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How to deal with subordinates when you're new (doctor & nurses)?

Hello Lucio,

I'm a resident physician and I work with nurses. And power dynamics can often be very tiresome with them. The setting is the following, as residents:

  • We are both learners and employees
  • We change hospitals every 6 months or every year
  • We are supposed to give nurses orders but often either they have often more experience in the job than us
  • They are part of the staying team so they have more informal status and power than us
  • Some of them are frustrated with their pay, their choice of career or that they're stuck in their professional/personal lives, so they are bitter

I don't know how to react as they often send "barbs" (the assholes, not the cool nurses) and I don't really know how to react, because:

  • Sometimes I don't even detect them, I'm not on the defensive, so I don't even see them coming
  • I don't know how to react in a professional setting where I'm the new guy (today was my first day)
  • So I end up not being able to defend myself and being walked over

I read your "how to not let people undermine you", it's very good like the rest of the website. Do you have any specific advice for this situation? I already started to enforce "collaborative frames" and I can see the change already.

Here is an example from today. The cafeteria was closed and I wanted a coffee so I asked one of the cool guy nurse where can I get a coffee. Another nurse intervened and said: "you are a doctor and you don't have any coffee capsules?". I answered: "no I don't". But it's only 2 hours later that I realised that it was an attack even though I felt it emotionnally in the moment. I realised she was implying that I was stingy or anything else that was negative anyway. After I got my (free) coffee, I went back to her and introduced myself with a smile, she was all smiling.

I thought about that and I could have answered: "What are you implying?". But I'm thinking maybe it's too agressive. I don't have a default response to these people and it makes me feel weak. Any tip?

I know these people have low self-esteem but I still need to defend myself. I also understand that scared people are agressive.

correction: I want to add "... self-esteem and are insecure..." (NOT smart alecing)

Hey Amerok,

Yeah, I can understand the situation.
Those are very normal "power-teething issues" you are facing.

The good news is that they most often go away as you gain more experience and as you become a common fixture in the environment.

In good part, those are knee-jerk reactions.

You're entering an already existing power structure where people have been operating for a long time already.
Many of them as you say know more than you do about processes and daily activities, and there you waltz in, without yet knowing much about the environment, without having yet proven yourself... And you go straight over their head.
That's how some of them feel, and it's (in part) understandable.

A good way to head off that risk is this: as soon as you arrive, you congregate the team and make a small speech about how happy you are to be there, and where you state they are the knowledgeable ones, and that you will need to learn a lot of things from them.

They already know you're the boss, and that's your way of saying "I respect your expertise guys, and I'm not here to micromanage you". That's your first olive branch, and it will prevent much of the initial backlash -save maybe the truly worst troublemakers, but they're a minority-.

Then you might add some personal touch about something you truly believe that it's important about their work. For example, that you see nursing as the real "face" of the hospital, the most important link between patients and healthcare.
Granted, if you got cynical ones in the team they might think you're posturing and giving the usual boss-speak. But you're not doing it for the most cynical, you are doing it to set up an initial frame of collaboration and respect with the majority.

Setting Frames Later On

If it's too late to give that initial speech, you can still set-up that frame through individual interactions.

When a nurse explains something to you don't know, you can say "thank you for sharing that with me, I appreciate it, it's very useful to get me up to speed and learn how things work here".
Ask questions, show you're eager to learn from them. Do it without submissive body language and once you gathered all input, be the one who makes the final decision. So you make sure that you end up in that good quadrant of high-warmth/high-power mix (one that Clooney so well inhabits, BTW).

I think it's especially important in the medical profession that you avoid a frame where you, as the doctor, must have all the answers all the time.
That's the mindset some of those nurses might have, and you might want to correct that.
You're the doctor, and you're their boss. And if something is not sure, you're the one responsible for the decision. That's for sure. But you want a team of people who contribute and bring their expertise.

As Jack Welch said:

Why should you only get a pair of hands when you get their minds, for free

And not just for free, actually, but for a huge net gain, and for a more fulfilled workforce.

You're a doctor, you don't have coffee capsules

That's what suggested me that nurse has the type of mindset where "doctors must know everything".

It's a terrible mindset because it condemns you to pretend you got all the answers, and naturally makes nurses frustrated because they feel they're just dumb executors of orders.
Bad for you, bad for the nurses, terrible for the patients.

From a power-dynamics perspective, that was a passive-aggressive assault on your authority.
As if to say "you're not acting like a real doctor should act" and, possibly, "are you good enough to lead us"?

That would have been a good moment to go for that frame of both collaboration and mutual respect that you expect.

For example:

Nurse: You're a doctor, you don't have coffee capsules
You: (pause, get closer, nonverbally show you're in control) It's interesting you say that. Yes, I am a doctor. But that does not mean I have all the answers. Or, in this case, the coffee capsules (smiles to release some tension). Sometimes you, or him (point to other nurse), or Mark (name of another nurse) or anyone else will know far more than I do. And I expect you guys to let me know when you know more than I do. It's only with collaboration that we will be able to do a good job together

When the next time you're not sure what to do, here is a simple to follow:

  1. Always refer back to the collaborative frame
  2. If you're still stumped, ignore the zinger, look and be superior
  3. If it was offensive, pull ranks and push back on it: A passive-aggressive remark will not damage your authority too much, but an offensive remark that you let pass by, will.

Your answer was not too bad. Depending on your nonverbal and tonality, it was very close to "ignore it".

Firing the Worst Offenders

This course of action will work with the majority of nurses and reports.

Sometimes you'll stumble on some true black sheep and toxic employees.
That's when you can start thinking of firing some of them to preserve the team.

Can you fire nurses?

If so, you can consider a few months down the road to let go of the worst offenders. Otherwise, they might poison the rest of the team, and thwart your attempts of having both respect and a collaborative, helpful workforce.

As Phil Jackson said:

Good team management is about keeping those who hate you away from all the rest

Assholes & Self-Esteem

By the way, that idea that assholes or abusers are low in self-esteem is not always true.
Roy Baumeister makes a compelling case that the people most likely to attack others are those with a combination of high and fragile self-esteem.

So when the high perception they have of themselves is threatened, they lash out and get combative and aggressive.

That's one of the reasons why it's so important to develop an antifragile ego.

Have you read the forum guidelines for effective communication already?

Great answer as usual! Great analysis, thank you very much Lucio for taking the time!

Some supplementary informations to give a clearer picture:

  • I'm a doctor, but a junior doctor, so there is no speech. We joined as 4 new junior doctors
  • I cannot fire people: I can only fire me.
  • Regarding Assholes and self-esteem: yes you're right, great point. This book is already on my list.

I'm looking forward to read your reviews about books. I do appreciate your critical thinking mind. I never heard about the book by Jack Welch before. Thanks for making me know about it.

Thank you very much! I'm hooked on your "Social Power" course, this is just so good!

I was young officer, official "captain" to  a group of experienced firefighters. I could not fire them or punish them. I did not have my superior's support. He was bypassing me and communicating with the person right below me in the rank, who was the unofficial- real leader of the group. I did not have any allies in the group.

What would you do in this kind of situation?

 

Quote from Incognito on May 7, 2020, 10:13 pm

I was young officer, official "captain" to  a group of experienced firefighters. I could not fire them or punish them. I did not have my superior's support. He was bypassing me and communicating with the person right below me in the rank, who was the unofficial- real leader of the group. I did not have any allies in the group.

What would you do in this kind of situation?

It's not an easy situation.

The biggest hurdle is your superior's behavior.
He behaved very unprofessionally and actively poisoned the atmosphere.
Communicating directly with someone's reports is the best way to undermine that person's authority and to introduce nasty politics in the group.

Usually, in these situations, you cannot go to the unofficial leader beneath you, because his interest is to keep the situation as it is -and potentially even getting rid of you-.

Among the available options two common ones are:

  1. Address the boss right away: with this option, you seek to change the situation with the only person who can change it right away, your boss
  2. Work the environment first: with this option, you seek to change the unofficial power dynamics first without officially addressing the situation.

Option 1 seeks to get your official title and authority recognized right away.
You go to him, and tell him that you're the captain, and the information should flow from him to you. You should prepare for this one very well, and calibrate to your boss. If he's a touchy type of person, you must be very indirect and never make it feel like you're blaming him. If he cares about having a well-performing team, then your angle must be about "having a well-functioning team", etc.
It can be a quick short cut to fix the issue.
The risk with option 1 is that if you don't yet have people's trust and respect, they might not be willing to give it to you just because you ask for it, either up the chain from your boss (the most important), or down the chain with firefighters.

With option 2, instead, you seek to grow into your official title.
This option recognizes that a big title before you're fully ready for it can be a liability for you as well.
You pretend you're not too bothered about the situation and you focus on earning the title. You learn the job well, and prove your worth day by day, and you make some allies based on mutual respect. As your expertise and network increase, you also start acting with more power and status... And then naturally and organically grow into your true position.

A mix of options is also possible.
You could go to your boss and say you understand you're new and your focus now is on learning and that you're OK with the unofficial leader carrying much of the weight until you're ready.
And if you go with option 2, you can focus on learning and growing and then as soon as you feel you're ready, you go to your boss and basically say "now it's time we start honoring my title because I got the skills to back it up".

Which one works best depends on the environment and how hostile or not hostile it was, your personality, your boss' personality, and the relationship between the boss and the unofficial leader.

Have you read the forum guidelines for effective communication already?

Half of the group below me were allies with the informal captain. I asked a lot of questions in order to learn. They fought me indirectly by not talking to me, not providing me information. Later on, two bully guys jokingly said they would hit me and nothing would happen. I said I would speak the vice ceo who was in our capital. It was a lie but I had to do something. I informed the informal leader. I told about the firefighters threatening me to my supervisor. My supervisor told me that I was a child that left the subordinates to take advantage of me. The subordinates stop talking to me and were talking badly about me in the other teams of the local city. Soon, firefighters from other teams stopped talking to me. I was too good-soft to everyone. Even when all this happen. I was smiling and eager to help. I think that was my mistake.

About another power dynamics:

A child had vomited while in my presence in the sink because I did not know where the vomit bags where (as I'm new). After that, I tried to clean it up without much success. The nurse comes in and I explain to her and she tells me she's going to ask the cleaning lady (which is her role).

After that, I go to the nurse to ask her where are the vomit bags in this room and she shows me.

After this event, in the same room with another patient, the nurse tells me before leaving the room (half-jokingly):

  • "Here are the vomit bags"
  • I reply: "Can I use this one? it's larger", pointing to the sink and joking
  • She said: "Yes and then you can ask the cleaning lady"

So this is a common power dynamics. It's the nurse implying that they do all the shit job while we get all the glory. This is largely false. Because (if I don't forget), I always do my best to clean after me. Even in this case, I asked her where the bags where spontaneously and I even told her: "because us men we have trouble finding things". So at the 2nd interaction, she already knew that I knew. So it was clearly a power move. Plus, most doctors would have not even asked where the bags are. So she behaved as if I did not have been proactive to prevent a 2nd occurrence. And then pretends like I'm not willing to do the shit job (which I was).

I thought about it and next time, I will just say: "I know, I just asked you earlier, don't you remember?"

What do you guys think?

It's very common, due to the imbalance of power, to paint doctors in a bad light for good and bad reasons. Nurses usually do this as a group. After such an event, they gather and talk and say: "this doctor (aka the new guy) made me do this shit job because he did a shit job, blablabla". So, usually I counteract this with being 100% professional 98% of the time. But I still have progress to make.

Quote from Incognito on May 8, 2020, 2:08 pm

Half of the group below me were allies with the informal captain. I asked a lot of questions in order to learn. They fought me indirectly by not talking to me, not providing me information.
Later on, two bully guys jokingly said they would hit me and nothing would happen. I said I would speak the vice ceo who was in our capital. It was a lie but I had to do something. I informed the informal leader. I told about the firefighters threatening me to my supervisor. My supervisor told me that I was a child that left the subordinates to take advantage of me. The subordinates stop talking to me and were talking badly about me in the other teams of the local city. Soon, firefighters from other teams stopped talking to me. I was too good-soft to everyone. Even when all this happen. I was smiling and eager to help. I think that was my mistake.

I see, sounds like a highly toxic environment that was already fully stacked against you.

The environment might have already been against you from the moment you stepped in.
And you might have contributed to it with some initial behavior.

As you learn, you definitely also must show some strength.
Not in the job proper, as you're learning that, but in your general demeanor.

With those two bully guys, it definitely sounded like a test.
When you said you'd speak to the vice CEO, that might have made you come across as personally not strong enough. The two of them might have felt like you were the guy who "tells on" them and goes to the big daddy to ask for help.

Any answer that showed you were not scared would have been better.
Something like:

Bully: we could hit you and nothing would happen
You: I could do the same and people would cheer for me (ones ups him back by going from "nobody would say a thing" to "they'd actually cheer for me")

If whatever you said in jest wasn't enough, and they'd keep on going with their "jokes" about hitting, then you'd have to change the frame and turn serious.
Remove their cover of "joking" and address the threat. Something like:

You: Hey, Joe, joking for joking is fun, but they way you're talking about does not sound like a joke, but like you're trying to threaten me or something.
I don't know what's your goal here, but I'm gonna tell you only once, so listen up.
Don't you ever threaten me again. Ever.

Have you read the forum guidelines for effective communication already?

Here is the new episode, with the classical hospital character: "the nurse bully". So basically in every team and every hospital there is several nurses usually who are plain bullies. Basically, they justify it because you're "new", "a beginner" or anything in between.

However, I decided that I deserve respect. So when this nurse who was already being belittling me and other junior doctor, she called me "chouchou" in french with a derogatory tone, which means like "cocco" in italian maybe or "sweetie" in english. So I told her an expression in french something like: "we haven't kept the pigs together", which means we are not so related that you can relate to me like that.

It's not because I'm "new" or a "beginner" that I allow myself to be bullied. I am used to this situation as it is a common occurence in hospitals. The next phase, which I'm now is a light or hard form of ostracization by the nurses. Because one of the group doesn't like me (basically she's a dick), they band together and make me feel or understand that I'm not liked. As lieutenant Aldo Rayne says: "I've been chewed before". Meaning I can handle this passive-agressiveness.

They know we are being evaluated by our chiefs (2 levels above me) and that they will ask their opinion about us. So this is the kind of power they have over junior doctors. And these evaluation will determine our carriers, so they're quite important.

I spoke about this fact with my direct supervisor and even if he did not say anything specific about it, I now know they're talking about me behind my back and that I'm the new target that they're trying to bend. I know because they did it to other junior doctors I'm still working with.

So, my basic strategy is to deliver excellent work, excellent service to the patient, talk politely and with respect to all my colleagues, to make allies through me giving value, basically to be spotless. What I have to be better is with my documentation, to be more uptodate with it. We are overworked as you know so there is a lot of extra work to be done during our free time, which is not accounted nor payed.

Anyway, I know that on the long term I will win because I already did it in the past. As I get better, as more people trust me in the team, this kind of attacks find no more ears to listen to it because they just ring false. I know they will always look for all the small mistakes I will do and it's ok, I'm the learner, I will learn. I spoke of this situation with my supervisor and basically he told me to "play the game", meaning to please and reassure the nurses. I will do it more of course, however:

What do you think of submitting to this kind of individuals and intimidation vs accepting their dominance?

There's a value balance between self-respect and acceptance. Personnally, I choose self-respect. I loved your article about the fact that we deserve respect from everybody. I did not find it, could you send me the link ?