A Nurse's Viewpoint
But do they play as a team?
By Roberta B. Abrams, RNC, MA, LCCE, for HealthLeaders.com, Dec. 17, 2001
Many hospitals trying to rebuild their departments of nursing (and pharmacy, and radiation therapy, and rehabilitation therapy, etc.) are spending significant sums of money waxing eloquent in a variety of media messages about "how wonderful it is to be part of our team." I've been reading many of these messages and find myself thinking about the facilities. Among the questions that occur to me are:
How much did they pay the consultants who advised them about the fiscal advantages of staff reductions?
How long did it take them to realize that implementation of those recommendations had led them down the primrose path to fiscal insolvency?
How long did it take them to realize that lack of appropriate staffing has led to increased errors, discharge delays, inappropriate readmissions, a stream of resignations, and increased sick days for remaining staff?
Has the financial department calculated the costs of the temporary agency staff that they are paying to replace those who were cast away in their specious savings? What about the costs of attempting to recruit and prepare new staff?
What kinds of incentives will they use to try to rebuild the staff? What will they cost?
Do they understand the concept of "team" - and what will it take to teach them the real meaning of "team"?
Among other things, I consider myself an educator. To share the construct of "team building" from an educational perspective, let's look at the way things are and the way that they need to be to really have a team. We will, of course, do that from A Nurse's Viewpoint.
All hospitals have mission statements. They can usually be found in lovely frames in the main lobby. Who wrote them? How much input was received from the clinical staff members who deliver the care in the facility? Do the staff members agree with the statement? Have they read it?
All too frequently, mission statements are crafted by the people in the marketing department who are skilled in marketing, but have little or no knowledge about providing patient care. In a team-driven facility, the mission and goals of care have been discussed and defined by the caregivers. Action plans have been devised to actualize the mission, and all staff is committed to implementing the plan.
How are staff meetings structured? Who attends them? Is there dialogue, or are messages delivered? All too frequently, staff members are embroiled in a morass of meetings. The administrative staff meetings are run by the hospital's chief executive officer or other senior staff. Messages are delivered dealing with the need for increased productivity, improved "customer relations," conservation of scarce resources, an inspirational message or two, and even a poorly crafted attempt at humor.
I have attended these meetings. To stave off terminal boredom (when necessary) I would count sleepers, readers, and writers (of messages to their staff), and calculate the cost of the meeting (hourly salary of all participants multiplied by the meeting time). Discretion precludes publishing those figures. Administrative staff would then meet with their minions to relay the messages, sometimes disavowing all responsibility for the content, like: "I wish I didn't have to bring this to you, but in Administrative Staff meeting, the Big Boss said . . . ." And so it proceeded down the chain of command. (There are healthcare facilities that have at least four tiers of staff before the caregivers.)
In hospitals where team is the modus vivendi, there is a relatively flat organization table. Meetings tend to be comfortable, informal, and focused. The agenda is published in advance, with input from all involved departments. Every attempt is made to schedule at times convenient for the majority of those involved.
Everyone is expected and encouraged to participate in the business at hand. Questions are asked, and new and different ideas stimulated. When there is disagreement, it is clear that the dispute is about the action, not the people involved. There are no attempts to suppress conflict. There is a well-developed understanding that the goal of these discussions is to explore all possible options and to arrive at consensus, where the ultimate actions are at least acceptable to all involved.
Team-focused facilities understand and utilize the concept of shared leadership. They recognize and value the formal leader, but share leadership responsibilities. Leadership functions move within the group predicated on circumstances, needs, and skills of different members.
In "quasi-team" facilities, the expectations frequently focus on the need for unanimity. Diversity and individualization must succumb to the "institutional mode."
In contrast, facilities that really understand and are team builders realize the strength that is woven in the acquisition and development of a diverse team. I like the analogy of a tapestry. A tapestry made of but one kind of thread is not as strong nor as interesting as one featuring a diversity of colors, textures, and lengths. So it is with groups. In a real team operation, those involved understand and value the differences among them. They celebrate their differences and utilize them to enhance the group and its work.
In "quasi-team" facilities, new members are brought to the "team" without team input. In nursing, for example, the chief nursing officer is usually selected by the chief executive officer and her/his appointment is imposed on the group, usually without its input. In contrast, where team is a way of life, not a four-letter word, selection of formal leaders, as with other major decisions, is a group process.
Several years ago, one of the nursing units for which I was responsible needed a new nursing leader. Having learned of the power of "group genius," I had the staff describe characteristics that they wanted in their leader. A cast of candidates was assembled, and interviewed first by the involved staff, and then by her peers in my leadership group. A candidate who appeared to possess all necessary skills and qualifications was chosen.
It was not long after assumption of her responsibilities that we collectively realized that while she interviewed well, the follow-through was unacceptable. The staff met with me, and described the reasons for their dissatisfaction. The good news was that they also accepted shared responsibility for her appointment. Since she was still in her probationary period, her termination proceeded without incident. We repeated the process with a new candidate and achieved the goal of selecting an appropriate leader for the unit. Throughout the several months occasioned by our process, the staff remained intact, and morale, though briefly shaken, was quickly restored.
That demonstrates another facet of teamwork - the process of self-evaluation. Episodically, the team needs to do an in-depth assessment of its level of function. With all the rapid changes occurring in healthcare delivery systems, it is not surprising to find that processes that worked well in the past may cease to do so. If the team is intact and the members secure in their roles and responsibilities, restructuring can be accepted as a way of life. There is no need to find someone or something to blame, and the group energies can focus on process improvement.
Do these team-focused places really exist? Of course they do. Finding one may require a bit of effort. If you are seeking to contribute your talents to such a place, talk not to the recruiter, but to the staff. If, on the other hand, you are an administrator seeking to convert your dysfunctional group into one with focus, energy, and commitment, go forth and find some real leaders. Be prepared to not just accept, but to promote the tenets of team. It will not be easy, especially if your facility is an obstipated bureaucracy of long duration. Be prepared for the critics, the doubters, those who say it can't be done. Acquire a team focused on the goal. Find the needed resources to get the job done. And be prepared, at end of day, to celebrate the victory.