Breaking down barriers
By Sue Brailey on 25 May 2018 Midwives Magazine
Sue Brailey explains why how we address each other within the interdisciplinary team has a large impact on how a team communicates and works together.
The #hellomynameis campaign was launched in 2014 by the terminally ill doctor Kate Granger (hellomynameis.org.uk, 2017). Kate, who died in 2016, had been shocked and disappointed that, while on the receiving end of healthcare, she found that many healthcare professionals failed to introduce themselves. She started the campaign in order to remind staff about the importance of introductions in healthcare and to promote person-centred compassionate care. Since the launch of the campaign, many trusts have introduced name badges for their staff with the words ‘Hello, my name is… [for example] Jane or Bill’. Most healthcare workers have embraced this opportunity to break down barriers, but some members of the medical profession have refused to have their first name on the badges, insisting on being referred to as, for example, Dr Smith.
Efforts to improve communication between healthcare professionals and service users has had the unintentional effect of highlighting schisms within the interprofessional team. While, at first glance, terms of address appear an innocuous detail, the effect of this distinction is to reinforce status and hierarchy among healthcare workers. The midwifery and medical profession often have a discordant relationship, highlighted by governmental investigations into poor care such as the Morecambe Bay inquiry (Kirkup, 2015). Poor working relationships between midwives, obstetricians and paediatricians have been identified as resulting in a ‘them and us’ culture leading to poor communication that can hinder clinical care (Kirkup, 2015; Department of Health (DH), 2013; Taran, 2011). So how can improvements be made to the current working situation between midwives and the medical profession?
The organisation of the NHS is hierarchical. Formed shortly after the second world war, it seemed logical to base its structure along army lines, which is reflected in terms such as ‘house officer’ or ‘doctors’ mess’. The existence of hierarchy within organisations has been identified as being problematic (Weller et al, 2014; Barrington-Bush, 2013; Gladwell, 2008) for the following reasons: hierarchies tend to assume the worst in people, a system where people have to ‘work their way up’ encourages people to gloss over their weaknesses and play up their strengths, reducing opportunities for learning. Hierarchies encourage decision-making outside the situations where they will be applied. Decisions affecting women and midwives are often made by people high up in the hierarchy distanced from practice situations, resulting in sometimes unpopular decisions that can impact poorly on client care.
A problem with the existence of hierarchy within healthcare provision is that it can negatively impact interprofessional communication and consequently patient care and safety (Kirkup, 2015; DH, 2013; Alvarez and Coiera, 2006; Sutcliffe et al, 2004).
Lessons from the airline industry
The NHS can be compared in many ways with the airline industry: it is expensive, with a potential for mistakes to cause loss of life. Many of the processes used to reduce errors within healthcare have their origins in the airline industry: for example, the use of checklists and formalised handover procedures. Hofstede (2001) identified power differentials as causing errors and coined the term ‘power distance index’ to describe attitudes towards hierarchy and how much a culture respects and values authority.
An example of the potential danger of a large power distance can be seen in the story of Korean Air. In the 1990s, Korean Air had a very poor safety record. Black-box recordings following crashes suggested that airline crew were so subservient to their captains that they allowed planes to crash rather than contradicting or challenging their captain. This large power distance was recognised by new management, and measures were introduced to improve communication. One new measure was the insistence that all crew members call each other by their first name. The use of first names was recognised as being key to improving communication between staff members. Using first names in the clinical area could result in more equality among people thereby encouraging debate, discussion and more effective teamwork. Now Korean Air is as safe as any airline (Gladwell, 2008).
One of the recognised inhibitors of good communication and subsequent good-quality care is the existence of professional tribes (Weller et al, 2014; Baxter and Brumfitt, 2008). The insistence of some medical members on not being on first-name terms with other members of the interprofessional teams reflects the existence of tribes within healthcare and can be viewed as a reinforcement of status and power within the hierarchy.
Tribes within healthcare arose due to the establishment of professional groups, which were originally designed to protect and regulate standards of care. Over time, they developed a unique culture transmitted through a process of socialisation that starts in training. Physicians are trained to take charge and assume responsibility for decisions and, alongside the high status afforded the medical profession in society, reinforced by gender and class issues (Hall, 2005), this disparity of power and status among healthcare professions can make for uneasy interprofessional working.
The doctor-nurse game originally described back in the 1960s (Stein, 1968) is still being played out in maternity wards (Holyoake, 2011), where the power dynamics of hierarchies can foster dishonesty and poor information-sharing (Barrington-Bush, 2013). The disempowerment experienced by many lower down the hierarchy encourages subterfuge. An illustration of this can be found in the anecdotal inaccurate reporting of vaginal examinations. Rather than having an open discussion with colleagues about cervical dilatation rates in labour, the powerlessness felt by many midwives can lead to discrepant reporting on vaginal examinations that results in a false narrative on the true progress of labour.
Lack of a shared mental model
One of the effects of tribalism among healthcare professions is professional isolationism resulting in a lack of a shared world view or mental model (Weller et al, 2014). A recent example of this can be seen in the discourse between Lesley Page, then-president of the RCM, and obstetrician Hans Peter Dietz, on the dangers of normal birth ideology (Dietz, 2017; Page, 2017). This involved an exchange about normal birth with both parties revealing diametrically opposing views and contradicting mental models when talking about the same topic. The existence of a shared mental model has been identified as one of the critical underpinning mechanisms of effective teamwork (Salas et al, 2008). The absence of a shared mental model can result in two disciplines looking at the same thing but seeing two very different things (Petrie, 1976). This is a common occurrence in maternity care, when midwives and doctors can have diametrically opposed views of a given scenario, a situation that can negatively impact on women and babies’ care. Without
a shared mental model, members of the team are unable to fully contribute to clinical care.
Shared mental models lead to a common understanding of a situation, resulting in efficient problem-solving and decision-making. Crucial to the development of a shared mental model is effective communication and collaborative practice. But how can this be promoted?
Forming a healthcare team from a collection of different disciplines to form a cohesive whole with common goals can be a way of facilitating interprofessional working (Weller et al, 2014). This can also help to develop a common mental model or world view. The formation of democratic teams with flat hierarchies, in which every member feels valued, encourages open team communication and therefore improves patient care. This can be promoted by the use of first names, as how people address each other has a powerful impact on people’s perception of hierarchy and their place within it.
Multidisciplinary teams of different professions often result in members of the team behaving in accordance with their own tribe rather than collaborating with each other. Encouraging people to view themselves as a healthcare professional rather than as a doctor or midwife may help to establish more collaborative working practices (Weller, 2012). This concept is very much aligned to ‘communities of practice’ (Wenger, 1998), a theory describing how people can effectively work together. The community of practice has a shared goal, common interests and practice; members of the community learn together about their domain in practice and develop shared language and tools. Many commonalities exist between doctors and midwives, but a strong hierarchical structure often serves to hinder the development of a community.
Education for health professionals remains largely discipline-specific with minimal interaction between the professions: this serves to reinforce the existence of professional tribes. Convincing universities to combine some aspects of medical and midwifery training has often proved to be problematic, and consequently few examples of this opportunity exist. Few healthcare professionals receive specific training on teamwork and, while many improvements have been made in medical training on how to communicate with patients, less emphasis lies on communication with other healthcare professionals (Brindley and Reynolds, 2011).
Training teams together is recognised as promoting interdisciplinary teamwork and improving outcomes (Reeves et al, 2017; Weller et al, 2014). Teams that work together should train together, and many hospitals now try to facilitate this in the form of mandatory training. However, this training often results in midwifery study days with junior members of the medical team attending some days. Consultants rarely attend and if they do are often there in an advisory capacity, which further serves to reinforce hierarchy. Switching to maternity study days that all members of the team are expected to attend may help to promote a better understanding of each other’s roles, help to generate a shared mental model and develop a community of practice.
The degree to which healthcare professionals effectively work together has a huge impact on the quality of healthcare that people receive. Poor communication has been highlighted as one of the most common factors in examples of cases where there have been poor outcomes for women and babies (DH, 2013). How we address each other has a large impact on how a team works together and terms of address can be used to reinforce hierarchy, the existence of which is known to be detrimental to the care of women and babies. The use of first names helps to flatten hierarchy and foster more open communication leading to the shared common goal: the provision of safe, compassionate care for women and babies.
Hello, my name is... four Key Values
A simple introduction is the first step on the ladder of a therapeutic relationship.
- Communication - Breaking bad or difficult news should be handled sensitively.
- The little things - The difference between a good and a bad experience: holding hands, introducing yourself, sitting down, taking the extra moment.
- Person-centred care - This shouldn’t be just a phrase. Kate received efficient, timely care when her antibiotics were changed, but she hadn’t been informed of the reasons behind the change.
- Seeing the patient - Contextualise the person. They aren’t just a problem, or a bed number.
7 Ways to overcome barriers to healthcare team communication
- Teach effective communication strategies
- Train teams together
- Train teams using simulation
- Define inclusive teams
- Create democratic teams
- Support teamwork with protocols
- Develop an organisational culture suporting healthcare teams
Weller et al, 2014
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Sue Brailey is a caseloading midwife and senior lecturer in midwifery at Middlesex University, London