CHAPTER 15
Communicating Across Hierarchy
Take a look at the following true stories, described in brief:
A male surgeon swears at a female clinician over the phone. When he later apologizes, he says, “I never would have spoken to you that way if I had known you were a physician.”
A physician remarks one day, “We’re now being dictated to by administrators, the people who weren’t smart enough to get into medical school.”
When a nurse disagrees with a doctor’s plan of care, he offers to give her $50 to pay for her application to medical school so that she can gain decision-making authority.
A nurse manager reports that a senior physician who rounds with residents and fellows on her floor fails to acknowledge or make eye contact with the bedside nurses caring for mutual patients.
These true stories from our work in healthcare reflect mismanaged hierarchies. Managing hierarchies effectively is essential because hierarchy represents a necessary but potentially toxic aspect of healthcare culture. This chapter presents various hierarchy challenges and offers tools for building a more effective workplace using relationship-centered communication skills.
It is easy to defend the importance of hierarchy. If every member of an orchestra tries to be the conductor, the entire performance will be botched. Musicians need to know to whom to turn for instructions. In healthcare, if clinicians are resuscitating a patient, each person needs a clear understanding of who does what and who is in charge to maintain order and ensure that the most qualified person will ultimately make the decisions. No one would advocate eliminating all hierarchy in healthcare settings. However, it is essential to consider the potential harms of hierarchy and ways to mitigate these harms without eliminating the benefits.
Hierarchy is defined as a system in which people are ranked above or below each other with regard to status and/or power. Hierarchy can signal who is more important, who is more valued, and who has more control and authority. Many types of hierarchy exist in healthcare. Any of the following may find themselves elevated or depressed in hierarchies: doctors, nurses, physical therapists, pharmacists, men, women, people from different racial and ethnic groups, executives, case managers, technologists, administrators, and secretaries. The list goes on. Hierarchies also exist with regard to how much different people are paid. What message do we send about how we value our colleagues when we pay cardiologists more than infectious disease specialists or men more than women?
Hierarchies can be stressful. Research on primates and humans has consistently shown relationships between social hierarchy, biological measures of stress, and health.1 People need to feel valued and respected, with control over their environments and activities. When team communication norms convey a different message—one of devaluing, disrespect, and control by others—team health and function will likely suffer. The questions “Who is in control?,” “Who is most important?,” and “Who has power over whom?” have great psychological impact for most people. There is a reason children protest to their parents, “You’re not the boss of me.”
We can manage hierarchies in healthcare better by applying relationship-centered communication skills. Listening, power sharing, curiosity, reciprocity, expressions of empathy, and transparency regarding our motivations, goals, and feelings can all help establish and sustain effective relationships in settings of hierarchy.
Hierarchy in Healthcare Teams and Organizations
Unnecessary and inappropriate hierarchies can result in diminished team performance and unsafe care. When one of us was a student, a patient suffered a stroke after receiving 10 times the appropriate dose of a medication that raises blood pressure. The nurse had warned the physician that the dose seemed too high but was told not to question his orders. Power differences blocked communication and resulted in a significant patient injury. Cases like these in healthcare and aviation have led to changes in both industries that give key participants an active voice regardless of their rank.2
Hierarchy can be communicated both explicitly and implicitly and is often emphasized in the education of healthcare professionals. In the “hidden curriculum” of our training, we learn our first lessons about those who are expected to speak up and who are expected to keep quiet, who are to be treated with respect and who are to do as they are told.3 Hierarchy is reinforced both inside and outside the clinical setting. In many institutions, exclusive dining spaces and preferential parking provide physicians with enhanced access. Unspoken understandings among team members and patients often result in physicians being addressed with the title “Dr.,” while other team members are addressed by their first names or not at all. When senior physicians enter an interprofessional team meeting and all seats are occupied, other team members may feel compelled (or expected) to vacate their seats. As discussed in Chapter 3, introductions and nonverbal cues matter: they are the ways in which we, effectively or ineffectively, establish rapport and set the stage for subsequent communication.
Some hierarchical distinctions serve functional purposes. A physician taking a call from home may rely on preferred parking to provide prompt care in urgent clinical situations. However, other hierarchical distinctions impede communication with potential detriment to patient care. While the tradition of a “doctor’s lounge” may, in part, be intended to facilitate discussions of patient care and foster a sense of collegiality among physicians, other team members may feel excluded and devalued, and an opportunity for interprofessional communication is lost.
Adding to the complexity of formal hierarchy in healthcare is its intersection with other identifiers, including gender and race. These identity differences affect communication with patients (see Chapter 14), and also among team members (see Chapter 12). For example, women working in healthcare are often assumed to be nurses, and many black physicians share stories of being identified by patients and other healthcare professionals as custodial staff. When others make assumptions about roles based on gender or race, anyone may feel a need to be more adamant about asserting their own position of authority, with the unintentional effect of undermining team relationships. Our organizations are threatened both by the hierarchy that demeans nursing and custodial roles and by the sexism and racism that create associations between categories of people and professional roles.
Traditionally, hospitals have drawn a distinction between medical staff and all other staff. The delineation was relatively simple because there were fewer roles, and formal designation of power was fairly straightforward: those who wrote the orders held the power and were entitled to make governing decisions. With increasing diversity of professional roles, the “in” and “out” groups have messier borders. Where do nurse practitioners, physician assistants, optometrists, and psychologists belong? They may write orders to be implemented by nurses, but should they hold the same governing power as physicians? A range of answers exists, and varied structural solutions have been employed. In some institutions, only physicians are eligible to be members of the medical staff and thus to vote on bylaws decisions, and yet these bylaws may affect physician assistants, nurse practitioners, and others. Similarly, the dominant position of physicians is reflected by physician assistants, nurse practitioners, and others being referred to as “nonphysicians,” “physician extenders,” or “mid-level providers.” The implication is that a nurse is a “low-level provider” and a physician is a “high-level provider,” with relative value apportioned on the same sliding scale.
One challenge when attempting to flatten hierarchies is that groups accustomed to being elevated within hierarchies may fear they will lose their special designation. In one of our hospitals, all team members who provide direct patient care were asked to wear a badge identifying them as a “caregiver.” Some physicians protested the change, expressing concern that the uniqueness of their role was diminished by what seemed to be an excessively inclusive and vaguely worded category. “I completed medical school and residency, and I am a physician, not a caregiver,” one said. If we blur role differences, we risk creating confusion and stripping people of a part of their identities; if we accentuate role differences in the wrong way, we risk making some groups feel unimportant and devalued. Yet the question of whether a scrub nurse has a different and distinct role compared to an anesthesiologist is not the same question as how a scrub nurse ranks in importance compared to an anesthesiologist. When applied to hierarchy, the goal of relationship-centered communication is for people to feel valued without having to feel superior.
Best Practices
How does adopting a relationship-centered framework guide us in communicating effectively across hierarchy? Table 15.1 shows a summary of the ways in which core team attributes relate to hierarchy.
TABLE 15.1 Key Issues to Attend to in Managing Hierarchy
Of course, real life rarely presents a dichotomous choice between “poorly managed” and “well-managed.” There is no one-size-fits-all solution, and the complexities of dysfunctional hierarchy do not lend themselves to rapid resolution. Our effectiveness depends on multifaceted and sustained efforts.
In the following sections are some best practices toward fulfilling this vision of a well-managed hierarchy.
1. BE THOUGHTFUL ABOUT HOW AND WHEN TEAM MEMBERS ARE ADDRESSED
Consider this example. Rounds take place on ward 9V. The attending physician, Dr. Livingston, goes from room to room with two interns and a medical resident. The nurses call him Dr. Livingston. He calls them by first name. He and the nurses refer to the interns simply as “Dr.,” and it’s unclear if they know their names.
How often have we been on medical teams where the leader does not know everyone’s name? When we watch our children’s sports teams practice or visit their classrooms, we’ve noticed that the coaches and teachers know all the kids’ names. They see it as part of their professional responsibility. Chapter 3 highlighted the importance of introductions and names during patient interactions. Proper introductions are also important to effective team interactions. While some may roll their eyes at the perceived redundancy of introductions, it is important to recognize that assumptions about being known by one’s name and role (or the irrelevance of knowing another’s name and role) are very much tied to the power of hierarchy.
As coaches and teachers know, we can work together more effectively when we make it a priority to know who everyone is. Investing a minute or two at the beginning of a team discussion can have an equalizing effect and foster more balanced participation. Consistency in addressing fellow team members may also help to counteract hierarchy. If physicians are addressed as Dr. X, then consider addressing other team members by last name as well (Ms. or Mr. X, Nurse X, for example). Alternatively, all team members might choose to refer to one another by their first names.
2. IMPLEMENT PROCESSES THAT SUPPORT PARTICIPATION AND DECISION-MAKING BY ALL TEAM MEMBERS
Here’s another illustrative example. Dr. Diaz is medical director of a primary care clinic. In the past year the clinic has transitioned to a team-based model of care. After much effort, the logistics of this major change have been implemented, including daily huddles. Aware of the need for efficiency, Dr. Diaz typically begins the huddle by providing updates and listing priorities for the day. She is always careful to ask if anyone has questions or comments. Most days she remembers to end the huddle by thanking the team members for their hard work. While all team members are present and on time for the huddle (no small feat), Dr. Diaz notices that a medical assistant, Ms. Lewis, and a social worker, Mr. Gonzalez, rarely speak. The huddles are shorter as a result, but clinic flow is often delayed later in the day when these same team members raise important concerns to colleagues (and, indirectly, to Dr. Diaz).
Dr. Diaz is a well-intentioned leader who recognizes the importance of creating formal opportunities for interprofessional team communication. However, her experience demonstrates that bringing all team members together and asking for their input is often not enough to counteract the silencing effect of hierarchy. In the same way that asking a patient, “Do you have any questions?” as we walk out the door is likely to have low yield, both the timing and the wording of Dr. Diaz’s invitation undermine her intention of fostering balanced participation. By running the huddle and initiating it with her agenda and perspective, Dr. Diaz risks sending an implicit message to the team about the relative (and lesser) value of their agendas and perspectives, a message that is most likely reinforced throughout the healthcare system. What might she do differently to achieve her desired results?
Dr. Diaz decides to make team huddles the subject of the next staff meeting. She invites each team member to share his or her perspective about what is working and what could be more effective in the huddles. After everyone else has spoken, she shares her perspective and explicitly names the importance of all voices being heard during the huddle. She asks the team to generate “team huddle ground rules” that incorporate staff feedback, including the need to promote balanced participation and efficiency. Based on team discussion following a suggestion by Mr. Gonzalez, a plan is made to rotate the responsibility of facilitating the huddle. The ground rules are posted in the huddle workspace and referenced at the beginning of each huddle. During the next month, Dr. Diaz notices increased participation by Ms. Lewis and Mr. Gonzalez. In the few instances when they don’t speak, Dr. Diaz calls for a “ground rules” check-in and asks what the team might do to ensure all voices have been heard. Others begin to emulate this behavior, and Dr. Diaz observes the team accepting greater responsibility for the effectiveness of the huddles.
In Chapter 13, respect for autonomy and collaborative decision-making were named as important components of effective conflict engagement. While Dr. Diaz could try to develop a solution for this problem on her own, doing so might only reinforce the problematic dynamic she seeks to change. By engaging the team in problem solving, she not only yields a more effective solution but also conveys that she values all perspectives.
Dr. Diaz is intentional in her decision to share her perspective last. When those who are lower on the hierarchy are given opportunities to contribute early in the discussion, they may perceive less risk of contradicting others. Formulating ground rules makes expectations explicit and promotes shared accountability for upholding functional team norms. By relinquishing her role as “leader” of the huddle, Dr. Diaz helps to build all team members’ skill and comfort in participating actively. These skills are directly applicable to other team interactions, including those that involve speaking up about safety concerns.
3. CREATE A JUST CULTURE4
A risk in hierarchical cultures is that people lower in the hierarchy may feel unsafe if there is a culture of blame rather than a culture of problem solving. A “just culture” is one in which teams adopt a problem-solving approach so as to prevent future problems rather than an approach that focuses on blaming people. This does not mean that individuals are not accountable for their behavior. Rather, it recognizes that problems often occur because systems are flawed and make it too easy for things to go wrong. When an intern discharges a patient with the incorrect dose of her diabetes medication, a just culture supports focused feedback for the intern in the context of a broader team discussion of the system by which orders are reviewed and implemented. The intern learns that naming and investigating errors as a team is a process of improvement, not one of shaming.
4. DELEGATE SO THAT TEAM MEMBERS HAVE SOME CONTROL OVER THEIR LOCAL ENVIRONMENT
While it is frequently necessary to communicate organizational goals that need to be accomplished, look for opportunities to give team members freedom to choose how to accomplish those goals. While employees expect to be told what needs to be done, it can feel demeaning to be told how to do it. We accept it when our spouses tell us to take out the trash; we are offended if they tell us how to take out the trash. Furthermore, the results are likely to be better when informed by varied perspectives. On Dr. Diaz’s team, for example, Mr. Gonzalez proposes an effective modification to the facilitation of team huddles. Similarly, if a hospital ward is tasked with reducing the readmission rate or average length of stay for patient falls, it can be beneficial to allow the people working on the ward to develop solutions so that the solutions are informed by the specific conditions on the ward.
5. APPLY PRINCIPLES OF RECIPROCITY AND MUTUALITY TO TEAM INTERACTIONS, INCLUDING FEEDBACK
Reciprocity can be a powerful way to flatten hierarchy. For instance, when a leader has a feedback conversation with someone he or she supervises, it is an opportunity to receive feedback on his or her leadership as well as to give feedback on the other’s performance. Chapter 10 framed effective feedback as a relational process in which inquiry, empathy, and specific observations are used to foster shared agenda setting for continued professional development. While hierarchical relationships offer both explicit and implicit permission for unidirectional feedback (from the top to the bottom of the hierarchy), this approach may limit receptivity to feedback and the accompanying growth opportunities that exist for all team members, regardless of their position. So, in addition to the team-based interventions Dr. Diaz used to improve huddles, she might also have one-on-one conversations with each team member. She could start by offering a self-assessment of her own leadership skills and then openly invite feedback, a process that can foster balanced team participation.
6. HOLD TEAM MEMBERS ACROSS THE HIERARCHY TO THE SAME STANDARDS
When an institution sets policies and standards and then selectively enforces them, with only some groups held accountable, resentment grows and leaders may be perceived as hypocritical. If nurses are expected to arrive to clinic on time but doctors are allowed to show up late, nurse morale and team cohesion suffer. An organization that allows its surgeons to verbally abuse residents or nurses in the operating room cannot reasonably proclaim to value treating people with respect and compassion. Effectively detoxifying hierarchy in healthcare requires all team members to uphold professional standards and communicate respectfully regardless of role.
7. FOSTER TRANSPARENCY BY ACKNOWLEDGING HIERARCHY AND ITS EFFECTS
One of the more effective ways to detoxify hierarchies is to acknowledge them. This can make it safe to talk openly about tensions and make team members feel better understood and supported. If one group (doctors, men, respiratory therapists, for example) is doing most or all of the talking, naming the dynamic (preferably by a member of the group) can make it easier to address the issue. It may be as simple as saying, “I notice that we’ve heard from several of the physicians, and I’m wondering what the nurses and administrators in the room think about the issue.” If processes or procedures are put into place to improve the work environment by managing hierarchies more effectively, it helps to be transparent about the goal. We can imagine Dr. Diaz saying, “It’s important to me that everyone on our team feels respected and has a voice in our meetings. I want to change the way we run our huddles in order to achieve those goals.” The effectiveness of transparency depends on implementation of the previously discussed best practices. Team members are most likely to communicate openly as members of a just culture in which leadership has demonstrated its capacity to both give and receive productive feedback.
Conclusion
Modern healthcare is highly structured and hierarchical. There are many rules about who is allowed to do what. Many of these distinctions are critical for patient care and safety. However, these distinctions have also been used to create “in” groups and “out” groups. Who gets to eat in the special dining room? Who gets the best parking spots? Who are called by their first names, and who are called by their titles? Who finds that people don’t even bother to remember their names? Who is expected to speak, and who is expected to listen? Who gets away with bad behavior, and who gets reprimanded? Who is treated with respect, and who is disrespected or ignored?
By answering these questions and taking the necessary steps to promote an environment in which everyone feels valued, respected, and empowered, we create more effective teams and a stronger and more engaged workplace culture. The effectiveness of relationship-centered communication is best realized when its fundamental principles are applied in all relationships, including those across hierarchy.