve his problem.

Left Alone, Muck Grows
Having muck within the health care team or in parts of the team prevents complete trust within the team. Trust can be simply defined as complete confidence in another person's word or actions, the absence of worrisome attention. It is difficult to ask patients--people who are waiting, who sense danger and who feel fear already--to trust a group of strangers who do not completely trust each other. Therefore, the muck must go.

The first step is to recognize that having muck in and of itself is not wrong as much as it is disadvantageous. Everyone I have ever met, several pretenders notwithstanding, gets himself or herself into the muck at times. To blame yourself for getting into the muck gets you no further than, for instance, Jim blaming Gloria, or his rank, or his background, or his sex, or his education, or his disadvantages in life for his muck. In Jim's case, since he thinks Gloria is to blame then Jim will have to wait for Gloria to change to get himself out of the muck! The more Jim is accurate that Gloria is contributing to the problem, the longer Jim's wait once he starts blaming Gloria. Blaming oneself leads to a different, but equally baffling, trap. Once you start blaming yourself, you feel bad. Then one day you recognize that you are blaming yourself and feeling bad about it. Now everyone knows he shouldn't blame himself, so he can only blame himself for blaming himself! A downward spiral. The actual fact is that getting in the muck is a very human thing to do--but so is getting out.

Recognizing one's own participation in mucky situations, objectively recognizing that participation, is quite different than blaming oneself or someone else or a situation for your plight. That recognition is, in fact, the gateway out of the muck. Then, and only then, you can see which on your list of complaints or dissatisfactions are attributable to yourself, and thus easily corrected, and which are attributable in part or in whole to the other people involved. To achieve this kind of objectivity, one must get the complaints and worries out of the mind, where they just rattle around and worry us more. Left in the mind, complaints and worries cause us to lose perspective. To start getting out of muck in a particular situation we therefore want to get the mucky contents out of our mind: for instance, down on paper.

Look down the list to see how, by omission or by co-mission, you have been participating in the muck, or in allowing it to grow, or in allowing it to stay there. Look at that list of participation to see which of your habits can be easily corrected.

Those ways we participate in making our own discomfort (i.e., "hooks") vary in as many ways as there are different people and different automatic habits in the world. Some hooks we have more or less in common with other people, and some are unique to each of us as an individual. One of the common hooks is to hesitate to express immediately what is really on our minds before it builds up. The justification for the hesitation or omission nearly always boils down to a fear of consequence, and the result of that hesitation is usually the actualization of some form of that, heretofore, only imagined consequence.

For example, Dr. Jones, an attending physician, and Ms. Smith, a nurse, have developed together what has now become pretty nearly continuous failure to communicate clearly together. Ms. Smith started off doing pretty well in her communications with Dr. Jones, being direct and informative when appropriate. As was her custom with previous physicians she had worked with, Ms. Smith would state her opinions without undue force but also without undue fear and hesitation, both when those opinions agreed with what seemed to be the plan and also when an opinion or piece of information might have caused a review and possible revision of the current treatment plans. In that way Ms. Smith was acting as a positive creative member of the health care team, making those contributions needed when a situation calls for maximum input before a direction is chosen or changed.

At first, Dr. Jones seemed to receive that input without undue reaction and he, therefore was also acting as a positive and creative member of the team, actually listening to his team members and at times visibly using the information to the patients' advantage. But over the past several months Dr. Jones has appeared to Ms. Smith as distracted and irritated when information and opinions were offered. After several instances of this perceived behavior, Ms. Smith began to feel that her comments were not welcome and probably not even heard anyhow. Several other members of the team had the same impressions and discussed that impression, not with Dr. Jones, but with each other when Dr. Jones was not around. On one occasion some months ago Dr. Jones actually blew up at Ms. Smith when she questioned a dosage prescribed on the ward by Dr. Jones. Ms. Smith's question had been posed tactfully, and, in her mind, his reaction had been rude and unjustified.

Ms. Smith had no difficulty finding complete agreement among other team members for her feeling about Dr. Jones reaction. Looking back now, Ms. Smith can see that from that point on she volunteered only the minimum information to Dr. Jones, often stifling her own heartfelt opinions about what might be best for a particular patient at a particular time. After all, who needs it?

Dr. Jones, for his part, feels utterly responsible for his patients' welfare, a responsibility he feels he shares with no one and, therefore, he has developed a sense of caring that has become distracted, and easily irritated when questioned or when he imagines he is being challenged about a particular mode of care. His deepest fear, unidentified but nevertheless active within him, is getting discovered making an error in the care of his patients. He has, therefore, gradually become motivated in part by this fear of consequence, which of course will make much more probable the actualization of those heretofore imagined and
feared consequences.

What are the hooks? They exist, as they nearly always do, on both sides of what has now become a silent contest manifested by a communication gap that results in disharmony, albeit unspoken disharmony, and discomfort on this part of the health care team. Ms. Smith's holding back is perfectly justified, as hooks always are. In her mind, to talk frankly with Dr. Jones results in a flare-up, which she doesn't want. Acting on or not acting because of that fear is the hook. Also, Ms. Smith has agreement from other staff, also justified, that Dr. Jones reacts at times irrationally.

Obtaining and not acting because of that agreement is hook number two. Then, too, Dr. Jones appears distracted and disinterested and probably, in Ms. Smith's mind, doesn't want challenging or questioning information, and certainly wouldn't act on it anyhow.

Hook number three. All of these hooks are perfectly justified, and all result in Ms. Smith getting closer to the things she wants least: a blowup on the ward, as mutual tensions mount toward the boiling point, and a compromise in care for the patient, as relevant information is withheld, communicated indirectly, or glossed over in an attempt to not rock the boat.

Dr. Jones' hook is his fear of making an error and being discovered. That fear is harmless in and of itself, but because of that fear, Dr. Jones has unknowingly developed an aura of inapproachability, relative inflexibility, and, at times, extreme irascibility. This aura is pronounced enough to have gained Dr. Jones a silent reputation. Dr. Jones has forgotten how to receive information, and he therefore cuts off his best, besides the patient himself, sources of information, the people who actually take care of the patient. He, therefore, inadvertently advances one step further toward an actual manifestation of his worst fear, to not do the very best possible by his patients.

In this scenario, both people, perfectly justified though they are, participate in erecting the communication and action obstacle. This part of the team, then, cannot act in complete harmony on the patients' behalf. Other members of the health care team get caught in the middle, listening to complaints from both sides.

In Summary
Everyone has fears, hesitations, and reservations about certain types of communications to certain people in certain situations. The hesitations are not the problem. Acting or not acting because of those hesitations may, though, result in what we all want least: actual realization of our fears and a compromise to forming and maintaining great teams which result in the best patient care.

It's a nice profession: a vital first step in delivering the help we all want to deliver is to be healthy in attitude ourselves. It gives us an excuse, if you will, to have and maintain for ourselves that ingredient so valued in every aspect of our lives, a healthy attitude that leaves times and attention for someone else.
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