Bedside Manners: Play and Workbook 9780801469220

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Praise for

Bedside Manners “I am not an actor, and I had never been in a play. That all changed when I was assigned the role of ‘Nurse 2.’ I was asked to read the script and prepare for rehearsal. After coaching and advice like ‘Scoop the words off the page and send them into the audience,’ I went home and practiced my lines. I did not realize the significance of this play until we were on stage in front of our audience. It all clicked. We did not embarrass our characters or the authors. It was not only fun but I learned a lot.” —Frank A. Rosinia, MD, Chairman, Department of Anesthesiology, Tulane University “Bedside Manners—the ‘s’ is important because this play within a book is about the relationships and interactions among health professionals. . . . The workbook section is full of suggestions and practical tips for enhancing learning. This is a great addition to the library of interprofessional resources and a thought-provoking read for all health professionals and learners.” —Jill E. Thistlethwaite, Professor of Medical Education, Director of the Centre for Medical Education Research and Scholarship, The University of Queensland School of Medicine, Australia “When the Colorado Hospital Association presented Bedside Manners at its annual CEO Forum, the play did just what it claimed it would do—advance the conversations about teamwork and communication in our hospitals by showing real-life examples of what takes place in virtually any hospital. . . . Using theater to explore these critical issues is an exciting way to promote interprofessional teamwork and communication. Every caregiver and hospital leader needs to see Bedside Manners. It is a performance no one will ever forget!” —Steven Summer, President and Chief Executive Officer, Colorado Hospital Association

“Play acting is such a great way to engage otherwise reticent people in the process of recognizing, discussing, and effecting behavior change. It is a lot easier to do this if you are pretending to be someone else. The beauty of this approach is that the necessary messaging is actually planted in the heart and mind of the actor in a powerful and effective way, all while they think that they are someone else. Brilliant!” —Terry R. Rogers, MD, CEO, The Foundation for Health Care Quality “Students in our Leadership Development for Health course performed Bedside Manners and it was a hit! Interprofessional teamwork is a concept that is taught throughout our program, but providing an avenue for experiential learning and dedicating time for discussion about the importance of communication between all team members cemented these lessons. By also focusing on the patient’s perspective, the play sheds light on the fact that communication needs to improve for the safety of our patients. The message was powerful and deeply affected the students and faculty who attended.” —Lisa Fidyk, MSN, MS, RN, Associate Program Director, Nursing Healthcare, Administration and Health Leadership Graduate Programs, University of Pennsylvania School of Nursing “In an era when teamwork is the mantra of patient safety, Bedside Manners can help jump-start a long-needed conversation about how doctors and nurses can collaborate rather than compete at the bedside. As a teaching tool, the play creates an opportunity for honest and informative dialogue with students across the health care disciplines.” —Kate McPhaul, PhD, MPH, RN, Assistant Professor, Work and Health Research Center, University of Maryland School of Nursing “Bedside Manners makes a significant contribution by synthesizing a body of literature and presenting it in a play rather than an essay or lecture. It may not be a primary text on patient safety or teamwork, but it is certainly a valuable supplement that can be used for teaching not only medical and nursing students but also practitioners well into their careers, as it provides experiential as well as intellectual knowledge.” —Robert L. Wears, MD, MS, PhD, University of Florida, Imperial College London

BEDSIDE MANNERS

A VOLUME IN THE SERIES

The Culture and Politics of Health Care Work Edited by Suzanne Gordon and Sioban Nelson For a list of books in the series, visit our website at www.cornellpress.cornell.edu.

BEDSIDE MANNERS Play and Workbook SUZANNE GORDON, LISA HAYES, and SCOTT REEVES Foreword by Lucian L. Leape, MD

ILR PRESS An imprint of Cornell University Press Ithaca and London

Copyright © 2013 Lisa Hayes, Suzanne Gordon, Scott Reeves Foreword copyright © 2013 Cornell University Scene 12 of the play was adapted from Stewart Massad’s “Watchers,” Journal of the American Medical Association (March 22, 1995), copyright ©1995 American Medical Association, and appears with permission. All rights reserved. Except for brief quotations in a review, this book, or parts thereof, must not be reproduced in any form without permission in writing from the publisher. For information, address Cornell University Press, Sage House, 512 East State Street, Ithaca, New York 14850. First published 2013 by Cornell University Press First printing, Cornell Paperbacks, 2013 Printed in the United States of America Library of Congress Cataloging-in-Publication Data Gordon, Suzanne, 1945– author. Bedside manners : play and workbook / Suzanne Gordon, Lisa Hayes, and Scott Reeves ; foreword by Lucian L. Leape, MD. pages cm. — (The culture and politics of health care work) Includes bibliographical references and index. ISBN 978-0-8014-7892-5 (pbk. : alk. paper) 1. Communication in medicine. 2. Health care teams. 3. Medical personnel—Training of. 4. Drama in education. I. Hayes, Lisa, author. II. Reeves, Scott, 1967– author. III. Title. R118.G67 2013 610—dc23 2013029180 Cornell University Press strives to use environmentally responsible suppliers and materials to the fullest extent possible in the publishing of its books. Such materials include vegetable-based, low-VOC inks and acid-free papers that are recycled, totally chlorine-free, or partly composed of nonwood fibers. For further information, visit our website at www.cornellpress.cornell.edu. Paperback printing 10 9 8 7 6 5 4 3 2 1 CAUTION: Professionals and amateurs are hereby notified that performance of Bedside Manners is subject to payment of a licensing fee. It is fully protected under the copyright laws of the United States of America, and of all countries covered by the International Copyright Union (including the Dominion of Canada and the rest of the British Commonwealth), and all countries covered by the Pan-American Copyright Convention, the Universal Copyright Convention, the Berne Convention, and of all countries with which the United States has reciprocal copyright relations. All rights, including professional/ amateur stage rights, motion picture, recitation, lecturing, public reading, radio broadcasting, television, video or sound recording, all other forms of mechanical or electronic reproduction, such as CD-ROM, DVD, information storage and retrieval systems and photocopying, and the rights of translation into foreign languages, are strictly reserved. Particular emphasis is placed upon the matter of readings, permission for which must be secured from the Authors in writing. This publication is sold subject to the condition that it shall not, by way of trade or otherwise, be lent, resold, rented out or otherwise circulated without the Authors’ prior consent in any form of binding or other cover other than that in which it is published. For information about licensing the play please contact Suzanne Gordon at [email protected] or www.bedsidemannerstheplay.com.

Contents

Foreword, by Lucian L. Leape, MD vii Acknowledgments ix Introduction, by Suzanne Gordon 1

PART 1 BEDSIDE MANNERS: THE PLAY by Suzanne Gordon and Lisa Hayes Cast of Characters 9 List of Scenes with Characters 11 About the Staging 13 Introducing the Performance 13 The Play 15

PART 2 BEDSIDE MANNERS: THE WORKBOOK by Suzanne Gordon and Scott Reeves Introduction to the Workbook 43 Producing the Play 44 Actor’s and Director’s Tool Kit 58 Production Checklist 61 The Play as Interprofessional Curriculum 62 Role-Play Activities 90 Notes 95 About the Authors 97

v

Foreword Lucian L. Leape, MD

To an outside observer it seems a curious paradox that those who work in health care, the most caring of professions, so often seem to care so little for one another. That’s not fair, of course. Most of us doctors and nurses get along well most of the time. Truly disruptive behavior is relatively rare. But lesser frictions abound and are major detractors from finding joy and meaning in work. High burnout rates among doctors, nurses, and even medical students reflect not only heavy workloads and long hours but also unhappy and stressful interpersonal relationships. Some studies indicate that disrespectful treatment by physicians is the major reason nurses quit. We “bake it in” in our educational system. Medical students have long complained of “education by humiliation,” the hazing rite of passage they must go through in the process of learning to be physicians—behaviors they may adopt as normative. Too often, following their role models, they learn to feel entitled to receive respect but not to give it. Despite the accumulating evidence that only by working in teams can we succeed in providing effective and safe care in our complex health care system, we still don’t teach interprofessional teamwork in most medical, nursing, pharmacy, or other health professional schools. It is not surprising that, without either training or modeling, few people do it very well. But it’s not just the lack of teamwork that is at fault. Many of our interactions are one-on-one, and of these, the exchanges between doctors and nurses have long been problematic, problematic in that too many physicians still think of nurses as assistants or subordinates who exist to do their bidding. This attitude persists despite modern nurses’ high level of education and training and the daily demonstration of their sophisticated clinical knowledge and skills, as well as traditional bedside caring. The problem is not lack of appreciation of knowledge and skills but of attitude, an attitude that impacts not only nurses but also many others who work in health care. vii

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FOREWORD

And attitude is what Bedside Manners is all about. Through multiple vignettes, all of which resonate with physicians, nurses, and others in health care, people can see how they are behaving and how it affects others. Having hospital personnel put on the play themselves makes it even more powerful; employing role reversals, where doctors play nurses and vice versa, makes it more powerful still. As the ancient Chinese proverb counsels, to understand where someone is coming from, you must walk in his shoes. Bedside Manners gives everyone a chance to take that walk.

Acknowledgments

This play and workbook are about teamwork and communication, which are, of course, at the heart of any theatrical performance. We would, therefore, like to recognize the team that has produced this book. We acknowledge, primarily, the considerable effort that went into our work with one another. First came an idea, then a dual collaboration, and finally, a triad. We also acknowledge Fran Benson, editor of the ILR Press at Cornell University Press, for taking the leap to transform this project from a play delivered by the Internet or individually printed copy to a published book. Ditto to everyone else at Cornell for believing in this project—Mahinder Kingra, Jonathan Hall, Nathan Gemingnani, Ange Romeo-Hall, and last but definitely not least John Ackerman and Peter Potter. We also thank Kitty Liu for all her patience and assistance. We thank as well Emily Lowry, Salman Keshavjee, and Charles Bardes for sharing some of their stories with us. Suzanne thanks the pilot John Griffiths for his conversation about CRM and of course, Patrick Mendenhall and Bonnie O’Connor. Thanks also to Bonnie for her initial help on the construction of the workbook. Thanks as well go to Michael Gardem for his advice about Liberating Structures techniques. The actors John Keller and Jennifer Ring provided invaluable help in constructing guidelines for actors and the production checklist. They have also helped to make many productions of the play an enormous success and have recruited other actors—Gregory Perri, Rowan Meyer, Ashley Everage—who have worked with us producing the play in various settings. We also thank Judy Fleishman and the Institute for Healthcare Improvement for supporting our work. We are grateful to the many physicians and nurses who shared their stories with us in various other settings. We thank Stewart Massad for the amazing story that is told by the character of Dr. David Brown at the end of the play. Finally, we would all like to acknowledge our spouses and families for all the support they have given us. ix

BEDSIDE MANNERS

Introduction Suzanne Gordon

The play Bedside Manners began with a conversation on an airplane. Almost ten years ago, I was flying to Seattle to give a lecture and began what I thought would be a casual chat with my seatmate. The young woman sitting next to me was a pediatric resident at Boston Children’s Hospital. Along with dozens of other pediatricians on the plane, she was traveling to a national meeting in Seattle. When I told her that I wrote about nursing and health care, we launched into what became a cross-country discussion about team relationships. She was in her second year of residency and confided that she knew nothing about what nurses did. Her medical school instruction, she told me, included next to nothing about nursing—apart from the fact that doctors “gave orders” to nurses. It certainly had no lessons about teamwork. She had little knowledge about nurses’ work or contributions and had absolutely no idea about the nursing hierarchy or nursing education. What was the difference between an LPN, RN, NP, and a host of other alphabet-soup titles, she wondered? How many shifts or hours did nurses work? When was shift change? Who was in charge of nurses? These were all mysteries to her. She explained that in her residency program some attendings advised her to make a point of talking to nurses because they had valuable information to share. These doctors made a habit of talking to nurses before and after seeing a patient or patient’s family and debriefed with nurses after their visits. Others did the precise opposite—limiting their contact to the brusque barking of orders and disappearing from the scene. In the “see one, do one, teach one” structure of the medical apprenticeship, it was pure serendipity which model of interprofessional relationship a student observed. She added that there was no mention of interprofessional teamwork in any part of her training. To doctors, the “team” constituted only other physicians or physicians-in-training. Ditto for the word “colleague.” 1

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I explained my view of nursing and interprofessional teamwork and the importance of both. She seemed eager to learn more. I asked her if she thought residents would be interested in learning more about nursing and other members of the health care team, “Yes, absolutely,” she replied. How could such lessons be conveyed, I wondered out loud. “Well,” she said, “the thing that had the most impact on us in medical school and our initial year of residency training was when real people would come and talk to us about real dilemmas. For example, it has been very valuable to hear parents come and talk to us about what it’s like to get bad news about a child’s illness.” How would doctors react to nurses talking about the sometimes parlous state of doctor-nurse relationships or even what it means to nurses when doctors and nurses work well together? I considered. What would it mean to have other members of the health care team talk about their problems and concerns in an interprofessional group? Would nurses or other “lower status” team members be fearful of talking about their concerns because they might be accused of “doctor-bashing?” Nurses who are perfectly comfortable complaining about doctors’ bad behavior would hardly be happy about discussing their sometimes passive-aggressive treatment of their physician colleagues. And would nurses be willing to reflect on how they treat colleagues under them—such as LPNs and aides? Although I didn’t see much potential in such real-life conversations, the resident’s comments percolated in my head. How can we best convey real-life situations and consequences to a health care audience on a topic that is both critical and controversial? As I pondered this question, the solution occurred to me—use theater. Write a play about health care relationships, communication, and teamwork. Once that question was answered, the next and more challenging one emerged. How do you write a play? I’m a journalist. I know how to write magazine articles, books, opinion pieces for newspapers, radio commentaries. But a play? Me? I love theater and have been going to serious plays since I was a child in New York City. My place, however, has always been as a member of the audience and not as someone who produced the words enacted on stage. This “how to” question seemed an insurmountable dilemma until several months later, when I went to an off-Broadway production in New York by the

INTRODUCTION

3

playwright and actor Lisa Hayes. Hayes was acting in her one-woman show “Nurse,” about a nurses’ strike in Buffalo, New York. I was surprised to see that she’d used some lines from one of my books in the play. Emboldened by this, I approached her after the performance, congratulated her, and then blurted out,” “Listen, do you think you might be interested in writing a play with me about doctor-nurse-team relationships? I know we just met, so feel free to say no. But might you consider it?” To my surprise, she instantly replied, “I’d love to.” “Great,” I said. “Let’s talk on the phone soon.” I left the theater both delighted and convinced that this might one day happen. Then, about a month later, just as I was about to leave for a monthlong trip to Australia, Lisa called to tell me she’d gotten a grant from the State University of New York at Buffalo. We were commissioned to write and produce our play on doctor-nurse relationships for Gender Week. We had a month and a half to write the script, get the actors, and perform the play. I was stunned. A month and a half? And I would be away for most of it. I sent Lisa all my taped interviews with physicians and nurses. She added her own research to the play and we actually finished it in time to perform it in September 2005. Although the play was well received, that was only the beginning of the really hard work. Our job over the next several years was to write a play that addressed what we know is a very serious issue—poor communication on the health care team, particularly between its two largest professions—and to do it in a way that did not scapegoat or blame any group of professionals while simultaneously pointing toward some solutions. That took a lot of work. In the final play, which took several more years to write, every scene is a dramatic rendition of a situation that actually happened. Some of the situations happened a decade or more ago. Some more recently. Some of its words are verbatim comments from nurses, doctors, and other health care professionals. In other instances, we have dramatized stories people have told us. The last and perhaps most powerful monologue has been included with the permission of the physician Stewart Massad, who wrote the story from which it was adapted, and by the Journal of the American Medical Association (JAMA), in which the story appeared.

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Our goal in the play was to create a balanced work. In Bedside Manners, the reader will find people who communicate poorly and those who communicate well. Although the play focuses primarily on physicians and nurses and the acute-care hospital setting, we have tried to expand the cast of characters to include others on the health care team and to include other settings. As the safety literature documents, 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 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 health care team relationships have a long history and are shaped not only by economics but also by gender, culture, religion, ethnicity, and many other factors. Although our play is meant to stimulate discussion about health care teamwork and suggest ways that doctors, nurses, and others in health care can develop the skills necessary to create and sustain genuine interprofessional teams, 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 even, dare I say it, fun. Initially, Bedside Manners was performed by professional or amateur actors only. Increasingly, however, doctors, nurses, or other health care personnel or students in health professional schools who are in the institution or conference at which it is produced also act in the play along with several professional actors. We encourage this method of production because the very act of working together to rehearse and perform the play is, in itself, an exercise in teamwork. Our rule in rehearsals, which don’t have to total more than a couple of hours before a performance, is that everyone is on a first-name basis and that everyone—no matter how high up in the health care hierarchy—graciously receives and accepts direction from whomever 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 witness chiefs of services being politely informed that they have to work on how to better deliver their lines. People separated by status hierarchies are flubbing their lines together, improving together, and then putting together a

INTRODUCTION

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performance that is usually very well received and that generates interesting conversations in which they take part. 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. One recent performance, done at a physician meeting in a community hospital system, is a case in point. We rehearsed and performed the play after several physicians involved in the patient safety movement gave a lecture to the group on patient safety and the importance of flattening the health care hierarchy. Several physicians in the group were clearly upset at this idea and made their objections known. Two of those physicians had been asked to be in the play. When I rehearsed with them, one of these physicians–who was playing a nurse—got furious. “I didn’t volunteer for this,” he said. “We have spent the whole morning doctor bashing and now here we are doing more!” he fumed. I took a deep yoga breath and suggested that he might not find the play an exercise in “doctor-bashing” if he stood back and read it through. “You sound really angry,” I added. “The character you are playing is pretty angry too. Perhaps you could channel your anger into your performance,” I suggested. We continued rehearsing, and he did just that. The next morning, his wife and daughter attended the performance along with his colleagues. When the actors took their bows, his colleagues congratulated him, and his family told him how proud they were of his work. He came up to me and exclaimed, “You know, I thought this was bullshit. I didn’t want to do it at all. But it was great fun. If you’re ever performing it again, I’d love to be in it.” It has been amazing to watch the initial distance between cast members dissolve as they work together and feel satisfaction after the performance and postperformance discussion or workshop—particularly if everyone goes out for a celebration afterward. In 2011, Bedside Manners was performed at the Institute for Healthcare Improvement (IHI) Patient Safety Executive Development Program. After performing in the play along with a surgeon in her large health care system, a nurse came up to me and told me how the surgeon’s behavior had changed after two one-hour rehearsals and the actual performance and talk-back. “I’m not sure he even knew my name before the play performance, but he did

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afterward, and when we were talking and I called him Dr.—he said, ‘oh come on and call me by my first name.’ ” Perhaps the most moving comment was made during the postperformance discussion when I asked the actors what it meant to them to be in the play. Dr. Mark Sand, a cardiothoracic surgeon and chief of staff at Florida’s Orlando Health, said movingly, “The play reinforces lessons we seem to have to learn over and over again. When we wound one another the wounds heal very slowly. When we invest in one another the rewards may come back for a lifetime. Someday, sometime, perhaps when we least expect it, we will all be patients. If for no other reason, we must unite with one another, at the bedside.” To accompany the play and make it more user-friendly, Scott Reeves, Lisa Hayes, and I 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. We also explain how to use the play as part of an interprofessional curriculum. Although some in our audiences have scoffed at such a “touchy feely” or unconventional way to present a serious issue, our experience has convinced us that theater is a useful tool to enhance teamwork, patient safety, and also to create more satisfying workplace relationships. Theater has been with humankind since almost the beginning of our history precisely because it is such a powerful tool. It can be used by those in health care who spend their days working with sick, frightened, anxious people, people who are, by definition, not at their best. Under the best of circumstances, their work is beyond difficult. Good communication and teamwork not only produces good patient outcomes; it helps health care professionals care for one another.

PART 1

BEDSIDE MANNERS THE PLAY

Cast of Characters (in order of appearance) Nurses 1, 2 and Doctors 1, 2: Of mixed ages and generations. Each actor plays several different nurses and doctors. Leah Jones: Mid-to-late fifties. Narrator of the story, a wise observer of the health care system as a former nurse now experiencing the “other side of the stethoscope.” Nurse Sally Grant: Early forties. Has been a nurse for twenty years, fifteen years on this medical-surgical (med-surg) unit. Has mastered the skill of communicating her medical assessment so that interns understand potential ramifications of decisions. Dr. Michael Evans: Early thirties. Was an intern on med-surg unit. Has learned to listen to the nurses. Mark King: Early thirties. Pharmacist irritated that nurses seem to think that they are the only ones who care about patients. Dr. Carl Rogers: Mid thirties. Senior resident. Frustrated at not being able to convince a nurse to increase pain medication. Nurse Ann Wilson: In her forties. Inflexible and unafraid to say “no” to doctors’ orders for increased pain medication. Dr. Stephanie Long: Late forties. Recounts her experiences as an intern but is now a patient safety officer. Nurses help her get through first “code.” Good comic timing is important here. Code Nurses 1, 2, 3: Help intern through her first “code.” (These roles can be combined into one if necessary.) Dr. Melony Strong: Mid thirties. Tries to juggle too many patients. Dr. Mark Cole: Mid forties. While on call, teaches new nurse even as he handles her middle-of-the-night phone call. Nurse Miranda Clark: Early twenties. Very new nurse who is timid and nervous about calling a doctor in the middle of the night. 9

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Dr. Jim Smith: Early thirties. He’s a resident in a pediatric ICU, where he had a run-in with a nurse about getting a line in a baby. Nurse Joan Adams: In her thirties. Is worried about the condition of their tiny patient. Dr. Patricia Davis: Late forties. Helps with dehydrated baby. Dr. Martha Davenport: Early-to-mid thirties. Frustrated in dealing with a nurse’s “punishment.” Dr. Robert Grayson: Early fifties. Is an attending at a major teaching hospital who thinks it’s important not to move on too quickly if there is something to be learned. Dr. Abby Jones: Late twenties. Yells at nurse for screwing up blood draw that nurse had done correctly. Nurse Carol Youngson: Early fifties. Chief OR nurse, tries to deal with new pediatric cardiac surgeon whose competence she questions. Dr. Jonah Odim: Early thirties. New pediatric cardiac surgeon whose actions lead to the deaths of twelve babies. Winnipeg Doctors 1, 2: Late forties or early fifties. Dismissive and condescending about nurses’ concerns about Dr. Jonah Odim. Dr. Jane Fitzgerald: Late twenties. ER intern on night shift, frustrated with nurse’s refusal to get X-ray. Dr. Raj Patel: Mid fifties. Chief of perioperative services, understands need to provide support to nurse who stops the line. Office Nurse: Any age. Dr. David Brown: Early fifties. Head of oncology division at teaching university, reflects on nurse who taught him to be a doctor.

List of Scenes with Characters Prologue

Nurses 1, 2 Doctors 1, 2

15

Scene 1

What Happens to Me?

Leah Jones

18

Scene 2

But Will They Need Me Tomorrow?

Nurse Sally Grant Dr. Michael Evans

19

Scene 3

What Just Happened?

Leah Jones Mark King

20

Scene 4

Frustrated Doctor

Dr. Carl Rogers Nurse Ann Wilson

20

Scene 5

Personal Mission

Leah Jones

22

Scene 6

Singing the First-Code Blues

Dr. Stephanie Long Code Nurses 1, 2, 3

22

Scene 7

Being Just a Patient

Leah Jones

24

Scene 8

Mix-up

Dr. Melony Strong

25

Scene 9

What’s in a Name?

Leah Jones

26

Scene 10

Ready for the Call

Dr. Mark Cole Nurse Miranda Clark

26

Scene 11

Lesson of the Dehydrated Baby

Leah Jones Dr. Jim Smith Nurse Joan Adams Dr. Patricia Davis

28

Scene 12

Perils of the Angry Nurse

Dr. Martha Davenport

29

Scene 13

Lessons from the Airlines

Leah Jones

30

Scene 14

Morning Report

Dr. Robert Grayson Dr. Abby Jones

31

Scene 15

Dr. Miller Doesn’t Tell Me Squat

Leah Jones

32

11

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Scene 16

How Many Dead Babies Does It Take?

Nurse Carol Youngson Dr. Jonah Odim Winnipeg Doctors 1, 2

33

Scene 17

A Case for No Hierarchy

Leah Jones

36

Scene 18

To Explain or Not to Explain

Dr. Jane Fitzgerald

36

Scene 19

Stopping the Line

Dr. Raj Patel

37

Scene 20

Last Call

Leah Jones Office Nurse

38

Scene 21

Stay and Watch

Dr. David Brown

39

About the Staging The play is performed reader’s theater style, with actors reading from scripts at music stands facing the audience. The actor playing “Leah” should be at a music stand stage right, slightly apart from the others, because she is the narrator of the story. There are two other music stands—one is stage center and has a sign that says “MD” and the other is stage left with a sign that says “RN or Other Team Member.” When an actor is playing a doctor, he or she moves to the stand that says “MD.” When an actor is playing a nurse or other team member, he or she moves to the stand so labeled.

Introducing the Performance The playwrights suggest that a brief introduction be given before the performance to set the context for both the play and the performance. The person introducing the play might say the following: We welcome you to this performance of the play Bedside Manners. The play is based on actual interviews with doctors, nurses, and others in the health care field. While some scenes are composites of different incidents, everything in the play is based on actual workplace experiences. Some of the things you will see in the play occurred more than a decade ago. Some occurred just several months ago. Many similar encounters are taking place in health care institutions all over the globe while we sit here watching or discussing the play. Although the play focuses primarily on physician-nurse relationships, it includes some encounters between other health care professionals. The encounters between physicians and nurses—whether problematic or promising—are emblematic of the communication and teamwork problems that occur in health care no matter what the professional or occupational category. As you watch the play, we encourage you to make a mental note of any strong reactions to material in the play. We also encourage you to think about

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which scenes offer you a window into the experience and perceptions of others with whom you work or mirror your own experiences or perceptions. Because you are watching a theatrical performance, we will repeat the instructions that you have often heard in other theaters. Please turn off any cell phones, pagers, smartphones, Ipads—or any electronic devices that have been developed in the last several hours. Please unwrap any candies or other food items that you may have brought with you so as not to distract the actors. And now, Bedside Manners.

The Play Prologue (Four actors enter and stand in a line downstage of the three music stands. They speak directly to the audience. Think of the Prologue as a series of musical phrases: “**” indicates the end of one phrase and the beginning of a new one. The “**” may also indicate that the actors become different characters.) Nurse 1: The human body is absolutely incredible. Doctor 1: Being a doctor—it’s all I ever wanted. Nurse 2: Nursing—it’s all I ever wanted to do. All: There’s nothing else like it. ** Doctor 2: My advice? Make nice to the nurse so she won’t torture you to death. A nurse can make your life miserable by waking you up in the middle of the night just when you’ve grabbed your only five minutes of sleep. Or she can protect you, let you get your sleep, depending on how you treat her. Nurse 1: One physician tells you to call him for any vital sign change; another says, “Don’t call me unless such and such happens.” You wake up a doc in the middle of the night and it’s not in the ballpark of what he wants to be woken up about, he can get very testy. Doctor 1: A nurse calls me late one night to ask for Tylenol for a patient with arthritis pain. I order it. Three weeks later the patient dies. Complications of surgery. Nothing to do with the Tylenol, but I get sued, along with everyone else who ever touched the chart or spoke to a nurse about the guy. Every single thing I say or do has repercussions. The buck stops here. Nurse 2: Doctors are always saying, “The buck stops here,” and in a way it does. But some of them use that as an excuse not to listen to anybody else. There was a problem with a surgeon at my hospital, so the nurses 15

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went to the chief of cardiology. He wouldn’t listen. We went to the chief of surgery. He wouldn’t listen. We took it all the way up to the head of the hospital. He wouldn’t listen. The buck stopped with him, and twelve patients died. Shouldn’t it have stopped with the nurses too? Doctor 2: A good RN has your back. While I’m securing the airway, she’s placing code paddles on the chest. She’s right there beside me. . . . Without her I’d be totally out of luck. Nurse 1: I was trying to track down this doctor about a patient. He always came by early in the morning when I was on the other side of the floor giving pain meds. I finally caught him in the hallway. Doctor 1: One day this nurse grabs me outside of a patient’s room. I have three more patients to check in on, I’m late for surgery, and this nurse insists on having a chat. Nurse 1: I explained some problems the patient was having and suggested a change in medication. He asked me what I saw on the sign by the patient’s door. I didn’t know what the heck he was getting at. The patient’s name? The doctor’s name? Doctor 1: I said, “You see those initials after my name—MD? You know what those stand for? Makes decisions.” Nurse 1: I pointed to the initials after my name—RN—and said, “You know what these stand for? Rejects nonsense.” Nurse 2: I brought up this thing of team communication to a nurse manager at my hospital who gave me the old, “Interesting. Oh, I’m late for a meeting.” Then I brought it up to the CEO. He gave me a patronizing smile and turned to go. I stopped him. “Listen, if a doc is abusive, he isn’t just going to lay into nurses. He’ll go after interns, residents, pharmacists, sometimes even patients.” He just shrugged and said, “What can I do? These are the geese that lay the golden eggs.” He doesn’t seem to realize that a lot of people have to sit on the egg if it’s going to hatch. Nurse 1: I’ve been a nurse for twenty years, and I’m damn good at it. I don’t want to be a doctor. I like what I do. I like spending time with patients. I like being a patient advocate.

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Doctor 2: If I hear one more nurse say, “I’m the patient’s advocate”—What does that make me? The patient’s enemy? Some nurses act like I’m an uncaring jerk whom they need to protect their patients from. I’m a patient advocate. I’m compassionate. Now, I know there are some difficult doctors who yell and scream and make life miserable. But they don’t just attack nurses. They go after med students, interns, residents. Sometimes I think that’s just how they learned to express authority. You know—see one, shout at one, teach one. Nurse 2: I’m supposed to work three back-to-back twelve-hour shifts. But if you think I get out after twelve hours, you’re dreaming. In Technicolor. Sometimes they make me work mandatory overtime, which means an extra twelve-hour shift. And I’m taking care of eight patients, maybe even twelve. And then I have to go home and take care of my kids and my husband’s mother. Tired? That doesn’t even begin to describe it. Doctor 1: Fatigue. That’s my life. I work at the clinic all day long seeing twenty to twenty-five patients. Then I’m on call that night. Then back to the clinic the next day and another twenty to twenty-five patients. Not to mention the computer charting. And everyone is bugging me all day long for orders, signatures, diagnoses, prescription refills, and more. I hate to admit it, but a lot of times my response to yet another request is colored by one fact—that I’m totally wiped out. Nurse 2: What’s the worst part of my job? All: STRESS! (The dialogue from here until the end of the Prologue should build in intensity, with the “crescendo” coming on the word “CHOCOLATE.” Actors should speak together when indicated.) Nurse 1: You want to know about stress? Nurse 2: Don’t get me started. Doctor 1: Stress—it’s my life. Nurse 1: People are asking me to set up a pelvic at the same time as they’re asking me to do an EKG. And then quick, go to the next two patients who’ve already been waiting ten minutes, not to mention the doc who’s having a flip out because she needs help removing a mole.

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Nurse 2: You’ve needed to pee for three hours, you haven’t eaten since yesterday, the attending is freaking out because the X-rays she ordered ten minutes ago aren’t in her hands, that witch of a supervisor is complaining that you haven’t learned to use the latest “flavor of the month” computer program— Nurse 1: And you’re getting paged— All: EVERY FIVE MINUTES. Doctor 2: I just got back from maternity leave. Between patients I had no time to pump milk for my baby. I’m hard as a rock. I see twenty-two patients a day. Then comes answering phone calls during my supposed lunch break, and finally when I finish for the day, I get to answer all those patient phone calls that have come in while I’ve been seeing other patients. My husband is having a meltdown, my baby barely knows her mother. I never sleep. Nurse 1: Is it any wonder I need— Nurse 2: Zantac. Doctor 1: Xanax. Doctor 2: Zoloft1 All: CHOCOLATE!

Scene 1 What Happens to Me? (Leah Jones, in her late fifties, was a nurse for most of her adult life. She is now battling cancer. Leah is the narrator of the story, the voice of wisdom and experience.) Leah Jones: Waiting. That’s all I seem to do anymore. Wait for this test, that treatment. It’s not so bad once I finally arrive; it’s just the effort of the journey—apartment to car, car to waiting room. And everywhere I go seems to involve long, long hallways. Several people have suggested that I get a walker or a wheelchair, but I refuse. I feel like as long as I’m walking I’m not really that sick. It’s strange being on the other end of the stethoscope. I’m a nurse, was a nurse. For thirty years. OR, pediatrics, labor and delivery, and finally a midwife. I had to stop working when I got too

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sick. It’s been interesting observing how nurses and doctors talk to me and about me, and how they talk to each other, or how they don’t talk to each other. You know, I’ve seen some great team communication. Some things have really improved since I began my career. But I’ve seen some other things . . . (Shakes her head.) When I was working, if the team had problems with each other, it really made everyone’s job tougher. But now as a patient—if people don’t consult with each other, what happens to me?

Scene 2 But Will They Need Me Tomorrow? Nurse Sally Grant: Doctor, I just checked on Mr. Smith. Dr. Michael Evans: (To audience.) Let me explain. I was an intern, and this nurse had been on the unit for fifteen years. Mr. Smith was what we called a “Triple A.” He’d just had surgery for an abdominal aortic aneurysm. When I saw him in the morning, he appeared to be stable, so I scheduled him to be released later in the day. Nurse Sally Grant: He’s sweaty and pale and the EKG shows he’s in A Fib. I looked at his lab work, and there is an imbalance of electrolytes. I think it’s the stress from the surgery and fluid overload that’s causing the problem. Dr. Michael Evans: Let’s give him Lopressor. Nurse Sally Grant: He has COPD. Lopressor could cause serious breathing problems. Do you want to try Cardizem? That would treat the elevated heart rate without aggravating the lung disease. And what about a diuretic for the fluid overload? Dr. Michael Evans: (To audience.) I followed the nurse’s advice. And when the medications started to work and the patient improved, I said, “Let’s discharge him.” Nurse Sally Grant: Are you sure? Dr. Michael Evans: (To audience.) When a nurse says, “Are you sure,” it usually means she thinks you’re about to do something really stupid, but she feels she can’t really say that, so she just says (with emphasis), “Are you sure?”

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She explained that our patient was still unstable, that as the medication helped his body eliminate excess fluids, he’d continue to be at risk for low blood pressure, shock, or low blood supply to the heart, which could cause a heart attack. And very subtly, she pointed out . . . Nurse Sally Grant: If any of this happens at home, the patient could die. Dr. Michael Evans: Let’s keep him here ’til we’re sure he’s stable. (To audience.) Hey, I’m not stupid. So I had the patient remain in the hospital. When the cardiologist came by to check on the patient, he said “Good call.” “Thank you, sir,” I said, “The nurse . . . ” “Keep me posted,” he said. Before I went off duty that day, I found the nurse and thanked her. Nurse Sally Grant: Why is it you doctors thank us when you’re interns and residents and think you need our help and then are too busy to talk to us about patients when you’re attendings? Dr. Michael Evans: (To audience.) What could I say? It was a fair question.

Scene 3 What Just Happened? Leah Jones: A few weeks ago I was in the hospital, recovering from yet another surgery. I don’t know what was going on with the patient in the bed next to mine, but I heard the nurse say, “I’m just trying to look out for the patient.” And this pharmacist just laid into her. Mark King: What do you think I’m doing—trying to kill the patient? You nurses take the cake—you act like you have the corner on caring about patients. Let me clue you in on something. Just because we’re not RNs and only rarely see the patient doesn’t mean we care any less about the patient than you do. Leah Jones: The pharmacist walked off one way, mumbling under his breath, the nurse the other way. The patient looked over at me and said, “What just happened?”

Scene 4 Frustrated Doctor (In this scene, the doctor’s lines are directed at the audience, and the nurse’s lines are directed at the doctor.)

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Dr. Carl Rogers: I’m a senior resident. I have a patient in sickle cell pain crisis. He’s been getting tons of Dilaudid, but it’s not working. He is crazy with pain. So I told the nurse to give him more Dilaudid. She said, Nurse Ann Wilson: I don’t feel comfortable with that. Dr. Carl Rogers: I told her I had just examined the patient and assured her that he really needed more medication. She said, Nurse Ann Wilson: I’m worried he’ll be opiate overdosed. Dr. Carl Rogers: I explained to her that traditionally what happens is that if someone is having a lot of pain, they can handle tons of opiates. It’s only if you take opiates when you’re not having pain that you become overdosed. And she said, Nurse Ann Wilson: (Digging in her heels.) I don’t feel comfortable giving him more. Dr. Carl Rogers: I told her I would be right there. That we could have an antidote at the bedside if she wanted, in case something happened. She said, Nurse Ann Wilson: (More insistently.) No. It’s just too much. Dr. Carl Rogers: So I suggested I call the attending to ask his opinion. She said, Nurse Ann Wilson: (With attitude.) Go ahead. Dr. Carl Rogers: So I called the attending, explained the situation, and he said we should definitely give the opiate. I told the nurse, and she said, Nurse Ann Wilson: (Adamantly.) No. Dr. Carl Rogers: (Increasingly frustrated.) So I told her to give me the medicine, and I would inject it myself. She said, Nurse Ann Wilson: No. Dr. Carl Rogers: Finally, I just called admitting and said, “Can you move this patient to a floor where the nurses will give him the pain relief he needs?” We were about to move him when the man became psychotic—literally— which can happen when you’re in so much pain. We had to take him to the ICU. Now I’m not saying that if we’d given him the opiate this would have been averted. There’s no way to tell. But letting people stay in this much pain can lead to a psychotic break. The nurse stood in the way of giving this man the pain relief he needed. Was it something I said or didn’t say?

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Is there some secret code I should have used? And what do I do about it now? Write up an incident report? It’s so frustrating.

Scene 5 Personal Mission Leah Jones: When I was working in a teaching hospital, my fellow nurses used to moan and groan at the arrival of each new set of baby docs. Some of them would really give them a hard time—you know, to show them who’s boss. Not me. I always felt that working with these doctors-in-training was one aspect of my job where I felt I really made a difference. So much of what doctors learn they learn at the bedside. I always made it my personal mission to help them understand what nurses do and to show them how to care for patients, not just treat them. More than once I would shame some young doc into staying in the room to watch a woman go through labor, instead of disappearing and coming back when it was time for delivery. And now? My life is all about finding a doctor who can help me.

Scene 6 Singing the First-Code Blues (Think of this scene as a Saturday Night Live sketch—go for the comedy. The three 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?

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Dr. Stephanie Long: I nodded again. Another nurse began to draw some blood and after a few seconds asked, Code Nurse 3: 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 3: 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

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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.

Scene 7 Being Just a Patient Leah Jones: The day I was diagnosed—it’s weird. Just because you’re a nurse, people think you’re somehow prepared. To be honest, deep down I probably thought that too. But when the doctor says, “You have cancer,” you’re not hearing it as a nurse. You’re just a terrified person, thinking about the will you’ve never made, and the daughter who’s getting married next year, and this can’t really be happening, and I’m going to wake up in a minute. I guess being a nurse has been an advantage. I know how to explain my need for more pain medication. But on the other hand, you’re lying in bed feeling awful, scared of dying, hooked up to all these tubes, and that nurse part of your brain is worried that the change of orders you heard an hour ago didn’t make it onto the chart. And you’re wondering if things go wrong tonight will your nurse call the doctor right away or will she wait because he gets nasty when she calls him. And you need to use the bedpan, but you can tell your nurse is having a very bad day, so you try to hold it ’til it looks like things have slowed down a bit.

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And then something happens, and you find you’ve wet the bed and now just added to everyone’s work, and you wish for the blissful ignorance of being just a patient.

Scene 8 Mix-up Dr. Melony Strong: I work in an outpatient clinic. As a primary care doctor. I’m part of a dying breed. People I knew in medical school said I was crazy to become a PCP. Ophthalmology they suggested. Interventional cardiology. Radiology. But no, not me. I love what I do. But there are some days when I wonder whether I made the right choice. Take today. My patient was scheduled for 9 am. But he was a no-show. So I did some paperwork and then saw my 9:20 patient. Since there was no one scheduled for 9:40 I took my time. At 9:56, the front desk paged me and told me my 9 am, the no show—finally showed. They told me they could put him in the 9:40 slot. It’s now 10:04 and the patient is not yet in a room and I have a 10 o’clock patient scheduled. I had to explain to the front desk receptionist that I had no time to see the 9 am. They were not happy about this. They insisted that I had time to see him because—and I quote—he was only 16 minutes late for the 9:40 slot. But he wasn’t my 9:40 patient, I told them. He was my 9 am patient. And I am seeing another patient in just two minutes. “But you didn’t have a 9:40 patient,” they said. “So what’s the big deal with seeing him?” By this time it’s getting to be like who’s on first. So the receptionist sends the patient to the nurse because the patient has severe leg pain. Of course, when she examines him the nurse feels the patient has to be seen. By me or another doctor. But there are just no slots. So the nurse has to beg a resident to see the patient. The patient gets seen, and the resident calls another attending. By now, we have a multicar crash. The receptionist is mad at me because I wouldn’t see the patient. The nurse is mad at me because she had no time, but she had to see the patient. The resident is frustrated at the nurse

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because he had to see the patient, and he’s also angry at me. Which he lets me know—sort of. What I’d really like to do is strangle my 9 am patient. Or was he the 9:40?

Scene 9 What’s in a Name? Leah Jones: When you spend a lot of time in a hospital bed, all kinds of things take on a completely different significance than they had before, when you were a nurse and not a patient. Like names. My name. Your name. It really bothers me that most of the hospital personnel coming in and out of my room don’t think of me as a person with a name but as an affliction. I’m not Leah Jones, but “Ovarian Cancer in 10C.” My last stay in the hospital I was in isolation, so everyone who came in had on a gown, covering up any name tag. My sister was in the room, as was a nurse. These two young people saunter in, gowns on, name badges hidden, and blithely announce, “We’re hematology.” I laughed and said, “Well, hi hematology. That’s nursing, this is family member, and I’m illness. Great to meet you!”

Scene 10 Ready for the Call (In this scene, it is important that the doctor speak very patiently and genuinely to the nurse and that both convey that they have had a positive experience as they hang up their respective phones. Both actors should use cell phones when performing this scene.) Dr. Mark Cole: I’m on call. I’ve been seeing patients since six in the morning. It’s 11 p.m., and my pager goes off. Again. I call the number. (Takes out cell phone and dials.) I wait. Nurse Miranda Clark: (Answers phone.) Four South. Dr. Mark Cole: Who paged Dr. Cole? Nurse Miranda Clark: (Nervously.) Oh, Dr. Cole, that was me. I’m calling from Four South. It’s about Dr. Johnson’s patient Mr. Bartholomew. His INR is 1.6.

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Dr. Mark Cole: (To audience.) That’s all she says. INR is the clotting parameter we use when following the blood thinner Coumadin. So I ask, (into the phone) What’s the dose of Coumadin he’s been taking? Nurse Miranda Clark: Oh, I don’t know. Wait a minute. (Turns her back to audience.) Dr. Mark Cole: I wait and wait. She finally comes back. Nurse Miranda Clark: (Turns to face audience.) 2.5 milligrams. Dr. Mark Cole: How long has the patient been on that dose? Nurse Miranda Clark: I don’t know. Wait a minute. (Turns her back to audience.) Dr. Mark Cole: I wait. Nurse Miranda Clark: (Turns to face audience.) One day. Dr. Mark Cole: What was he on before? Nurse Miranda Clark: Oh, I don’t know. Wait a minute. (Starts to turn again.) Dr. Mark Cole: No, no, you wait a minute. Four South. What’s your name? Nurse Miranda Clark: (Tentatively.) Miranda. Dr. Mark Cole: Miranda? Nurse Miranda Clark: Miranda Clark. Dr. Mark Cole: (Reassuring.) Miranda Clark. That’s a much clearer name than Four South. How long have you been working on the unit, Miranda Clark? Nurse Miranda Clark: Two days. I just got out of school. Dr. Mark Cole: Great! We’re so glad to have you. We need more nurses. Can I give you some helpful advice? Nurse Miranda Clark: OK. Dr. Mark Cole: The next time you have to call a doctor in the middle of the night, or really any time, introduce yourself with your full name, and be ready with all the information the doctor might need about treatment for this patient. Have you heard of SBAR? You know, Situation, Background, Assessment, Recommendation. Did they teach you that in nursing school? Nurse Miranda Clark: Oh God, I was so nervous, I forgot all about it.

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Dr. Mark Cole: Using SBAR makes it easier for you and for the doctor. So back to my question, Miranda Clark. What was he on before? Nurse Miranda Clark: Wait a . . . How about I find out and call you back with the information? Dr. Mark Cole: That’s a great idea. Thanks, Miranda Clark. Nurse Miranda Clark: Thanks, Dr. Cole. Talk to you soon.

Scene 11 Lesson of the Dehydrated Baby Leah Jones: I used to work nights. I liked it, except when I had to call some difficult doctor. If it’s 3 a.m. and there’s a problem with a patient, nurses have a very limited repertoire of what they’re allowed to do. You can’t order a chest X-ray or a urine culture. You can’t order labs on your own. You can’t get antibiotics. You can’t even get an aspirin. You have to call a doctor. The whole system is dysfunctional. And the stress is incredible. When I first went to work in a teaching hospital, the interns and residents were the ones who were overworked and exhausted. The nurses and attendings were the safety net. Now everybody is overworked. Everyone is tired and on edge. I was standing in line at the bank last week behind a young man in scrubs and a hospital ID badge. Turns out he’s a resident in the pediatric ICU where I worked for a while. When I told him that, he gave me a tight, polite smile, and I knew he must have had a run-in with someone, probably a nurse. Sure enough, they apparently had a baby come in who was seriously dehydrated. It was the middle of the night. Dr. Jim Smith: (To Leah.) We tried getting a line in, but nobody could access the vein. Nurse Joan Adams: Maybe we should let the baby rest and try getting the line in later. Dr. Jim Smith: I almost have it. Nurse Joan Adams: The baby’s exhausted. He’s practically turning blue from all the crying. Can’t we just let the baby rest for a little while?

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Dr. Jim Smith: Okay, I’ll get a cup of coffee and come back in half an hour. (He walks out of room and runs into Dr. Patricia Davis.) On your way home? Dr. Patricia Davis: This day seems like it’s been going on for a week. Dr. Jim Smith: Tell me about it. And this last thing—a dehydrated baby, and for the life of me, I couldn’t get a line in. I finally decided it would be better to let the baby rest and try again later. I hate to ask you this. Would you mind trying? I’ve heard how great you are at getting lines in. Dr. Patricia Davis: Sure. I’ll do it. Dr. Jim Smith: Thanks. I hate to bother you when you’re on your way home, but it would be great. Dr. Patricia Davis: No problem. (Walks into room and speaks to nurse very brusquely.) Get me a 24 gauge IV. Nurse Joan Adams: What? Dr. Patricia Davis: (Her tone is even more irritated.) Get me a 24 gauge IV. Nurse Joan Adams: What do you mean, an IV? (Turns to Dr. Jim Smith.) What’s going on? We agreed to let the baby rest. Are you trying to kill this baby? Dr. Patricia Davis: You don’t want my help? Fine. I’m out of here. (Storms out.) Dr. Jim Smith: (Starts after Dr. Patricia Davis.) Hey, I’m sorry. (Turns to Nurse Joan Adams.) What is your problem? Do you have any idea? (Shakes head, runs after Dr. Patricia Davis.) Look, I’m sorry. (Pause again, turns to Leah.) You know who got criticized? The attending. The chief of the pediatric residency program said she acted in an unprofessional manner when she left the patient. He took the nurse’s side, not ours. (He sits.) Leah Jones: (To audience.) My questions is, why do our conversations have to degenerate into whose side you’re on? Shouldn’t we all be on the patient’s side?

Scene 12 Perils of the Angry Nurse Dr. Martha Davenport: You don’t know the meaning of torture until you get a nurse pissed off at you. I was short with a nurse one day in front of a

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patient. I’d had a bad day. I admit it. But instead of talking to me about it, she charges off to write up an incident report. Last week I told this same nurse not to give a patient an opiate. She turns around and does it anyway. Then comes to me to sign the order afterward. I was furious. But I bit my tongue and calmly explained why that patient should not be given an opiate, and I said I would sign the order this once but not to do it again. She does it again. Same patient. Same opiate. Same “Doctor will you sign the order?” I said, “No, no way.” Suddenly I had her attention. If I don’t sign, then that means there’s an opiate missing from the locked drug cabinet, which is an invitation for an investigation by the DEA. She cried. But I refused. And then the punishment started. The pages every fifteen minutes. The calls at 4 a.m., “Mr. Smith’s magnesium is 1.9. It’s down from 2.0.” At 4:15. “I have an order to give Mrs. Clark Tylenol if her temp is over 101. It’s exactly 101. What do I do? 4:27, Doctor . . . ” The other nurses can’t believe what this woman keeps pulling. It’s frustrating for me—this is the first time I haven’t gotten along with a nurse. My mother was a nurse, my sister is a nurse—they trained me well. But they didn’t train me for how to deal with this. (Her pager goes off. She looks at it, then looks at audience.) Guess who?

Scene 13 Lessons from the Airlines Leah Jones: My daughter’s husband, Steve, is a pilot. Steve told me that pilots go through this special training called “crew resource management” to improve safety by improving communication and teamwork. Apparently a lot of crashes were happening because someone like a flight attendant or a copilot was too intimidated to tell something to the captain, like you know, if we turn left we’re going to fly into a mountain. The whole idea is that leadership means utilizing all your available resources—which means people not just technology. He said they keep this blue card in their flight kit along with the maps and charts. This card has a list of recommendations for effective communication, including things like, “Stop talking and listen. Abandon your idea if the other one is better. Be assertive if required. Get input and recommendations.” It suggests asking questions, like “What would you feel comfortable with?”

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Steve said he was flying a cargo plane from Dubai to Paris once, and his copilot was worried that they didn’t have enough fuel on board. Steve thought they had plenty and knew that if they stopped to refuel, it would cost an extra $10,000 and an hour delay. But instead of saying, “Hey, I’m the captain, suck it up kid,” he talked through the options with the copilot and asked “What would you be comfortable with?” They agreed to keep close track of the fuel, and if it looked like they needed more, they would stop to refuel. That was fine with the copilot—he got to be part of the decision-making process. I keep wondering why we’re not doing this kind of training in health care. I can tell you, from the vantage point of a patient, I’d feel a lot better if I could be confident that the resident would speak up to the attending if she thought something was wrong. And that the nurse would be persistent if he thought there was something wrong with my medication.

Scene 14 Morning Report Dr. Robert Grayson: (To audience.) I’m an attending at a major teaching hospital. I was at morning report with several residents, discussing cases with the chief of medicine. The first case up was that of a patient whose sodium level was low. 110 instead of 140. This kind of hyponatremia can cause a seizure or arryhthmia. The resident explained, Dr. Abby Jones: (To Dr. Robert Grayson.) I was sure it had to be a mistake. How could it be so low? The nurse must have drawn the blood too close to the IV site. So, of course, I yelled at the nurse. I told her she shouldn’t have drawn the blood so near the IV site, and then I drew a second blood test myself. Dr. Robert Grayson: (To audience.) And you know what the resident discovered? The sodium level was 110. Now, we could have just moved on and discussed the differential diagnosis and why the sodium level might be so low. But there was something else going on here, and I thought it was important to address it. One of the problems in medicine is that we’re always in such a hurry to find the answer and move on to the next patient that we let things slide that we shouldn’t. When I questioned this resident further, you know what I found out?

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Dr. Abby Jones: (To Dr. Robert Grayson.) I guess I was scared. I never had a patient with sodium levels that low, so I figured the nurse screwed up, and I yelled at her. I didn’t know whom else to yell at. Dr. Robert Grayson: As we talked through the chain of events, she realized that there were other places where a mistake could have been made—the equipment could have been faulty; the lab tech could have mislabeled the blood sample tube; the patient could have been in trouble, as she was. If she’d taken the time at the beginning to talk to the nurse instead of lashing out, she would have known that the nurse had done the blood draw correctly. (To Dr. Abby Jones.) Had she apologized to the nurse? No. (Dr. Abby Jones shakes her head no.) Should she? Yes. (Dr. Abby Jones nods affirmatively.) That’s another thing I believe. We need to use the words “I’m sorry” a lot more often than we do. And “thank you.” Never underestimate the power of good manners. At the bedside or anywhere else.

Scene 15 Dr. Miller Doesn’t Tell Me Squat Leah Jones: Since I got sick, I’ve been impressed with the time and care my doctors have taken in talking with me, explaining things. There’s been a big push in recent years to improve doctor-patient communication, and it’s helped. You don’t hear as many of those jokes, like the one where a grandmother telephones the hospital and asks, “Is it possible to speak to someone who can tell me how a patient is doing?” The operator says “I’ll be glad to help, dear. What’s the name and room number?” The grandmother says, “Holly Finkel in Room 302.” The operator replies, “Let me check. Oh, good news. Her records say that Holly is doing very well. Her blood pressure is fine; her blood work just came back as normal and her physician, Dr. Miller, has scheduled her to be discharged on Tuesday. The grandmother says, “Thank you. That’s wonderful! I was so worried! God bless you for the good news.” The operator replies, “You’re more than welcome. Is Holly your daughter?” The grandmother says, “No, I’m Holly Finkel in 302. Dr. Miller doesn’t tell me squat!”

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Doctors are doing a better job of talking with patients, but everybody’s communication skills still need improving. When I was in the hospital for a biopsy, I shared a room with a woman about my age. Her doctor came in and gave her some very bad news. She started to cry. He finished explaining what he needed to explain then turned around and walked out, right past the nurse who was coming in. He didn’t say anything to the nurse— not what he’d just told the patient, not what it meant, not even hello. The nurse had to learn from the patient what the doctor had said, then track down the chart to figure out what it meant. I asked her, “What’s his problem?” She said, “That’s the way he is. It’s standard operating procedure. What can I do? I’m just a nurse.” That’s always been a pet peeve of mine, that phrase, “just a nurse.” It’s an excuse for not taking responsibility. So I said to her, “Are you sure he even knew you were the patient’s nurse? Maybe you could have said, ‘Doctor is there something I need to know? I see the patient is in tears.’ ”

Scene 16 How Many Dead Babies Does It Take? Nurse Carol Youngson: Dr. Odim. Welcome to Winnipeg. I’m Carol Youngson, the chief operating nurse. I thought perhaps we could schedule some runthroughs, to get the team working together effectively. Dr. Jonah Odim: (Looks irritated at request.) I don’t think that will be necessary. Nurse Carol Youngson: (Looks stunned at response.) Could you look through the supply catalogs and tell me what you would like me to order? Dr. Jonah Odim: (Even more irritated.) I don’t have time for that. Why don’t you just order what you usually order. (Holds cell phone to ear and walks off.) Nurse Carol Youngson: (Sighs and turns to audience.) That was how it began, one of the most horrific cases in Canadian medical history. We had lost our chief pediatric cardiac surgeon in Winnipeg, so they recruited this young surgeon out of Boston Children’s Hospital named Jonah Odim. His letters of recommendation didn’t say much. People just assumed

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he was great because the program he trained in was great. Turns out no one ever talked to any of the great people in the great program, or they’d have found out that he wasn’t so great. After only a few weeks, I was in the nurse manager’s office begging for help. So were nurses from the pediatric and neonatal ICUs. I’ve worked with over one hundred surgeons, assisted at thousands of surgeries. I may not know how to perform the surgery I’m assisting on, but I certainly know good surgical technique when I see it, and I wasn’t seeing it here. He was screwing up even basic stuff that residents do— his cannulas were falling out, for God’s sake. He was tearing vessels. It was a nightmare. Two children died. We needed to do something. The nurse managers backed us up. But the higher-ups in the medical staff and hospital administration wouldn’t listen. The head of cardiac surgery said, Winnipeg Doctor 1: Carol, there’s no need for you nurses to get all worked up. Dr. Odim came very well recommended. Besides, there’s a learning curve in every surgical program. You’ve just got a personal problem with Dr. Odim. It’s getting in your way. Besides, this is a medical issue not a nursing issue. Listen, if you don’t think you can handle the job, tell me, and I’ll find someone to replace you. Nurse Carol Youngson: I admit it. I didn’t like him. I didn’t like the way he treated nurses, and I didn’t like the way he treated women. But in my twenty-year career I’ve worked with plenty of doctors I didn’t like. I wasn’t complaining about his personality. It was his incompetence I had a problem with. Another baby died. And another. After working my way up the ladder, to no avail, I went to the chief of surgery. We had worked well together in the past. I thought we were colleagues, even friends. I asked him to come and observe Odim’s techniques. You know what he said? Winnipeg Doctor 2: I don’t take orders from nurses. Nurse Carol Youngson: (Looks like she has been punched in the stomach.) I didn’t know what to say to that. I was so taken aback I turned and left. It got so bad that I couldn’t take the tiny patients from their parents and bring them to the operating room. I had to have someone else do it. When

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I take a patient from a parent, if the patient is old enough to understand, I usually tell the child, “You’ll be seeing mommy and daddy soon.” Or I’ll tell the parents, “You’ll see your baby in the ICU in six or ten hours.” I couldn’t do it. I felt like a liar. I couldn’t look them in the eye and tell them they were going to see their child, because half the time I didn’t think the child was going to come out alive. I wanted to tell those parents to take their babies and run. But how could I? Respected doctors were telling them the surgery would be fine. I was just a nurse. One day we had just completed a repair on a three-day-old baby’s heart, and things looked good. I looked away for a second. Then I heard a gasp. The aortic cannula had been knocked out, and Odim, in his efforts to restore it, had destroyed the repair. The baby died on the table. The next day I went to the medical director and the director of nursing, and the hospital finally required Odim to have a cardiac surgeon present when operating on complicated cases. But three weeks later he did another openheart surgery on a neonate without requesting help. The baby bled to death in the OR. This was the twelfth death and Odim’s last case, because physicians said they would no longer refer patients to him. The hospital sent out a news release announcing the program’s suspension, and all hell broke loose. You work your whole life to help patients because that’s what you love to do. Then you watch all of these babies die needlessly because no one will listen to you, because, they say, you’re just being emotional. It was the longest medical inquest in Canadian history. I was on the stand for thirteen hours. And you know what the 558-page report concluded? That over and over again, doctors didn’t listen to nurses. Hospital executives didn’t listen to nurses, and as a result care was compromised. That’s all true. But what the report missed was the fact that Odim was trained in a system that discourages anyone from asking for help. He was in way over his head, and I don’t think he’d learned the skills to communicate that. What he did learn was that calling an attending for help at night or on the weekend gets you a bad mark and that stopping the action when you’re in doubt is not an option. We’re all trapped in this terrible system. I left the hospital. I left nursing. I haven’t even kept up my license, because I’m never going back.

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Scene 17 A Case for No Hierarchy Leah Jones: A friend of mine is a nurse at Johns Hopkins in Baltimore. She was one of the people involved with that case that was in the news a few years ago. Maybe you heard about it. This eighteen-month-old baby crawled into a scalding hot bathtub and got second-degree burns over 60 percent of her body. Josie King her name was. Three weeks into her recovery her heart stopped because of severe dehydration. One of the best hospitals in the world and this little girl dies of dehydration. It was a problem of communication as well as the fact that no one would listen to the family. The information was there, but no one put it all together. Josie’s family was devastated. My friend was a basket case when it happened. It hit everyone who worked on the case really hard. Nobody likes losing a patient, but when it happens because of something you did or didn’t do, well—it’s just . . . But you know what that family did? They gave $50,000 of the money they received in the out-of-court settlement back to the hospital that killed their daughter to start the Josie King Patient Safety Program. One of the ideas behind the program is that there can be no hierarchy when it comes to safety. The voices of the nurse, the resident, the pharmacist, and the technician have to be as welcome as that of the surgeon. Now rounds include more than attendings and residents—they involve nurses, pharmacists, respiratory therapists, family members. It’s amazing. My friend keeps telling me that I should come work at Hopkins when I get better. If I get better, the only place I plan to work is in my garden.

Scene 18 To Explain or Not To Explain Dr. Jane Fitzgerald: The other night, after midnight, we had this kid admitted with a fractured femur. He’d been shipped over to Children’s from some ER a couple of hours away with an X-ray, but no one could find the X-ray. So I told a nurse to get an X-ray stat. An hour later I ask, “Where is the X-ray?” He says he hasn’t got it. “Why?” He gives me some long song and dance about trying to find the X-ray. So again I ask, “Why haven’t you gotten the X-ray done?” He tells me it wasn’t a quote (can do “air”

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quotes.)—“appropriate” order. I blew up. “Your job isn’t to think about whether an order is appropriate. Your job is to think about how quickly you can fill my orders.” I needed that X-ray. I know I sounded like a witch, but I was wiped out. I hadn’t slept in days. Then this attending comes in. She’s great with nurses. She asks what’s going on and this nurse explains to her that the kid is exhausted. Can’t the X-ray wait until morning so the kid can get some sleep? The attending calmly explains that if the kid really has a fractured femur we need to know it right away. The nurse actually says okay. Then gives me a death-ray glare as he walks out. How did this attending learn to deal with all this? Did they teach it at her medical school? We sure as hell didn’t learn it at mine. And what do they learn in nursing school? If that nurse had just explained he wanted the kid to get some sleep, I could have explained why the X-ray couldn’t wait, and we would have both saved ourselves a lot of aggravation. Why don’t they teach us how to work together? Why does this have to be so hard?

Scene 19 Stopping the Line Dr. Raj Patel: We talk a lot about mutual support in teamwork. In surgery nothing is more important. I know because I’m a surgeon as well as the chief of perioperative services. I know how easy it is to make mistakes— particularly today, when there’s all this pressure to keep the line moving. If you don’t make it possible—expected even—for anyone to stop the line if they think there’s a mistake, people can die. Even if their call turns out to be wrong, they have to know they can stop the action without being punished. About a year ago a newborn was referred from a community hospital to our teaching hospital for a surgery in the middle of the night. The surgeon who was going to perform the operation the next day just happened to be there and saw the baby. The next morning everything was set for the surgery. Except there was a problem—a big one. The name on the baby’s wristband didn’t match the name on the OR schedule and on the chart. Following our protocol and Joint Commission rules about patient identifiers, the nurse said we couldn’t proceed with the surgery until we made sure we had the right baby. The surgeon disagreed. “It’s the right baby,” he said, “I met her

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last night.” The nurse persisted. You have to confirm the patient’s identity with two identifiers, name, birthdate, name on wristband, name on chart. You can’t just ask eighty-five-year-old Mrs. Jones, are you Mrs. Jones, and take her nod as formal identification. When you call your bank to find out your balance, they ask you five questions. That’s even more important in the OR. But the surgeon didn’t want to wait the twenty minutes it might take to sort all this out. He insisted on proceeding. It just so happened that the patient’s parents weren’t on site, and obviously the baby couldn’t jump in to identify herself, so the nurse persisted. She stopped the line. They checked on the floor, and it turned out that it was the right baby but with the wrong wristband. So after a half hour the operation went on as scheduled. After it was over the surgeon complained to me about the nurse. He wanted me to intervene and discipline her. Great, I thought, this is a perfect opportunity for me to emphasize the need for support. Just not the kind he wanted. I made sure to go and talk to the nurse very publicly and also to write a letter that would go in her employment record. I thanked the nurse publically for following protocol and for being vigilant. I told her she did just what she was supposed to do. And I made sure the surgeon knew what I was doing. Yes, it was the right baby. So in one sense, he was right, and the nurse was wrong. But what if it hadn’t been the right baby? If I hadn’t supported her—and insisted on the need to follow hospital protocol—worse, if I had reamed her out as the surgeon wanted, would she ever intervene to protect a patient again? (Shakes his head and walks off center stage.)

Scene 20 Last Call Leah Jones: I feel like my life has come full circle. My old doctor had run out of ideas, so I’ve come to see one of my baby docs from way back when. I came across his name in one of those magazine articles, you know, the ten best doctors to see if you have cancer. I always thought someone should write a companion article—the ten best nurses to have. Office Nurse: Leah Jones? Leah Jones: That’s me. Wish me luck. . . . I wonder if he’ll remember me. (Moves back slightly.)

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Scene 21 Stay and Watch Dr. David Brown: I was an intern in another lifetime. A hotshot. Efficient, hard, angry, and young. After four years in medical school I had memorized figures and physiology, tables, drug doses, and arrogance. I was working in obstetrics, checking on a seventeen-year-old mother of two who was about to become a mother of three. It was a slow night. I took her history, finished her physical, drew blood, glanced at the monitor, then I wished her the best and headed for the door promising to be back for the baby’s birth. A nurse was standing there. Leah. Leah Jones: (Moves in closer to Dr. David Brown.) Stay and watch. Dr. David Brown: I gaped at her, trying to think of an answer. I had been taught how to give orders to nurses not how to talk to them. She looked at the scribbles on my clipboard and asked, Leah Jones: (Moves even closer to Dr. David Brown, looks over his shoulder at script.) Did you learn anything from that? I thought you boys were here to learn. Dr. David Brown: She was taunting me. Her lips smiled but not her eyes, and her smile was a challenge. When I didn’t storm out, she softened a bit. Leah Jones: Stay and watch. See what it takes for a woman to bring a child into this world. (Sits facing audience, still in character.) Dr. David Brown: We watched as the baby came down, careless of its mother’s cries. We delivered the child in the labor room with the father looking on. All the senior residents were asleep, all the attendings still at home. Over the next four years Leah taught me to be an obstetrician. More than that, she taught me to be a doctor, taught me to see, to feel, to listen, to touch, to speak, to understand. She taught me to sense labor’s slow cadences, the crescendo of pants and grunts and moans that ended with an infant’s cry. She taught me to read the trajectory of a child’s descent in the way a woman twisted, to see which would go bad, which would end with the knife. She taught me to talk down screaming children birthing children, to coach women into puffing their fears away. Stay and watch, she’d said. I left that hospital and moved to the city for an oncology fellowship. And I learned to forget Leah’s lessons: cancer, like the sun, blinds those who

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look on too directly. I was gone eight years. I came back to head a division at the university where I had trained. No one from my resident class had stayed. The junior faculty who had taught us had gone gray. The old chairman had been forced out. My favorite mentor had retired. There was a rumor that Leah had set up as a nurse midwife in a small town nearby. I tried to track her down, with no success. It was Leah who found me, finally. She came to my office, self-referred, with a folder full of photocopies and a plastic box of slides. She had lost weight but not heart, had cut her hair but kept her smile. We chatted about our pasts, our plans, and disappointments. We talked about her future, both knowing she had none. It was a quiet meeting except for the thumping of my heart. Radical surgery, chemotherapy, radiation: she’d endured all, knowing their futility. Always a professional, she watched herself die and reported to me every symptom of her slow decline, the site and radiation of her pain, the crackling of her skin, her tremor, her stoop, her hobble, her cough. Eleven days ago a brain metastasis bled. Her kidneys failed soon after that. Her lungs were choked with cancer. Her liver was dying. The humor and the light, the wisdom and the joy of her all gone. I should go, too. But I stay. I watch her breath suck in and out inside the mask. Her half-lidded eyes flutter with the effort. Just before dawn she quits. (Leah bows her head.) A penlight in her eyes, two fingers at her throat, a stethoscope on the washboard of her ribs, and it’s over. I could say good-bye, but the woman who would have heard it is gone. Stay and watch, she said on that night long ago. I did. (Actor returns to his seat. Then all the actors stand to take a bow.) (Curtain.)

PART 2

BEDSIDE MANNERS THE WORKBOOK

Introduction to the Workbook Bedside Manners is a teaching tool designed to help health care professionals explore the vexing problem of interprofessional collaboration and teamwork.1 Based on real people and situations, the play provides a nonthreatening entry point to a discussion of a range of interprofessional issues linked to delivering care in a safe and effective manner. The play and workbook explore the sometimes harsh reality that is all too often obfuscated by the rhetoric of teamwork, patient safety, and concern about patient outcomes. Performing, viewing, discussing, and analyzing the play can serve to help people generate a deeper understanding of the infrastructure on which interprofessional teamwork must be built. An important component of this is what Suzanne Gordon calls interprofessional team intelligence (TI)—the skills needed to lead a team, be an effective team member, and build sustainable teams. This play was written to help foster the kind of TI on which patients’ lives depend. Team intelligence can also reduce stress and increase staff morale and job satisfaction. After watching or performing the play, doctors, nurses, medical and nursing students, managers, hospital executives, and other professionals can begin or enhance a dialogue that may lead to safer patient care, better working relationships, and greater job satisfaction. Although the play deals primarily with physician-nurse relationships, other groups of health care professionals are included in some of its scenes. With the permission of the authors, it is also possible to add or subtract a scene or character from the play to incorporate other professional groups to illuminate various interprofessional issues or add a scene or content that reflects the local problems of the group presenting the play.2 For example, one could write a scene in which a pharmacist is involved in a drug administration problem that affects medicine and nursing, or a scene set in a teaching hospital could be replaced by one that takes place in a community hospital or outpatient clinic. This Bedside Manners workbook contains two main sections. The first section, “Producing the Play,” provides guidance for putting together a performance

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for a single event, including suggested approaches for postperformance discussions and workshops. It is followed by an actor’s and director’s tool kit and a production checklist. The second section, “The Play as Interprofessional Curriculum,” offers a framework for using the play as part of an academic or workplace communication or teamwork course, discussion, or initiative that would include students, staff, or hospital management. Each scene is listed with background information (“Context”) along with themes and issues addressed in the scene (“Group Discussion”). This is followed by suggestions for role-play activities. Although we have divided this workbook this way, there is not a neat division between producing the play and using it for teaching purposes. We encourage people to freely move between the sections so that they may tailor the insights or suggestions to their local needs.

Producing the Play For those not involved in theater, producing Bedside Manners may at first seem daunting. The information provided here should demystify the process. Covering topics from casting to rehearsals to postperformance discussion, this section provides clear guidelines for putting together a successful production that will maximize the play’s impact. Bedside Manners is written to be performed “reader’s theater” style. This means that performers face the audience and read from scripts usually placed on music stands. Not only does this style take off the pressure of memorizing lines for performers but it also helps focus everyone’s attention on the content of scenes rather than on production values. The style is akin to the art of reading a story out loud, where the spoken word of the reader and the imagination of the audience combine to create a narrative journey. In this case, the narrator of the story is the main character, “Leah,” a nurse whose illness provides the frame for exploring the topic of team communication. The play weaves together Leah’s observations and personal stories with scenes that illustrate the types of issues and communication challenges to which she refers. Bedside Manners features thirty-one characters, with roles that range in size from one word to multiple pages of dialogue. The play has been

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performed with as few as four and as many as twenty actors. Although you can certainly perform the play using only professional actors, we have found that after presenting this play for nearly a decade, it is most effective when actual health care professionals or others who work in health care institutions act in the play.

Staging the Play with Real-Life Professionals, Students, Hospital Staff, or Others Interested in Patient Safety Concerns If you’re using the play in a health care professional school, students, faculty, or both act in the play. If you’re presenting a play at a conference, retreat, or workshop, people attending it either volunteer or are asked to act in it. If the play is used in a hospital or other health care facility, doctors, nurses, and other staff can be asked to volunteer to act in the play. We have used this method to present Bedside Manners in outpatient clinics, hospitals, health professional schools, at patient safety conferences, and in other health care settings. The play can also form an explicit part of interprofessional education curricula. Presenting the play using some of the members of your audience is also an excellent exercise in team building—particularly if you try to use members of different professions and ask people to portray someone who is not from their particular profession (e.g., casting a nurse as a physician and a physician as a nurse). Featuring people who work alongside each other in the play makes it not only a more entertaining but also a more moving experience. When asking nonprofessional actors to act in the play, you should consult the casting material at the beginning of the play, and try to cast actors as characters that they most closely resemble. If that’s not possible, don’t worry. It is theater after all. (If you have a female playing a part written for a male or visa versa make sure to change the pronouns in the script!) When you put out the call for volunteers, see if anyone has experience as an amateur or professional actor, and ask that person to be in the play. You’d be surprised how many health care professionals have theater experience (or at least dreams of being onstage). It will be important, however, to do at least one rehearsal before the performance. The time commitment will not be excessive—one or two hours

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to rehearse the play, then an hour to perform the play. Actors should also plan to participate in any postperformance discussion or workshop. Once the actors are chosen, give them copies of the script well ahead of time, and ask them to look at their part and read it over more than once out loud. They need to become familiar with their lines (not memorize them) so they can read them convincingly in a performance. When rehearsing the actors, remind them that they are acting, not just reading. It’s important for them to convey the feelings of the character they are portraying (see actor’s and directors’s tool kit at the end of the workbook). Make sure to remind them to look up at the audience while they are reading and avoid keeping their heads glued to the script. When mounting a production of the play with nonprofessional actors, it’s very helpful to hire two or three professional actors to act in it as well. This should not be expensive and well worth it. We explain how to find professional actors below. When presenting the play to an interprofessional audience, always make sure that the people introducing and acting in the play come from the professions represented in the audience. Although interprofessional teamwork has become the new mantra in health care, there is tremendous resistance to adopting the behaviors and attitudes on which genuine interprofessional teamwork depends. It is especially important to make sure that leaders in your school, institution, or at your conference introduce the play and explain the importance of the issues it addresses. For example, if you are in a hospital and performing the play in front of an audience of physicians and nurses, make sure that a physician leader (not just a nursing leader) is not only in the play but introduces the event. We cannot overstate the importance of making sure that the play is introduced in a way that highlights, rather than undermines, its content. When using the play with an interprofessional audience, it is also critical to make sure that the seating arrangements in the auditorium, classroom, or conference room reflect the interprofessional nature of the group. When people enter a room, they tend to sit with people they know—which in health care, means they will sit with those in their professional siloes. This will affect how they perceive and engage with the performance and postperformance

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workshops or discussion. To make sure an audience engages in an interprofessional experience, you should have various colored 3 × 5 cards on hand. Give these out as people enter the room, making sure people have different-colored cards. Direct them to the section devoted to their color. If you are using round tables, use the same method to make sure people sitting at the tables are not interacting with people from their profession. Alternately, if there is a large audience in an auditorium, the person leading the event should allow everyone to take their seats. Before the play begins, this person should ask, “How many of you are sitting next to someone you know? Please raise your hands.” He or she should then say, “since we are here to explore issues of communication and teamwork, here’s your first teamwork exercise. If you’re sitting next to someone you know, please get up and move, and sit next to someone you don’t know. We’re on the honor system here. Then introduce yourself to the people on either side and in front of and in back of you.” When that’s done, whomever has been designated to introduce the play should do so.

Do I Need a Director? Whether you are using professional actors for a full production or students for an informal presentation in a classroom, someone will need to serve as director for the play. The role of the director is important in both cases, though the function and duties vary slightly. When producing the play for a conference or other formal event, the director’s role may encompass everything from casting to staging to postperformance facilitation. Although the staging of the play is quite simple, the director’s job goes beyond directing traffic. The director will need to make sure actors are speaking loudly enough, that they understand what the character is saying and why, and that they are delivering the dialogue with the appropriate force and emotions. Depending on the situation, a director may be the person who schedules rehearsals and interfaces with technical staff regarding sound and lights. He or she may also facilitate any postperformance discussion of the play if there is not a separate presenter to do this.

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For an informal presentation of the play by students in a classroom, at a conference, or in a hospital, the director could be a student or a professor, or physician or nurse. In this situation, the director will make sure that the play is cast, the actors receive their scripts and role assignments, and that they understand the importance of becoming familiar with their role in the play (lines and cues) because there will not be a formal rehearsal. The director should consult the Actor’s and Director’s Tool kit and Production Checklist below.

How Should the Play Be Staged? As mentioned earlier, the play is written to be performed “reader’s theater” style, which makes it possible to perform in a theater, on a platform stage in a large conference hall, or simply in an area at the front of a classroom, lecture hall, or other meeting room. The only “set” pieces are three music stands. (If you are doing the play in a small classroom, music stands may not be necessary.) One stand should be placed in the center of the performance area. This stand should have a neatly lettered sign that is visible to the audience that says “MD.” A few feet over, stage left, is a music stand with a similar sign that says “RN or Other Team Member” At stage right is the third stand that does not have a sign. This is where “Leah,” the narrator of the play, will stand. The staging of the play consists of having the actors move to the appropriate music stand for their character. For example, an actor playing the character of a doctor will do so from the middle music stand. There may be occasions during the play where it is more effective to break out of this pattern. If the room where the play is being performed is large or the acoustics are poor, microphones should be placed at each of the music stands. Wireless microphones can be used if the number of actors is small. Provide enough chairs for the actors behind the music stands so that all the actors can be seated before the play begins and move from their chair to center stage for reading their lines then back to their chair when their lines are finished. At the end of the play, when the last actor playing “Dr. David Brown” finishes his monologue, all the actors rise, stand together, and take a bow. No special lighting is needed. If you have a platform stage at the front of a large conference hall and there is only the room’s general lighting, that is fine. However, if you have access to a lighting system, simply lower the lights on

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the audience area so that only the actors are illuminated to help focus the audience’s attention. Check in advance that the actors have enough light to see their scripts. Sometimes when working with lighting systems in conference situations, the lights might illuminate the actors but cast shadows on the music stands. Clip-lights on the music stands are a possible solution in this case.

How Do I Find Professional Actors? For large events such as a national or regional conference, you might want to hire two or three professional actors (and, perhaps, a director) to ensure that the quality of the performance is high. Professionals will understand the needs of the script and be able to adapt to the physical constraints of the venue. As we said above, allotting time for at least one rehearsal—of two hours in length—is recommended. As we also said above, anchoring a performance by nonprofessional actors with two or three professional actors is quite effective. One of the easiest ways to go about hiring professional actors for your production is to find an experienced director and let the director find the actors. The drama department of a local college or university is an excellent place to inquire about directors. If your city has a professional theater company, you can also contact them to see whom they would recommend to direct a performance. If using union actors you can contact the Actors’ Equity Association for a simple one-time-only reading waiver. Actors and directors involved with this kind of project can be paid anywhere from $100 to $1000, depending on the situation. For example, if you hire a local actor who has a full-time job but performs on the side, you may need to pay only $100. However, if the local actor makes a living from acting (and is a professional AEA union member), he or she might charge more, but the quality of your production rises. Actors’ Equity Association is a helpful organization that will work with you and meet your needs. And if you choose to bring in professionals from somewhere else (Los Angeles, New York, Toronto, etc.), you might need to pay them much more. Community theaters can also be an excellent source of actors and directors. Members of your planning committee might know someone involved with such a group. Because these are volunteer organizations, you will probably be able to find actors who will volunteer their time. You might still need to pay a director.

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What Should I Do after the Performance? People who see the play when produced as a stand-alone event may well discuss it later with friends and colleagues, but the play has the most impact when combined with structured postperformance activities. These can include panel discussions, facilitated conversations with the audience, and improvised scenes based on the play or examples given by audience members. What follows are some suggestions for postperformance activities based on our experiences using the play. All of these can be combined into a two-, three-, or four-hour workshop. This kind of workshop is an excellent way to prepare for—or follow—interprofessional education activities (workshops or seminars) or team-training interventions such as TeamSTEPPS.3 After the play is over and before the actors leave the stage, one person should be in charge of facilitating a postperformance discussion of the play. That person might want to begin with the following device, which is called “Windows and Mirrors.” The discussion leader should ask the audience members to turn to a person next to them or form small groups and discuss the following questions: 1. What moment in the play was a reflection or mirror of your own experience? 2. What moment in the play was a window into someone else’s experience? After the audience members have had a few minutes to discuss their responses, ask them to share them with the entire group. If there is a large group, it will be useful to have microphones available so their comments can be heard.

Structural Issues the Play Illustrates Many of the audience comments generated by the Windows and Mirrors exercise may focus on personal experience. That’s why it’s important for the facilitator to then ask the audience what structural or system issues they believe the play addresses. The facilitator should say something like the following:

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“What structural or system issues does the play address? For example, how does fatigue—hours worked—have an impact on the interactions in the play? What about work organization, workload, or interprofessional hierarchy—is it functional or dysfunctional? What other structural issues can you identify that have an impact on teamwork and patient safety?” After a discussion of audience impressions and insights from the play, you could do another exercise as follows, which is inspired by the methodology TRIZ.4 Ask the audience to continue working in pairs or groups and consider this question: “If you want to make sure that poor communication, collaboration, and teamwork in the workplace is guaranteed, what would you do? Please write down one or two things that you could share with the group.” When the audience has finished its discussions, ask people to share their items, and list the comments on a flip chart. You can return to this list during the latter part of the discussion or workshop when you ask people for suggestions of action items.

Scene Rescripting Replay Scene 11, Lesson of the Dehydrated Baby, with the same actors who performed it in the play. The moderator of the discussion asks the audience if anyone has an idea of how one character could change how he or she behaves or what that character says in a way that would transform the interaction depicted in the scene. The moderator asks people to be specific, as in, “Don’t tell the nurse or doctor to be nicer; describe exactly what that character should say.” The moderator asks the audience to come up with something specific and concrete that every character in the scene could say or do. Then the moderator asks members of the audience to raise their hands if they have an idea for a particular character. The actor in that role then goes to that audience member who whispers instructions into the actor’s ear. The scene is then repeated with that actor following the advice he or she received. In this way, members of the audience begin to become de facto writers and directors in the play. You can also divide the audience into smaller units and ask them to consider specific scenes in the play. (Have copies of these scenes available, which is permissible if you have licensed the play.) You can use questions suggested

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in the workbook to initiate discussions, or you can ask what went wrong—or right—in a scene and suggest how it could be done better or how excellent communication can serve as a model for improved teamwork. In the next section, The Play as Curriculum, you will find two “re-do” scenes that can help guide this exercise. In each case, there is an original version of the scene based on the event described in the play, which is followed by an alternative version (“re-do”) of the same scene in which the rescripting alters the outcome. After actors from the play perform the original version of a scene, the director or facilitator should ask members of the audience how they viewed the different choices the characters made. The actors then perform the “re-do” version and discuss how this particular rescripting changed the outcome.

Short Presentation of Concepts Addressed in the Play When leading workshops following the play, it is useful to discuss the following key topics and concepts. These are central to good teamwork, collaboration, and communication and thus to patient safety.

what a team is and is not Although people in health care tend to use the term “team” for almost any grouping of individuals in the profession, this practice often overlooks the composition and function of a team. Research that one of us (Scott Reeves) has undertaken has highlighted the fact that there are multiple forms of interprofessional working arrangements—not only teams but also collaborations and networks. It’s beyond the scope of this workbook to analyze the distinctions between these types of interprofessional work. For the purposes of this discussion, it is useful to understand that a collection of disparate individuals who are assigned to the same patient, unit, or facility does not in and of itself constitute a team, a group of collaborators, a network, or any other cohesive work formation. A team is instead a group of people working together to advance a common goal. These people explicitly share this goal, as well as the same mental model, information, plans, protocols, and feedback

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mechanisms. As Edgar H. Schein puts it so well, “We do not typically think of an effective team as being a group of people who really know how to help each other, yet that is precisely what good teamwork is—successful reciprocal help.”5 Below are some of the components that we believe are important in transforming a disparate configuration of individuals in health care into a functioning interprofessional team of people who assist each other to help patients.

team intelligence Contemporary discussions of health care safety and teamwork often include a focus on helping health care professionals develop what is called “emotional intelligence” (EI). While EI is certainly important, we believe creating genuine interprofessional teamwork requires moving beyond the individualized concept of EI to that of team intelligence (TI). As Suzanne Gordon has defined it, TI is the active capacity of individual members of a team to learn, teach, communicate, reason, and think together, irrespective of position in any hierarchy, in the service of realizing shared goals and a shared mission.6 TI has the following requisites: • Team members must develop a shared team identity that allows them to articulate a shared mental model, shared language, and shared assumptions. • Team members must be willing and able to share information, cross monitor, and coach all members of the team, as well as to solicit and take into account their input, no matter their position in the occupational hierarchy. • Team members must understand one another’s roles and work imperatives and how these mesh so that common goals can best be accomplished. • Team members must help and support one another so that each individual member can perform his or her job efficiently and effectively. TI produces not only action but also effective interprofessional interaction and collaboration.

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distributed cognition In high-reliability, safety-critical industries, the creation of TI is grounded in the recognition that safe and effective job performance requires individuals to engage in a specific kind of group cognition—what the cognitive anthropologist Edwin Hutchins calls “distributed cognition.” Recognizing the existence and importance of distributed cognition is essential to the creation of true teams and collaboration in health care. As Hutchins explains: All divisions of labor, whether the labor is physical or cognitive in nature, require distributed cognition in order to coordinate the activities of the participants. Even a simple system of two men driving a spike with hammers requires some cognition on the part of each to coordinate his own activities with those of the other. When the labor that is distributed is cognitive labor, the system involves the distribution of two kinds of cognitive labor: the cognition that is the task and the cognition that governs the coordination of the elements of the task.7 Put in everyday language, what Hutchins is saying is that all the participants in a real team need to know not only what they are doing but also what their colleagues are doing. (This means, of course, that they need to think about the people from the other professions with which they work as colleagues working together to deliver patient care). They also need to be mindful of what it takes to coordinate various tasks and activities.

situational awareness Situational awareness is a key component of effective interprofessional collaboration and teamwork. Helping your professional colleagues or team members maintain situational awareness is one of the jobs not only of the team leader but also of team members. What is situational awareness (SA)? It’s the ability to maintain an awareness of the big picture even as one is involved in a crisis or occupied with a narrow, concrete task.8 The proverbial example of the loss of situational awareness is a couple driving down a road arguing. They are so focused on their dispute that they neglect to notice that

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they have strayed into the other lane and that a huge truck is bearing down on them. The result? Not surprisingly, a crash. One of the jobs of a team leader is to make sure his or her team does not get so narrowly focused that the team members lose the big picture and thus fail to realize their common goals.

cross monitoring One way team leaders and members maintain SA and prevent, manage, and contain errors is to cross monitor one another’s performance. Cross monitoring involves learning how to constructively voice concerns and remind people that they are losing SA or that they are about to make a mistake. A genuine team in a high-reliability industry is specifically concerned about mistakes and assures that people are invited to cross monitor one another to help avoid catastrophe and thank each other when they do so. The concept of cross monitoring helps people reframe interactions in which a “subordinate” questions an action or judgment of someone of a higher status. The traditional concept of “insubordination,” so well illustrated in the case of nurse Carol Youngson and Winnepeg Doctor 2, inhibits interventions that are not, in fact, intended as challenges to status or authority but are genuine manifestations of concern for patient safety.

team leadership and membership Teams need leaders but they also need members. As Robert Ginnett has written, “Leadership is not about leaders in a vacuum—it is about leaders in relation to followers in a particular setting. Is there such a thing as leadership without followers? The fact is leadership is a group phenomenon.”9 On a genuine team, what is the role of the leader? We believe it is to help each member of the team do his or her job efficiently and effectively, which, in health care, means helping each person prevent, manage, and contain errors. This contrasts the traditional notion of the leader as commander in chief with an approach in which leadership is facilitative in nature. Similarly, in genuine interprofessional teamwork and collaboration, the role of the team member does not involve following “orders” blindly but instead demands inquiry, advocacy, and assertion.

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psychological safety Edgar H. Schein and Warren G. Bennis first described psychological safety in their book Personal and Organizational Change through Group Methods. One of the key conditions for learning, Schein and Bennis argue, is “unfreezing” so that people who need to learn new behaviors or ideas develop curiosity about human behavior and about themselves. Essential to unfreezing is a climate of psychological safety so that people can “take chances without fear and with sufficient protection.” Learning new ideas and behaviors requires a stickingone’s-neck-out-without-reprisals attitude, as distinguished from playing it safe. A climate that is psychologically safe encourages provisional attempts and tolerates failure without retaliation, renunciation, or guilt.10 Amy Edmondson argues that psychological safety helps to create the kind of institutional learning that is a nonnegotiable requirement of highreliability organizations. “Psychological safety describes individuals’ perceptions about the consequences of interpersonal risks in their work environment. It consists of taken-for-granted beliefs about how others will respond when one puts oneself on the line, such as by asking questions, seeking feedback, reporting a mistake, or proposing a new idea.”11 A psychologically safe environment is thus one in which people feel they can ask a “dumb question,” stop the line, or challenge a superior about safety without fear of retaliation, humiliation, or disregard. This is the very heart of teamwork and team functioning.

interprofessional education Interprofessional education (IPE) is an increasingly popular approach used in health care institutions and professional schools across the globe. It is defined as “two or more professions learning from, with, and about each other to improve collaboration and quality of care.”12 Interprofessional education is much more than a group of different professionals sitting together in a room learning a common subject. That is a part of interprofessional education, but the heart of IPE involves active interaction between professionals that allows them to understand one another’s roles, pressures, concerns, and to understand one another as both members of professions as well as unique individuals. Reading the play and workbook, performing it, and discussing it is by definition a true IPE experience.

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Audience Skits If time permits in a workshop or class presentation, ask members of the audience to break up into small groups and construct a skit of their own as a useful and engaging way to deal with issues raised in the play. Groups of four to six are an optimal number for this exercise. If the audience is interprofessional or interoccupational, make sure that the small groups include members of different professionals. Ask the members of the groups to work together for about twenty minutes to create a skit of no more than five minutes that illustrates poor communication and teamwork. Give them the following outline: 1. Your skit, like every good story, must have a clear and specific beginning, middle, and end. 2. Your skit must involve characters from at least three different areas (e.g., nurses, doctors, security guards, patients, etc.). 3. Your skit must involve a fictional circumstance and fictional characters in which communication and teamwork broke down between members of the team, and as a result patient safety and care were compromised. 4. Using the ideas discussed in the play and workshop, the group should redo the skit so that it presents a solution that enhances communication and teamwork. The different groups will then be asked to present their skits and rescriptings to the larger audience. In our experience these skits effectively engage the audience. Even though the skits are short, in the process of devising the skits and rescriptings members of the audience begin to truly absorb some of the lessons and concepts illustrated and addressed in the play. And they have fun doing it.

Action Items The final component of a workshop on Bedside Manners should include a discussion of what we call “action items.” Ask the audience to again meet in pairs or groups to consider one or two things they could individually work on to enhance teamwork, communication, patient and staff safety, and satisfaction.

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Suggest that their action item be a practical issue or problem that they could effectively address. Then write down one concrete thing that they could do about it. If you are using the TRIZ-inspired exercise outlined above, the facilitator could refer back to the list that the group generated and ask people to center their action items on that list. If people have identified behaviors or structural problems in the group discussion—fatigue, workload, and socialization into toxic hierarchy—they could also add those to the list. People should be specific about their action items. Again, you are not looking for comments such as “be nice to each other,” or “don’t be negative.” You are trying to generate a list of concrete things people can do. For example: Don’t just listen, solicit input. Use the question, “What would you be comfortable with?” Stop harassing new interns. Welcome new nurses when they come onto the unit. Use SBAR in communication. If time permits and the group is not too large, you can add another exercise to the action item section of the workshop. This is known as 25/10 Crowd Sourcing, an exercise from Keith McCandless’s Liberating Structures website.13 Ask participants to write one concrete action item on a 3 × 5 card. Ask them to share their action items with the person sitting next to them. Then ask that person to rate the action item on a scale of one to five, with one being the lowest score and five being the highest. The highest-scoring action items should then be read out loud to the group and suggestions for follow-up shared.

Actor’s and Director’s Tool Kit First and foremost we hope that working on and performing this play is fun. Although many of the circumstances and results of the actions of characters are quite serious, the acting company really should approach the script with a sense of playfulness.

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For the Actors 1) All acting is about action. The most important questions to ask yourself as an actor are: what is someone doing to me and what am I doing in response. You want to be clear and concise and pick easily definable and achievable actions. Example: a parent yells at his teenage daughter for scratching the family car, and the teenager yells at the parent at the unfairness of his response. That is the summary of the story, but in order the make the story active, find clear definable action verbs that you can use as a point of focus: the parent is berating, or chastising, or cutting down the teenager, while the child in response is defending, or deflecting blame, or objecting to the parent’s treatment. Know what you are doing to whom you are talking and you have pinpointed the secret to making the text come to life. 2) Many of you may be playing a role that is slightly outside your life experience. For example, a doctor may play a nurse, a nurse may play a pharmacist, a security guard may play a patient. It is important to focus not on your preconceived notions of how those professions act or respond to situations but rather to be true to the text and empathize with the conditions and circumstances of what that person is going through. 3) This is a staged reading but that does not mean that we have to be completely glued to our scripts. When you rehearse on your own, take a short time to work on the following skill. While standing with your script in hand glance down at the page and silently read a line of text. Take your time to put into your memory just that one line. Now, lift your eyes from the page and speak to a point on the wall in front of you. Say that one line aloud and complete the entire thought before returning your eyes to the text. Do not be concerned about the time it takes to go through several lines in just this way; a natural flow will find you. This may sound simple but practicing this fundamental technique goes a very long way in finding comfort and concentration when performing.

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For the Director 1) Give all actors a copy of the script well in advance of the performance. 2) Give all actors a clear understanding of the roles they are performing. 3) Give all the actors copies of the actor’s tool kit.

Rehearsal Checklist 1. VENUE SIGHT LINES: Clearly communicate with the actors where to stand on stage for prime visibility. 2. NO HIDING BEHIND SCRIPTS: Have the actors hold scripts no higher than just below chin level so their mouths can be seen. 3. LOOK UP FROM THE TEXT: Remind actors that when they are speaking they should look up from their script and not rush the delivery of their lines. This will help bring sound up and out toward the audience. 4. WHAT ARE YOU DOING?: Remind actors to have a clear idea of what they are doing to whomever they are speaking, whether it be to another actor or to the audience (e.g., I am berating, I am cutting down, I am convincing, I am cajoling, I am seducing, I am backing off, and so on). 5. MOVE WITH PRECISION AND SPEED: Clearly communicate with the actors when to stand and where to meet their scene partners in the playing space. Also remind them that when their scene is over they should cleanly and quickly return to their seats so there is a flow to the following scene. 6. Adjust space lighting if needed. 7. Add microphone amplification if needed. 8. POINT OF FOCUS: Remind actors that while they are sitting on stage they are always a part of the show even when they are not acting. Encourage them to watch their fellow actors on stage instead of reading along in the script. They can anticipate their entrances without having their heads buried in scripts. This helps the audience know where to direct their attention.

Production Checklist Division of Labor To do the play you will need the following production people (if needed, one person can perform both roles and the role of director as well): 1. A presenter who will introduce the play (as per script in play and above) and lead any discussion or workshop following the play. 2. Organization point person (OPP). This person is responsible for making sure that everything that is needed for a performance is accomplished and provided.

Preperformance Checklist • Contact is made between the presenter or director and the OPP. • The script is licensed by contacting Suzanne Gordon via email (see the copyright page of this book). • The OPP books a room, auditorium, or other space in which the play is presented. If a workshop is to follow, ideally space will have round tables at which participants can work following the performance. The OPP arranges for there to be individual chairs on stage for all performers and three stand-up microphones on stage if the venue requires it. • The OPP provides a copy of this book, Bedside Manners, to each actor. • The OPP produces and provides brochures explaining the play or any other handouts for audience members. • If colored 3 × 5 cards are used to direct audience members to sit in different sections (see above) the OPP makes sure there are cards available and that color or symbol sections in the room are blocked off.

Casting the Play The director is responsible for casting the play. As far as casting is concerned, the director will be in contact with the play and workshop presenter to determine what roles will be cast. 61

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If doing the play with a multidisciplinary group, try to cast people from different disciplines (doctor should play nurse, nurse should play doctor, and so on). If your group has people of different genders and ages, then try to match up the gender and age of the character, but if it doesn’t don’t worry, this is supposed to be fun, just cast people you think will be enthusiastic performers. So if you’ve got too many women or too many men, it’s not a problem. The director should cast the roles well enough ahead of time to get cast members their scripts so that they can read and rehearse their lines before the actual play rehearsal.

Remember! Actors should not receive their scripts on the day of performance. Having the scripts ahead of time vastly improves the quality of the performance and enhances the play’s usefulness. Even receiving the play two days ahead is better than getting it on the day of the performance!

The Play as Interprofessional Curriculum For medical and nursing school faculty, for unit or hospital managers, or for associations providing continuing education, Bedside Manners can serve as the central or supplemental text for a course on interprofessional communication, collaboration, and teamwork. The professional and interprofessional conflicts and dilemmas the characters encounter in the play offer the opportunity for additional reading, in-depth discussion, problem-solving exercises, and role-playing. Students, faculty, or working professionals can also identify similar situations they have experienced, witnessed, or heard about, and use these for further discussion. The play can thus function as a tool that allows them to consider how to develop strategies to enhance interprofessional communication, collaboration, and teamwork. A key aim of using the play as curriculum is to make explicit a number of backstage issues that underpin interprofessional relationships (e.g., power

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differentials, hostile stereotyping, interprofessional friction) that are often masked by front stage performances. In using these terms, we refer to the work of the sociologist Erving Goffman who defined the backstage as an arena where our true values, views, and attitudes emerge. This contrasts with front-stage performances where we try to present ideal versions of ourselves.14 The well documented “doctor-nurse game” provides a good example of a front-stage performance that masks a rich world of backstage attitudes. According to the rules of this game, nurses will often suggest a range of care options, overlooked by the doctor. She—or he—does this in a way that ensures no explicit questioning of the authority of her medical colleague. Or she may allow the physician to think the idea she has actually presented was hers. This type of front-stage behavior—well illustrated in scene six—masks a range of views about this interprofessional performance which the nurse may only present backstage—usually to other nursing colleagues.15 Bedside Manners can help people explore and expose a range of factors related to working and communicating in an interprofessional manner. While the activities presented below can be undertaken by a range of professional and occupational groups, for us, the greatest value is to integrate it into an IPE curriculum so that it gives participants a realistic interprofessional experience. The following section breaks down many key scenes from the play. For each scene we have selected, we provide some context, as well as key points for interprofessional discussion, debate, and reflection. We have also included some useful readings with certain scenes to provide additional insights into the nature of the phenomenon under exploration.

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PROLOGUE Context The prologue provides an overview of how doctors, nurses, and other team members communicate with each other. The mantras used in health care highlight the embedded attitudes and perceptions that can inhibit interprofessional teamwork and collaboration. For example, a doctor insists that “the buck stops here” because every decision has repercussions and can lead to a lawsuit. A nurse counters that this attitude may justify shutting out nurses of the decision-making process and can lead to patient harm. Similarly, RNs who insist that they are “the patient’s advocate,” may anger physicians or other professionals who may think, “So what am I? The patient’s enemy?” The prologue also explores experiences health care professionals share, including overwork, exhaustion, and stress.

Group Discussion 1. What interprofessional conflicts are highlighted in this prologue, and how are they relevant to your audience and profession? 2. How do these interprofessional conflicts have an impact on patient care? 3. How does each profession construct the other—as obstacle, as ally, as competitor, or as resource?

Selected Reading Hackman, Richard J. Leading Teams: Setting the Stage for Great Performances. Boston: Harvard Business School, 2002. Reeves, Scott, Simon Lewin, Sherry Espin, and Merrick Zwarenstein. Interprofessional Teamwork for Health and Social Care. Oxford: Wiley, Blackwell, 2010. Schein, Edgar H. Helping: How to Offer, Give, and Receive Help. San Francisco: Barrett-Koehler, 2011.

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Scene 1 WHAT HAPPENS TO ME? Context For most of us, the experience of being a patient is far different from that of being a friend or family member visiting a patient. For a doctor, nurse, or other health professional, however, the experience of becoming a patient, of being on the other side of the bed rail, brings the world of health care into sharp relief in a completely different way. Leah’s question of “What happens to me?” recognizes that the day-to-day challenges of interprofessional communication and teamwork in the workplace are not simply annoying, frustrating, or upsetting but also sometimes life threatening.

Group Discussion 1. Have you ever been a patient in a hospital? If so, how does it feel to be on the other side of the stethoscope? What do you see from that vantage point? 2. Has your personal experience changed your professional and interprofessional practice? If so, how? 3. What are the differences between how patients see interprofessional work in health care, settings and how you experience this in the workplace?

Selected Reading Baker, D. P., S. Gustafson, J. Beaubien, E. Salas, and P. Barach. Medical Teamwork and Patient Safety: The Evidence-based Relation. Literature review. AHRQ Publication No. 05-0053. Rockville, MD: Agency for Healthcare Research and Quality,. 2005. http://www.ahrq. gov/qual/medteam/. Heymann, Jody. Equal Partners: A Physician’s Call for a New Spirit in Medicine. Philadelphia: University of Pennsylvania Press, 2000. Rosenbaum, Edward E. The Doctor. Ivy Books, Mti edition, 1991.

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Scene 2 BUT WILL THEY NEED ME TOMORROW? Context This story came from a veteran nurse who works at a major Southern teaching hospital. Her question to the resident stemmed from her dismay and frustration after teaching scores of doctors-in-training over the course of her career. She understands her role perfectly, which is why she so carefully instructs the doctor in the dangers of giving one medication rather than another and in sending the patient home too early. The doctor-in-training also recognizes the role of the nurse and tries to acknowledge it to the senior physician. He does not succeed, at least not onstage. The implications of the attending physician’s failure to listen to the resident are serious. By racing off and not allowing the resident to acknowledge the role of a team member, the attending perpetuates the myth that patient care depends only on solo acts rather than on the effective collaboration of a variety of players.

Group Discussion 1. What have you observed about interprofessional interactions between doctors and nurses? 2. How do doctors and nurses communicate? Do they routinely talk to one another before seeing a patient and then discuss and debrief afterward? 3. What are the implications of these interprofessional communication issues for the delivery of patient care—positive, neutral, or negative?

Selected Reading Hutchins, Edwin. Cognition in the Wild. Cambridge: MIT Press, 1995. Lewin, Simon, and Scott Reeves. “Enacting ‘team’ and ‘teamwork’: Using Goffman’s Theory of Impression Management to Illuminate Interprofessional Collaboration on Hospital Wards.” Social Science and Medicine 72 (2011): 1595–1602.

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Scene 3 WHAT JUST HAPPENED? Context In this brief scene, Leah talks about witnessing a pharmacist blow up at a nurse in front of a patient—an explosion triggered by the nurse’s comment, “I’m simply trying to advocate for the patient.” In observing nurses and writing about nursing for years, Suzanne Gordon has been struck by nurses’ claim to patient advocacy and doctors’ irritation in responding to it. Many doctors respond in the same way as the doctor in this scene: “So what am I? The patient’s enemy?” Interestingly, doctors are not the only ones who react in this manner. In talking about her work in the hospital setting, a social worker told Suzanne Gordon that, whenever she walked into a patient’s room, the nurses became maternalistic. They act as if it is their job to protect the patient and that everyone else is about to harm the patient.

Group Discussion 1. Does nursing’s claim to patient advocacy put doctors and other health care staff at the same kind of disadvantage as medicine’s claim to esoteric scientific and diagnostic skill? 2. What impact does this have on developing effective interprofessional relationships between health care providers? 3. What other labels have you and others used to describe different categories of worker in the health care setting?

Selected Reading Gachoud, David, Mathieu Albert, Ayelet Kuper, Lynfa Stroud, and Scott Reeves. “Meanings and Perceptions of Patient-Centredness in Social Work, Nursing, and Medicine: A Comparative Study.” Journal of Interprofessional Care 26 (2012): 484–490. Nelson, Sioban, and Suzanne Gordon, eds. The Complexities of Care: Nursing Reconsidered. Ithaca: Cornell University Press, 2006.

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Scene 4 FRUSTRATED DOCTOR Context This scene, based on a true story, highlights the interprofessional conflicts and tensions that may occur at the bedside in front of patients. In this case, the physician felt his attempts to attend to the nurse’s concerns and solicit her input were in vain. There could be many reasons for the nurse’s behavior. Perhaps she had a bad experience with a patient in the past when opiates caused serious problems—complications for which she may have even been blamed. Her failure to explain her refusal to help manage the patient’s pain and provide an alternative suggestion clearly had serious consequences for the patient, as well as for nurse-physician relationships.

Group Discussion 1. What are the professional and interprofessional challenges that appear in this scene? 2. Could the doctor have dealt better with the nurse? If he asked the nurse to explain her concerns, could this have enlisted her support for finding a solution to the patient’s pain? 3. Could the nurse have more effectively expressed her concerns? Should she have presented an alternate plan for managing the patient’s pain? 4. Have you ever experienced a situation in which actions of another professional had a negative impact on patient safety and workplace morale?

Selected Reading Fisher, Roger, and Daniel Shapiro. Beyond Reason: Using Emotions as You Negotiate. New York: Penguin, 2005. Miller, Karen Lee, Scott Reeves, Merrick Zwarenstein, Jennifer Beales, Chris Kenaszchuk, and Lesley Gotlib-Conn. “Nursing Emotion Work and Interprofessional Collaboration in General Internal Medicine Wards.” Journal of Advanced Nursing 64 (2008): 332–343.

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Scene 6 SINGING THE FIRSTCODE BLUES Context What is notable about the interaction in this scene is the fact that the nurses are not comfortable directly coaching the doctor. They are playing a form of the doctor-nurse game in which they pretend that the physician knows what she is doing even when she clearly doesn’t. This doctor demonstrates “team intelligence” by recognizing that her authority is not diminished if she admits that she does not know everything. On a true team, leaders actively encourage input from team members, and team members coach one another without fear of reprimand.

Group Discussion 1. In teaching hospitals, who are the teachers, and who are the learners? 2. Do nurses teach doctors-in-training as well as more experienced physicians? How do doctors respond to this input? 3. What range of interprofessional learning activities could be used to improve this situation?

Selected Reading Chen, Chris W. Coaching Training. Alexandria, VA: American Society for Training and Development, 2003. Reeves, Scott, Joanne Goldman, and Ivy Oandasan. “Planning and Implementing Interprofessional Education for Health Care Professionals: Understanding Key Factors.” Journal of Allied Health 36 (2007): 231–235. Stein, Leonard. “The Doctor-Nurse Game.” Archives of General Psychiatry 16 (1967): 699–703. Stein, Leonard, David Watts, and Timothy Howell. “The Doctor-Nurse Game Revisited.” The New England Journal of Medicine 332 (1990): 546–549. Vaithianathan, G. H., et al. “Counterheroism, Common Knowledge, and Ergonomics: Concepts from Aviation That Could Improve Patient Safety.” Milbank Quarterly 89 (2011): 89. http://www.milbank.org/quarterly/8901feat.html.

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Scene 8 MIXUP Context In this clinic setting multiple staff members are responsible for the care of patients, many of whom are poor and may not share the staff ’s assumptions about appropriate behavior with regard to appointments. Such patients often do not show up or arrive late. The staff members, however, seem to greet each example of this “predictably unpredictable” behavior as if it had never happened before and as if they are completely taken by surprise. Patients thus constantly provoke minicrises like the one described in the scene. As a result, the staff becomes disorganized and falls into conflict.

Group Discussion 1. Do staff members in this setting function as a team? Do they have a shared mental model? 2. Does the “predictably unpredictable” happen frequently in your work setting? Do you and your team adequately prepare to deal with it? 3. How does perceived status shape communication and conflict in this scene?

Selected Reading Tucker, Anita L., and Amy C. Edmondson. “Why Hospitals Don’t Learn from Their Failures: Organizational and Psychological Dynamics That Inhibit System Change.” California Management Review 45 (2003): 55–72. Stout, R. J., et al. “Planning, Shared Mental Models, and Coordinated Performance: An Empirical Link Is Established.” Human Factors 41 (1999): 61–71.

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Scene 9 WHAT’S IN A NAME? Context This scene is based on an encounter Suzanne Gordon witnessed at a major teaching hospital. In this encounter, two doctors simply identified themselves as “Hem/Onc.” What impressed Gordon was the fact that neither the nurses nor the doctors seemed to think there was anything odd about this. The nurse did not introduce herself to the doctors nor did she inquire about their names. The doctors did not introduce themselves to the nurse. The nurse did not suggest a briefing before the doctor talked to the patient. No one communicated.

Group Discussion 1. How should nurses and doctors identify themselves to their patients and to each other? 2. What assumptions are being made when a health care professional uses words such as “Hematology” or “Oncology” as an introduction, and how might this affect the patient? 3. What types of profession-specific jargon do you use in your work? How do you think this affects your communication when discussing a patient with a colleague from another profession?

Selected Reading Buresh, Bernice, and Suzanne Gordon. From Silence to Voice: What Nurses Know and Must Communicate to the Public. 3rd ed. Ithaca: Cornell University Press, 2013. Hall, Pippa. “Interprofessional Teamwork: Professional Cultures as Barriers.” Journal of Interprofessional Care. 19 (2005): 188–196.

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Scene 10 READY FOR THE CALL Context This scene about a call to a physician reflects a common occurrence in hospitals and other health care settings. Its depiction of a young nurse failing to provide basic information to a physician during a middle-of-the-night phone call will ring true for both doctors and nurses. In mentoring the new graduate, this physician displays the “team intelligence” that helps another team member become more efficient and effective. Although the nurse is initially skeptical about the encounter, the physician makes it psychologically safe for the novice nurse to learn. He also reinforces lessons about SBAR that are usually taught only nurse to nurse.

Group Discussion 1. How often do you get a call or request from a colleague from another profession but feel they have not presented you with sufficient information to make a judgment or perform your role? 2. Is this an unusual occurrence or a common one, and what is your response—to blame the person or the situation, or to coach? 3. What are some effective strategies to overcome these shortfalls with interprofessional communication?

Selected Reading Edmondson, Amy C., and Josephine P. Mogelof. “Examining Psychological Safety in Innovation Teams: Organizational Culture, Team Dynamics, or Personality?” In Creativity and Innovation in Organizational Teams, edited by Leigh L. Thompson and Hoon Seok Choi. Mahwah, NJ: Lawrence Erlbaum Associates, 2005. Gordon, Suzanne. “On Teams, Teamwork, and Team Intelligence.” In First, Do Less Harm: Confronting the Inconvenient Problems of Patient Safety, edited by Ross Koppel and Suzanne Gordon, 196–220. Ithaca: Cornell University Press, 2012. Institute for Healthcare Improvement. “SBAR Technique for Communication: A Situational Briefing Model.” http://www.ihi.org/knowledge/Pages/Tools/SBAR TechniqueforCommunicationASituationalBriefingModel.aspx. Reeves, Scott, and Simon Lewin. “Hospital-based Interprofessional Collaboration: Strategies and Meanings.” Journal of Health Services Research and Policy 9 (2004): 218–225. Schein, Edgar H., and Warren G. Bennis. Personal and Organizational Change through Group Methods. New York: Wiley, 1965.

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Scene 11 LESSON OF THE DEHYDRATED BABY Context This real-life incident illustrates a total communication meltdown (or TCM). Its real-life side effects were significant. First of all, the incident occurred in front of the baby’s parents, who were shaken and distraught as a result. When the director of the residency program heard about it, he called for a staff meeting to discuss the incident. Unfortunately, in this discussion, the director’s tone was perceived as blaming and judgmental. He appropriately criticized the attending physician for leaving the scene and thus abandoning the patient. He did not ask the group to learn from the incident and consider how to do things better the next time. Both doctors and nurses left the meeting feeling attacked. Residents felt their director did not support them and instead “took the side of the nurses.” Nurses did not feel well supported by their managers. Perceiving that they were blamed, members of the “team” became defensive. This case offers an excellent opportunity to do a chain-of-error analysis and to rescript and reimagine alternative ways of behaving, learning, and teaching.

Group Discussion 1. Did the resident handle the situation effectively? What about the attending physician? 2. Did the nurse effectively express her concerns? 3. Did the participants lose situational awareness?

Rescripting the Scene An exercise a class or group watching the play can do is to reenact this scene. People can ask one another how it could be handled differently. First, play the scene as it was performed originally. Then, as in the exercise described above, ask people to think of concrete, specific things that each character could do or say that would change the dynamic. Then replay the scene per those suggestions. Below is the script of the original scene and some ideas for a rescripting.

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dehydrated baby: original version Nurse Joan Adams: Maybe we should let the baby rest and try getting the line in later. Dr. Jim Smith: I almost have it. Nurse Joan Adams: The baby’s exhausted. He’s practically turning blue from all the crying. Can’t we just let the baby rest for a little while? Dr. Jim Smith: Okay, I’ll get a cup of coffee and come back in half an hour. (He walks out of room and runs into Dr. Patricia Davis.) On your way home? Dr. Patricia Davis: This day seems like it’s been going on for a week. Dr. Jim Smith: Tell me about it. And this last thing—a dehydrated baby, and for the life of me, I couldn’t get a line in. I finally decided it would be better to let the baby rest and try again later. I hate to ask you this. Would you mind trying? I’ve heard how great you are at getting lines in. Dr. Patricia Davis: Sure. I’ll do it. Dr. Jim Smith: Thanks. I hate to bother you when you’re on your way home, but it would be great. Dr. Patricia Davis: No problem. (Walks into room and speaks to nurse very brusquely.) Get me a 24 gauge IV. Nurse Joan Adams: What? Dr. Patricia Davis: (Her tone is even more irritated.) Get me a 24 gauge IV. Nurse Joan Adams: What do you mean, an IV? (Turns to Dr. Jim Smith.) What’s going on? We agreed to let the baby rest. Are you trying to kill this baby? Dr. Patricia Davis: You don’t want my help? Fine. I’m out of here. (Storms out.) Dr. Jim Smith: (Starts after Dr. Patricia Davis.) Hey, I’m sorry. (Turns to Nurse Joan Adams.) What is your problem? Do you have any idea? (Shakes head, runs after Dr. Patricia Davis.) Look, I’m sorry.

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dehydrated baby: rescripted version Nurse Joan Adams: Maybe we should let the baby rest and try getting the line in later. Dr. Jim Smith: I almost have it. Nurse Joan Adams: The baby’s exhausted. She’s practically turning blue from all the crying. Please, can’t we just let the baby rest for a little while? Dr. Jim Smith: Okay, I’ll get a cup of coffee and come back in half an hour. (He walks out of room and runs into Dr. Patricia Davis.) On your way home? Dr. Patricia Davis: This day seems like it’s been going on for a week. Dr. Jim Smith: Tell me about it. And this last thing—a dehydrated baby, and for the life of me, I couldn’t get a line in. We finally decided it would be better to let the baby rest and try again later. I hate to ask you this. Would you mind trying? I’ve heard you’re great at getting lines in. Dr. Patricia Davis: Sure. I’ll do it. Dr. Jim Smith: Thanks. I hate to bother you when you’re on your way home, but it would be great. Listen, the nurse and I agreed that we wouldn’t try to get a line in for a while. Let me introduce you to her and explain what’s going on. (They enter the room where the nurse is with the baby.) Hey, Joan, this is Doctor Patricia Davis, a pediatric intensivist. She’s really good at getting IVs in. I asked her if she could just try and see if we can take care of this now. If it doesn’t work, we’ll stop. What do you think about that? Nurse Joan Adams: Are you sure? Dr. Patricia Davis: I think I can do it; just give me one try. Nurse Joan Adams: Okay. What do you need?

dehydrated baby: additional alternatives Note: If the nurse were to ask “What if she can’t get the line in?” or if Dr. Patricia Davis doesn’t succeed in getting the line in, the resident could then say, “Let’s assess the situation. We’ve got a baby in tough shape. How long can we afford to wait before getting a line in? We need to discuss our options.”

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The next step could be returning to Scene 1 and asking participants how the scene could be changed if the nurse used a different strategy. For example: Nurse Joan Adams: (To attending physician.) We haven’t met. I’m Nurse Joan Adams. I’ve been with this patient for the past three hours, and I’m concerned about how agitated the baby’s getting. We’d agreed to let the baby rest. (Turning to the resident.) Can you help me understand why you changed your mind?

Selected Reading Schein, Edgar H. Helping: How to Offer, Give, and Receive Help. San Francisco: BarrettKoehler, 2011. Baron, Robert A. “Negative Effects of Destructive Criticism: Impact on Conflict, SelfEfficacy, and Task Performance.” Journal of Applied Psychology 73 (1988): 199–207.

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Scene 12 PERILS OF THE ANGRY NURSE Context Nurses sometimes joke about putting doctors in their place and “teaching them a lesson.” This kind of behavior is not a joke nor does it “teach” anybody much of anything. It does, however, have a serious impact on the possibility of creating or improving teamwork. Such passive-aggressive communication may appear to be a viable response to a problematic and unequal power relationship. If one reframes the issue in terms of safety and teamwork, this behavior and attitude firmly positions people not only in separate silos but also on opposing teams.

Group Discussion 1. Why do you think the nurse chose this method of interprofessional communication to deal with the physician? In your institution, do nurses welcome residents, interns, and medical students, or do they “put them in their place?” 2. How do unequal power interprofessional relationships affect one’s choice of communication style or strategy? 3. How can a nurse manager, attending, or chief physician have an impact on interprofessional communication in such a situation?

Selected Reading Gordon, S., and B. O’Connor. “What Goes without Saying in Patient Safety.” In First, Do Less Harm: Confronting the Inconvenient Problems of Patient Safety, edited by Ross Koppel and Suzanne Gordon, 41–61. Ithaca: Cornell University Press, 2012. Gotlib Conn, Lesely, Lorelei Lingard, Scott Reeves, Karen Lee Miller, Ann Russell, and Merrick Zwarenstein. “Communication Channels in General Internal Medicine: A Description of Baseline Patterns for Improved Interprofessional Collaboration.” Qualitative Health Research 19 (2009): 943–953.

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Scene 13 LESSONS FROM THE AIRLINES Context For many years, Suzanne Gordon has been interviewing and observing pilots, flight attendants, and other airline staff in an effort to better understand how the airline industry pioneered the kind of safety movement the character Leah talks about here. Crew Resource Management (CRM), is an amazing model that works. The story included in the play came from a pilot for Federal Express. The captain explained how he deliberately solicited the concerns of his first officer and worked to include him in decision making. The captain also gave Suzanne a card that pilots carry in their flight kits. These lessons from the aviation safety model demonstrate that it is possible to transform toxic hierarchies and create teams even when people have never met before and may never meet again, as was the case with these two pilots.

Group Discussion 1. How is the story from aviation applicable to health care? 2. How are the responsibilities of an interprofessional team leader and a team member illustrated in this scene? 3. Are there models of safety and teamwork from other industries that could be useful to improve interprofessional relationships in health care?

Selected Reading Baker, Lindsay, Eileen Egan-Lee, Maria (Tina) Martimianakis, and Scott Reeves. “Relationships of Power: Implications for Interprofessional Education and Practice.” Journal of Interprofessional Care 25 (2011): 98–104. Gordon, Suzanne, Patrick Mendenhall, and Bonnie Blair O’Connor. Beyond the Checklist: What Else Health Care Can Learn from Aviation Teamwork and Safety. Ithaca: Cornell University Press, 2013. Musson, David, and Robert L. Helmreich. “Team Training and Resource Management in Healthcare: Current Issues and Future Directions.” Harvard Health Policy Review 5 (2004): 25–35. Nembhard, Ingrid M., and Amy C. Edmondson. “Making It Safe: The Effects of Leader Inclusiveness and Professional Status on Psychological Safety and Improvement Efforts in Health Care Teams.” Journal of Organizational Behavior 27 (2006): 941–966.

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Scene 14 MORNING REPORT Context When an attending physician told us this story, we were impressed by the way he dealt with the resident. He did not just ignore her response to the nurse nor did he chew her out for her misbehavior. The attending also highlighted how the resident’s fear and anger response overwhelmed her situational awareness. He noted that instead of lashing out, the resident should have paused, taken a few deep breaths, and asked more questions. Moreover, the attending explicitly suggested that the resident seek out the nurse and apologize for her outburst.

Group Discussion 1. To what extent do people routinely act civilly and respectfully in your workplace? Is that the rule or the exception? 2. Do any of your colleagues or coworkers routinely apologize if they “lose it?” 3. Do team leaders routinely coach team members in better ways of interprofessional working and communicating with one another?

Selected Reading Chen, Chris. Coaching, Training. Alexandria, VA: ASTD Press, 2003. Lazare, Aaron. On Apology. New York: Oxford University Press, 2005. Reeves, Scott, Kathleen MacMillan, and Mary van Soeren. “Leadership within Interprofessional Health and Social Care Teams: A Socio-Historical Overview of Some Key Trials and Tribulations.” Journal of Nursing Management 18 (2010): 258–264.

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Scene 15 DR. MILLER DOESN’T TELL ME SQUAT Context Much of traditional health care professional training is focused on offering profession-specific experiences with dyads of doctor-patient, nursepatient, social worker–patient and so forth. Communication and information must circulate among all relevant professionals if patients are to be safe and health care providers are to have a satisfying work experience. Moreover, interprofessional communication and collaboration must be defined in inclusive rather than exclusive terms. Suzanne Gordon recently interviewed a physician who was baffled because a nurse did not understand the plan of care made for his patient. This nurse had expressed her concern that the doctors were utilizing futile treatments to keep the patient alive. The physician told Gordon that the patient’s relative was flying in from abroad and the patient hoped to hold on for just a few extra days to see her one last time. The doctor explained: “I don’t understand why the nurse doesn’t understand this. I mean, we discussed all this with the team.” Gordon asked the physician who was included in that conversation. “The residents, me, pulmonology,” he said, naming another medical specialty. Nursing was not included in the conversation. It’s no wonder the nurse didn’t understand what was going on. Gordon has also written extensively about the problematic phrase “just a nurse.” The consequences of this concept are illustrated in this scene and the following one.

Group Discussion 1. How do doctors and nurses in your institution learn interprofessional communication skills? 2. Do discussions about patient care and safety routinely include more than one profession or occupation? How do you define “team,” and “colleague” in your workplace? 3. Have you heard or used the phrase “just a nurse”? What was the context? What effect do these traditional ways of thinking have on patient care?

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4. What range of interprofessional education opportunities could be offered to improve this situation?

Selected Reading Frosch, Dominick L., Suepattra G. May, Katharine A. S. Rendle, Caroline Tietbohl, and Glyn Elwyn. “Authoritarian Physicians and Patients’ Fear of Being Labeled ‘Difficult’ among Key Obstacles to Shared Decision Making.” Health Affairs 31 (2012): 1030–1038. Zwarenstein, Merrick, and Scott Reeves, “Working Together but Apart: Barriers and Routes to Nurse-Physician Collaboration.” The Joint Commission Journal on Quality Improvement 28 (2002): 242–247.

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Scene 16 HOW MANY DEAD BABIES DOES IT TAKE? Context Unfortunately, this story is true. It illustrates the threat to patient safety when there are no team relationships. Although Youngson tried to raise crucial issues with a senior physician and persisted in her advocacy for patients, she was inhibited not only by the physician’s response but also by her conviction that she could go no further because she was “just a nurse.” Since her experience Youngson has left nursing. But she has not stopped talking about the lessons she learned from this incident. She advises nurses— and other professionals or health care workers—to be prepared in a similar situation. She tells them to use every tool in the book to continue to protect patients. She also feels that the medical system discouraged Dr. Odim from admitting that he needed help. In the medical system, some senior doctors think junior doctors will learn best if they are plunged into deep waters and left to sink or swim. The problem is, patients may sink with them. These attitudes place patients and their caregivers in great jeopardy. The total communication meltdowns (TCMs) that often result guarantee the worst patient outcomes.

Group Discussion 1. 2. 3. 4.

What do you think motivated Dr. Odim? What do you think motivated the other physicians? Were the doctors right? Was this a medical and not a nursing issue? In a similar situation, is there such a thing as a medical issue that is not a nursing issue or a nursing issue that is not a medical issue?

Rescripting Again, a rescripting exercise is a productive way to look at this particular scene. First, play the scene as it was performed originally. Then, as in the workshop described above, ask people to think of concrete, specific things that each character could do or say that would change the dynamic. Then replay the scene per those suggestions. Below is an enactment based on the original scene and some ideas for a rescripting.

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Nurse Carol Youngson I really want to talk to you about what’s going on in the OR. We’re all very concerned that Dr. Odim is in over his head. As you know, four babies have died and six have suffered terrible complications. I’m speaking now for nurses in the OR, NICU, and PICU. We’d really appreciate it if you’d scrub in on one of Odim’s operations to observe his technique. Winnepeg Doctor 2 Carol, I don’t take orders from nurses. Nurse Carol Youngson (Looks stunned, says nothing, turns around and leaves.)

version two: Nurse Carol Youngson I really want to talk to you about what’s going on in the OR. We’re all very concerned that Dr. Odim is in over his head. As you know four babies have died and six have suffered terrible complications. I’m speaking now for nurses in the OR, NICU, and PICU. We’d really appreciate it if you’d scrub in on one of Odim’s operations to observe his technique. Winnepeg Doctor 2 Carol, I don’t take orders from nurses. Nurse Carol Youngson That certainly wasn’t my intention. Four babies have died in the OR, and six others have had serious postsurgical complications. Many of us, including PICU and NICU nurses as well as a number of anesthetists, are concerned about Dr. Odim’s technique. But we are not surgeons. That’s why we need your expertise. Winnepeg Doctor 2 Carol, don’t you think you’re being alarmist? Nurse Carol Youngson I wish I were. I can’t tell you how delighted I would be to be proven wrong. Winnepeg Doctor 2 Well, Carol, you know, this is really a medical, not a nursing, issue. Nurse Carol Youngson I couldn’t agree with you more, which is exactly why we’re asking you to scrub in.

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Selected Reading Gordon, Suzanne. Nursing against the Odds: How Health Care Cost Cutting, Media Stereotypes, and Medical Hubris Undermine Nurses and Patient Care. Ithaca: Cornell University Press, 2005. ——. “Suzanne Gordon Interviewing Carol Youngson.” http://www.youtube.com, June 3, 2009. Quality and Safety in Nursing Education (QSEN). “QSEN: The Lewis Blackman Story (Part One),” http://www.youtube.com/watch?v=WElE_hRucpo, and other teaching resources, http://www.qsen.org/.

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Scene 17 A CASE FOR NO HIERARCHY Context The Josie King story has been much publicized. The Johns Hopkins Hospital has done extensive pioneering work in the area of patient safety, as has Sorrel King, who was the mother of the toddler Josie King mentioned in this scene. The points Leah makes about toxic interprofessional hierarchy are illustrated in this case, in which no one listened to the concerns of the family or certain nurses. The flattening of the hierarchy in health care is the only way to make patient safety a reality.

Group Discussion 1. What have you heard about the Josie King case and the efforts of Sorrel King and the Josie King Foundation to improve patient safety? 2. How does your institution respond to problems in patient safety (e.g., near misses, clinical errors)? 3. How interprofessional are the patient safety initiatives that are implemented in your institution? 4. What strategies could be used to flatten hierarchical interprofessional relations that exist across health care settings?

Selected Reading King, Sorrel. A Mother’s Inspiring Crusade to Make Medical Care Safe. New York: Atlantic Monthly Press, 2009. Reason, James. “Human Error: Models and Management.” BMJ 320 (2000): 768–770. Weick, Karl E., and Kathleen M. Sutcliffe. Managing the Unexpected: Resilient Performance in an Age of Uncertainty. 2nd ed. San Francisco: Jossey-Boss, 2007.

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Scene 18 TO EXPLAIN OR NOT TO EXPLAIN Context Suzanne Gordon heard this story from an RN working at a children’s hospital. In this case, the nurse did not explain why he believed that an order was inappropriate or why he was concerned about his patient’s lack of sleep. In fact, when the nurse told Gordon the story, he said that as an experienced nurse, he didn’t have to express his concerns directly to the resident. He was, however, quite irate at the resident’s response. This scene illustrates how people who should approach each other as colleagues instead often approach each other with a professional “chip on the shoulder,” which is both difficult to dislodge and prevents clear communication. This scene also highlights the issue of fatigue. The resident mentions her lack of sleep, which has made her more irritable. The issue of fatigue— experienced by both doctors and nurses—is a critical one to address to improve teamwork and patient safety because studies have documented that irritability is a common side effect of fatigue and can make communication less effective.

Group Discussion 1. What issues does this scene raise regarding medical “orders,” how they are given, how they are followed by members of other professional groups? 2. How could this scene have played out if a different approach to interprofessional collaboration had been used? 3. How does fatigue affect your ability or willingness for interprofessional communication and collaboration?

Selected Reading Dunn, E. J., et al. “Medical Team Training: Applying Crew Resource Management in the Veterans Health Administration.” Joint Commission Journal on Quality and Patient Safety 33 (2007): 317–325. Landrigan, Christopher P. “Physicians, Sleep Deprivation, and Safety.” In First, Do Less Harm: Confronting the Inconvenient Problems of Patient Safety, edited by Ross Koppel and Suzanne Gordon, 150–167. Ithaca: Cornell University Press, 2012.

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Reeves, Scott, Kathleen Rice, Lesley Gotlib Conn, Karen Lee Miller, Chris Kenaszchuk, and Merrick Zwarenstein. “Interprofessional Interaction, Negotiation and Nonnegotiation on General Internal Medicine Wards.” Journal of Interprofessional Care 23 (2009): 633–645. Salas, Eduardo, et al. “Toward an Understanding of Team Performance and Training.” In Teams: Their Training and Performance. Edited by Robert W. Sweezey and Eduardo Salas. Norwood, New Jersey: Ablex, 1992. Trinkoff, Alison M., and Jeanne Geiger-Brown. “Sleep-deprived Nurses: Sleep and Schedule Challenges in Nursing.” In First, Do Less Harm: Confronting the Inconvenient Problems of Patient Safety, edited by Ross Koppel and Suzanne Gordon, 168–179. Ithaca: Cornell University Press, 2012. U.S. Department of Health and Human Services. “TeamSTEPPS: National Implementation.” http://teamstepps.ahrq.gov/.

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Scene 19 STOPPING THE LINE As we said above, psychological safety is a key—perhaps the key— component in teamwork and patient safety. Staff in many hospitals and other health care settings recount being told they should act assertively if they fear a mistake is being made. When they do (particularly if they are pointing out a mistake being made by someone higher up the chain of command), they might not be thanked but instead be penalized. This is something the surgeon who told us this story understood all too well. He understood that you can’t just tell staff to act assertively to protect patients; you have to teach them how to do it constructively, and when they put these lessons into practice, they have to be supported—publicly. That is precisely what this senior surgeon and safety leader did in this real-life case.

Group Discussion 1. How many people in your institution, unit, or setting would feel comfortable pointing out a mistake to a person higher up in the health care hierarchy? 2. How many “leaders” or “superiors” in your institution would respond the way this surgeon did? 3. Do you feel psychologically safe in your work environment?

Selected Reading Edmondson, Amy C. “Managing the Risk of Learning: Psychological Safety in Work Teams.” In International Handbook of Organizational Teamwork and Cooperative Learning, edited by M. A. West, D. Tjosvold, and K. G. Smith. New York: Wiley, 2003. ——. Teaming: How Organizations Learn, Innovate, and Compete in the Knowledge Economy. San Francisco: Jossey-Bass, 2012.

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Scene 21 STAY AND WATCH Context This scene is taken from the article “Watchers” by Stewart Massad, which appeared in JAMA on March 22, 1995, and is used in the play with permission. This article was the inspiration for making the character “Leah” the narrator of this play. The last scene reconnects with the earlier scene in which we meet the veteran nurse Leah who wonders whether the young intern will remember the help she gave him as he matures as a physician. We ended that scene with a question. In this poignant last scene, the physician answers that question. Yes, he remembers. Not just privately but by writing this story he publicly honors the lessons this nurse taught him. He credits Leah with teaching him how to be a doctor. This act of giving public credit to a team member—especially one considered lower on the health care ladder—is the very essence of teamwork.

Group Discussion 1. What interprofessional communication, collaboration, and teamwork insights have you gained from this play? 2. Given the complexity of the interprofessional issues raised by the play, what are the three most important elements that perpetuate the poor relations among health care professionals? 3. When it comes to thinking about interprofessional collaboration, teamwork, and the notion of “team intelligence,” what changes would you like to see in your workplace?

Selected Reading Massad, Stewart. “Watchers.” JAMA 273, no. 12 (March 22, 1995): 914. Weick, Karl, and Kathleen Sutcliffe. “Mindfulness and the Quality of Organizational Attention.” Organization Science 17 (July/August 2006): 514–524.

Role-Play Activities Below we have provided a range of role-play activities based on a selection of scenes from the play. We have included ideas about how to set up the roleplays and also how to enact them to ensure effective interprofessional interaction between participants.

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Prologue

Select one of the interprofessional conflicts mentioned in the prologue and have participants identify a similar situation they have encountered. On one side of a blank piece of paper, they should write a description of the event from their own point of view. On the other side of the paper, they should write a description of the event from the perspective of the other individual involved. Gather all of the reflections, and put them in a container. Ask participants to pair up. Each pair will draw one reflection and create a short scene based on that event. Then ask one pair to perform their scene. (During this performance, if anyone has an idea of how the scene might be changed, that person should say, “Stop.” The participants should stop, and the person with the new idea should step into the role of one of the characters and continue the scene using a different strategy. This process can be repeated to see what other strategies might be employed in the same situation). When finished with the first pair’s scene, if time allows, repeat the whole process with the other pairs’ selected scenes.

Scene 1

Ask participants to write a personal story about being a patient in a hospital or being at the hospital bedside of a family member. Include specific examples of how interprofessional challenges had an impact on the quality of care the participant or the family member received. Ask participants to pair up and share their stories. Use these recounted experiences and turn them into roleplay activities.

Scene 2

Ask participants to write down the last time they recall being acknowledged for their work or the last time they acknowledged a colleague from their own or a different profession. Divide participants into groups and have them share

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their reflections. Ask them to consider the implications of the attending physician’s hasty response to the resident. Have each group create a new scene, using either the situation in the play or a similar situation shared by a group member. Incorporate the more positive interprofessional communication or collaboration strategies that the group discussed.

Scene 4

Have participants write down a situation in which a colleague’s actions had a negative impact on patient safety or workplace morale. Have participants share their reflections. Pick one or more situations and, as a group, develop strategies regarding how other team members might have addressed the situation. Have participants act out one or more of the situations discussed above.

Scene 6

Ask participants to write a description of a situation they have seen or heard about in which workers supposedly lower on the health care ladder taught something to someone “higher up.” Ask participants to then fold up their written descriptions and put them in a box. Then ask them to pair up. Each team draws a description from the box and does a role-play exercise based on the situation described.

Scene 9

Give participants two minutes to make a list of all the names, abbreviations, and other “jargon” routinely used when communicating with patients and with each other in front of patients. Ask participants to divide into groups and share examples of their own experiences with titles and jargon. Then ask them to create two scenes: an “original” scene that shows a negative use of names, abbreviations, or jargon and a “re-do” scene that illustrates how using one of the strategies discussed by the group could change a situation.

Scene 10

Ask participants to write about their own experience of not being fully prepared for a conversation with another team member. Ask participants to pair up and create a scene displaying ineffectual interprofessional communication during a phone call. After each team performs its scene, the rest of the group should brainstorm more effective communication strategies. Then the team should reperform the scene using these new strategies.

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Scene 12

Have participants write three examples of ways in which they have seen a colleague “teach a lesson” to another colleague from a different profession. Have participants share their examples and brainstorm more effective interprofessional strategies. Divide participants into groups, pick one “teach a lesson” example, and create two scenes—an “original” that illustrates a passive-aggressive communication strategy and a “re-do” that employs some of the strategies previously discussed.

Scene 13

Ask participants to write a description of a situation in which a higher-ranking professional solicited the concerns of someone lower on the health care hierarchy. Ask participants to share their examples. Then ask the group whether this kind of encouragement is the rule or the exception in their workplace. Divide into small groups. Have each group create a scene that illustrates the way CRM techniques can be used in their workplace to improve interprofessional relations. Perform the scenes and discuss.

Scene 14

Ask participants to write an example of a time when a colleague “lost it” and an example of when they themselves “lost it” with a coworker from another profession. Ask participants to share their examples with the group, and discuss ways in which the situations described might have been changed by different behavior. Ask participants to divide into pairs and write an apology scene based on one of the scenarios described. Then ask them to rescript the initial encounter in a way that changes the interprofessional dynamic of the scene and makes an apology unnecessary.

Scene 15

Ask participants to write three examples of training they received in intra- or interprofessional communication and conflict resolution. Ask participants to share their examples. As a group, brainstorm ways in which health care education could include more interprofessional training (formal and informal) to enhance communication, collaboration, and teamwork. Ask participants to divide into pairs and create a script of the scene Leah describes so that the nurse is more proactive with the physician.

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Scene 17

Ask participants to write about an incident of a serious clinical error at their institution and analyze how faulty communication or system failures contributed to the problem. Divide participants into groups. Each group should choose a specific situation and create a scene in which participants take an active role in transforming institutional culture (e.g., a scene in which “venting” is transformed into problem solving; a scene in a nurse manager’s or physician chief’s office during which team members make a case for changing a protocol).

Scene 18

Ask participants to make a list of three examples of when they were slow to act on medical orders or suggestions because they did not agree with them. Have participants share their examples and, as a group, strategize alternative approaches to dealing with the situations described. Divide participants into pairs and choose one of the incidents they described. Have them create two scenes, the “original” scene and then a “re-do” version that employs some of the strategies discussed.

Scene 21

Have participants write a description of their own “Leah,” someone who has influenced how they do their job and think about their profession. After participants share their stories, have the group brainstorm ways in which they could implement ongoing skill building in interprofessional communication and collaboration at their institution. Divide participants into pairs. Have each pair create a scene of transformation, an imagined encounter between one of them and a leader in their institution who has the power to make a change.

Notes

Note to the Play 1. The authors have no formal or informal affiliations with the manufacturers of any brand name—or other—drug mentioned herein.

Notes to the Workbook 1. Although we use the term “interprofessional” to describe collaborative education and practice activities, we do not restrict our view of “profession” to include only the usual suspects (physician, nurse, social worker). We have adopted a broader perspective to cover those individuals who work with the traditional professions in health care settings, including unit clerk, housekeeper, transport worker. 2. For permission to adapt the play, contact Suzanne Gordon at [email protected]. 3. See http://teamstepps.ahrq.gov/. 4. TRIZ is “a problem-solving, analysis, and forecasting tool derived from the study of patterns of invention in the global patent literature” that has been used in efforts to create behavioral change. Wikipedia, “Triz.” http://en.wikipedia.org/wiki/TRIZ, accessed March 12, 2013. 5. Edgar H. Schein, Helping: How to Offer and Receive Help (San Francisco: Barrett-Koehler, 2011), 3. 6. Suzanne Gordon, “Teams, Teamwork, and Team Intelligence,” in First, Do Less Harm: Confronting the Inconvenient Problems of Patient Safety, ed. Ross Koppel and Suzanne Gordon (Ithaca: Cornell University Press, 2012), 196–220. 7. Edwin Hutchins, Cognition in the Wild (Cambridge: MIT Press, 1995). 8. Suzanne Gordon, Patrick Mendenhall, and Bonnie O’Connor, Beyond the Checklist: What Else Health Care Can Learn from Aviation Teamwork and Safety (Ithaca: Cornell University Press, 2013). 9. Robert C. Ginnett, “Crews as Groups: Their Formation and Their Leadership,” in Cockpit Resource Management, ed. Earl L. Wiener, Barbara G. Kanki, and Robert L. Helmreich (San Diego: Academic Press, 1993), 89.

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NOTES TO PAGES 56–63 10. Edgar H. Schein and Warren G. Bennis, Personal and Organizational Change through Group Methods (New York: Wiley, 1965), 44–45. 11. Amy C. Edmondson, “Managing the Risk of Learning: Psychological Safety in Work Teams,” in International Handbook of Organizational Teamwork and Cooperative Learning, ed. M. A. West, D. Tjosvold, and K. G. Smith (New York: Wiley, 2003), 258. 12. Centre for the Advancement of Interprofessional education website, http://www.caipe. org.uk/resources/. 13. Liberating Structures website, 25/10 Crowd Sourcing, http://www.liberating structures.com/12-2510-crowd-sourcing, accessed December 8, 2012. 14. Erving Goffman, Presentation of Self in Everyday Life (Garden City, NY: Doubleday Anchor Books, 1959). 15. Leonard Stein, “The Doctor-Nurse Game,” Archives of General Psychiatry 16 (1967): 699–703.

About the Authors

Suzanne Gordon is an award-winning journalist and author who writes about health care delivery and health care systems. She is the author, coauthor, or coeditor of fifteen books, including First, Do Less Harm: Confronting the Inconvenient Problems of Patient Safety; Beyond the Checklist: What Else Health Care Can Learn from Aviation Teamwork and Safety; Nursing against the Odds: How Health Care Cost Cutting, Media Stereotypes, and Medical Hubris Undermine Nurses and Patient Care; and Safety in Numbers: Nurse-to-Patient Ratios and the Future of Health Care. She has written for Harper’s, the Atlantic, the New York Times Magazine, the Boston Globe, the New York Times, the Los Angeles Times, the Toronto Globe and Mail, and many other publications. She has been a radio commentator for CBS Radio and National Public Radio’s Marketplace. She is on the editorial board of the Journal of Interprofessional Care and is an assistant adjunct professor at the University of California School of Nursing. Lisa Hayes is an accomplished playwright and actor. As a playwright, her most recent creation is the musical Breast in Show, written with the composer and lyricist Joan Cushing, an exploration of the many facets of breast cancer. As an actor, Hayes has performed her one-woman show of Jane Eyre (eighty minutes, twenty-five characters) across the United States and at festivals in Edinburgh and Prague. And following the off-Broadway debut of her solo performance of Nurse! (based on interviews with nurses), she has performed the play in Rome, Krakow, and Istanbul, as well as in cities in the United States. After completing a PhD in American Studies from the University at Buffalo, Hayes added public history to her repertoire of careers. She is president and CEO of the Accokeek Foundation in Maryland, which stewards two hundred acres of Piscataway Park, a national park on the Potomac River directly across from George Washington’s Mount Vernon. 97

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ABOUT THE AUTHORS

Scott Reeves is professor of social and behavioral sciences and the founding director of the Center for Innovation in Interprofessional Education, University of California, San Francisco, and editor-in-chief of the Journal of Interprofessional Care. He is a social scientist with a PhD in health services research who has been undertaking health professions education and health services research for nearly twenty years. His main interests include the development of conceptual, empirical, and theoretical knowledge to inform the design and implementation of interprofessional education and practice activities. He has published over 120 peer-reviewed papers, numerous book chapters, textbooks, reports, and monographs, and many of his books and chapters have been translated from English into other languages, including Japanese, Norwegian, and Russian.