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Task overlap power move
Hello guys,
Context: nurses at the pediatric emergency department (endless source of learning power moves, which is good).
Situation 1: task overlap: interviewing the patient
Usually, it's set up in a way that the nurse first comes in with the patient and parents in the room, take vital signs and asks a few questions. Then they report back to me with a summary.
What this does:
It's a check of our work by the nurse (nurses are permanent employees, we are transitory): I think it's set up this way by management
It's a waste of time: I'll ask the same questions and will examine the child as well. It's twice the work and twice bothering the child and parent. The parent has to repeat it. Also in the mean time, I'm just waiting to enter the room.
There's a loss of information: usually the parent has a lot to say and since they said everything to the nurse. Then I can only ask closed questions. When they arrive they usually have a story to tell which they told the nurse.
It empowers the nurse: they get to learn more (knowledge and skills) and it sets them up as an intermediate to the patient (kind of triangulation).
What I do now:Â I enter at the same time or even before they bring the patient. But now it's a competition between me and the nurse to get the facts. I start to talk but as soon as there's a micro-silence, she starts asking questions. This is confusing to the parent and is not very efficient.
My idea: now I'm going to say to the nurse: "I'm going to ask the questions while you take the vital signs, is it ok for you?" or telling the parent (more dominant): "I'm going to ask you questions while my colleague is taking the vital signs".
Another idea is to ask them beforehand: "what info do you need for your notes?" So I can get the info from the parent while we are all in the room so the nurse can hear it and can move out of the room.
Situation 2: task overlap: calculation
I find the patient is dehydrated, so I'm going to order an IV line and fluids. I'm explaining the case to my supervisor who's correcting and teaching me. The nurse is nearby and comes closer to us. Now it's the time to calculate the amount of fluid. The nurse starts to calculate as I'm calculating (it's confusing me as I have trouble focussing). Then says: "I calculate this, calculate it and tell me what you have": yes, she's tasking me.
Next time I'll say: "I calculate it and I'll tell you the dosage"
That's one of the reasons this place is toxic: they empowered nurses to have more control over what is happening in the ED without the manager having to check by themselves. But it disempowers us (doctors) as they're taking tasks which are ours: interviewing, examining the patient, calculating the doses.
I understand they're able to do this and I'm glad. I think it's good to have a preliminary evaluation by the nurse to check for red flags if the doctor is not available in case he/she needs to be called for a faster evaluation. But in this case, it's more a flavour of: "we can do what you do" AKA we are doctors. As I said it's confusing to the parents as they don't understand what is happening.
So I have to sail this one smoothly as if they could report me or complain about me. My answer would be: "I'm being pro-active so I can see more patients otherwise I'm waiting and we lose time". That is exactly why I'm doing it.
And if you're wondering: yes these 2 power moves are done by the same nurse.
What do you guys think about these situations? Have you encountered it? If so how did you react?
Cheers!
Hi John,
I am taking a shot at answering, but the matter seems complex. My thoughts: the fact that this is set up by management makes it very risky to alter it, so I would consider if it is possible to regain power while still following the procedure.
Assuming you get to the patient after the nurse, you could say something to the patient to the effect of "Nurse x told me what you discussed. Did he/she get a full picture? Is there something else I should know?" (implying the nurse did something to your benefit / on your behalf).
Alternatively, you could consider accepting the nurse asking questions first (maybe saying something implying you allow her to go on), and then listen directly.
Then, when the nurse is over, you could ask additional questions directly to the patient, going deeper on what the nurse did not ask/receive. That way you would have no "overt frame battle", but you would still look in charge.
I agree with Bel. Also psychologically if she s been empowered and you try and wind that back you re taking status from her. Guaranteed conflict.
One option that came to me is letting her do the work but you framing the narrative. Hi I m Dr John and this is nurse Jaquelin.  She will be asking you a few questions to find out what's going on. And then I will see what we can do to help you.
If she disagrees on that you can say you like to do introductions because it's polite and makes everyone's job clear so the patient isn't confused.
I m assuming you would be making a diagnosis and arranging treatment. I.e. you have higher value in the process. If it's just initial patient screening i.e. the process is more segmented then we d need different responses.
Thank you Bel and Transitioned for your answers!
Quote from Transitioned on February 7, 2022, 10:22 pmI agree with Bel. Also psychologically if she s been empowered and you try and wind that back you re taking status from her. Guaranteed conflict.
True.
One option that came to me is letting her do the work but you framing the narrative. Hi I m Dr John and this is nurse Jaquelin.  She will be asking you a few questions to find out what's going on. And then I will see what we can do to help you.
It does solve the power dynamics issue. Here are more details about the workflow:
- A triage nurse ask what is the main complaint of the patient/parent: 5 min evaluation, this is already all the information needed to find out the speed at which a doctor has to see the patient
- A nurse brings the patient to the room: asks questions and takes vital signs
- I come in: so by the time I see the patient, it's the 3rd time they're telling their story.
If she disagrees on that you can say you like to do introductions because it's polite and makes everyone's job clear so the patient isn't confused.
Smart.
I m assuming you would be making a diagnosis and arranging treatment. I.e. you have higher value in the process. If it's just initial patient screening i.e. the process is more segmented then we d need different responses.
The problem is that in this environment, they often challenge our decisions. Sometimes they criticise them out loud where we can hear them (not very professional nor respectful). So unfortunately, it's a group with a majority of power/game players. It's a minority who play their role and/or collaborate with team spirit. So the context is influenced by this "feel" of the dynamics between us. I improved my relationship with them, but they have not changed.
Something else: if I don't see enough patients, I can be criticised for not being productive enough whatever their actions are. They often have conversations or are laughing while patients are piling in the waiting room while we are available to see the patients. So they are in control of the patients' flow and it's quite slow (something that cannot be openly discussed). So when they're having their conversations as patients are waiting and I'm available, I go to see them and say:
If you want to bring a patient in, I'm available.
This is something they cannot defend against and they go to work. I'm not ordering them around and all they can say is:
We're not available right now
Except in cases where it's obvious they are available and they have to go and do it.
If they go with the:
We're not available right now
I go with the:
Is it alright for you if I bring a patient in?
To which they cannot say "no". That's the whole problem with this place: nurses have most of the power and we must walk on eggshells. We must ask permission to do their job to keep the patient flow at a normal pace. That's part of the toxicity.
Yes, my job is to diagnose and to treat. However we are not very much respected by the nurses, whatever our skills and knowledge or the value we bring to the patient. Unfortunately, it's a toxic environment.
Thanks again for your help and feed-back guys! It's a challenging workplace.
I'm working there 20% (emergency). At the other place where I'm working 80% (kidney diseases) I get along very well with the nurses and we collaborate and respect each other. Because they are great people which I am happy to have as colleagues.Â
It's a bit complex to render this environment, but basically it's dysfunctional.
To give you an idea, many attending physicians left this organization very recently. Of the 10 attendings, only 3 stayed. Can you imagine? 70% of one layer of the organization left. There are other problems but basically doctors are not happy in this organization regarding training, organization/management and respect.
This team of nurses have been warned by their management (I've been told) and they're supposed to behave better. It's a bit better, but it's not ideal yet.
I'll update you on this dynamics.
Thank you very much for your help guys, it's much appreciated!
